Conference 11-21-2018

Katiyar Billing and Coding

Unfortunately I missed this outstanding lecture.

Williamson/Florek Oral Boards

Case 1. 45 yo male presents with fever and shortness of breath. Patient is tachycardic. Patient has history of type 2 diabetes. Exam demonstrates scrotal swelling, erythema, and crepitence. The patient required IV antibiotics (Vanco/Zosyn/Flagyl) and emergent surgical debridement.

Dr. Williamson made the point that diabetics with fournier’s gangrene may have sensory neuropathy that diminishes pain perception and may not be aware of an early perineal infection.

FOURNIER'S GANGRENE

Fournier's gangrene is a polymicrobial, synergistic, infective necrotizing fasciitis of the perineal, genital, or perianal anatomy. This process typically begins as a benign infection or simple abscess that quickly becomes virulent, especially in an immunocompromised host, and results in microthrombosis of the small subcutaneous vessels, leading to the development of gangrene of the overlying skin.

Patients with diabetes and alcohol abuse are disproportionately affected with Fournier's gangrene.6 Mortality rates have varied from 3% to 67%,7 but contemporary estimates range from 20% to 40%.8,9,10,11,12,13 Age over 60 and complications during treatment are the most important predictors of death.12,13

In advanced Fournier's gangrene, the local signs and symptoms are usually dramatic, with marked pain and swelling. Crepitus and ecchymosis of the inflamed tissues are common features. Prompt recognition of Fournier's gangrene in its early stages may prevent extensive tissue loss that accompanies delayed diagnosis or treatment. Treat with aggressive fluid resuscitation, gram-positive, gram-negative, and anaerobic antibiotic coverage (see also chapter 151, "Sepsis"). Recommended agents include piperacillin-tazobactam, 3.375 to 4.5 grams IV every 6 hours, or imipenem, 1 gram IV every 24 hours, or meropenem, 500 milligrams to 1 gram IV every 8 hours, plus vancomycin.7,8,9 Urgent urologic consultation is required for wide surgical debridement.7 The addition of clindamycin, 600 to 900 milligrams IV every 8 hours, or metronidazole, 1 gram IV, then 500 milligrams IV every 8 hours, to the antimicrobial regimen may be of benefit.7 Hyperbaric oxygen therapy in the pre- and postoperative setting is a treatment option but does not improve mortality.14 Admission to the intensive care unit postoperatively is typically required.7 (Tintinalli 8th edition)

Case 2. 2 yo female patient presents with decreased level of consciousness. Patient is hypotensive and tachycardic. The patient took some of mom’s medications. X-rays show radio-opaque pills.

 Radio-opaque iron tablets in the stomach.  The preferred method of GI decontamination is whole bowel irrigation (WBI). 6   Dr. Wilimson made the point to not do whole bowel irrigation in patients who have GI bleeding or signs of shock.  Activated charcoal does not adsorb iron. WBI with polyethylene glycol electrolyte lavage solution (PEG-ELS) should be initiated if pills are seen on abdominal radiographs. PEG-ELS is given by nasogastric tube at a rate of 25 mL/kg/h in small children and 1 to 2 L/h in adolescents and adults. The end point of therapy is a clear rectal effluent. It is also useful to obtain an abdominal radiograph after completion of WBI to confirm the absence of pills. Active GI bleeding, ileus, and bowel obstruction are contraindications to WBI. 6  (Pediatric EM 4th Edition)

Radio-opaque iron tablets in the stomach.

The preferred method of GI decontamination is whole bowel irrigation (WBI).6

Dr. Wilimson made the point to not do whole bowel irrigation in patients who have GI bleeding or signs of shock.

Activated charcoal does not adsorb iron. WBI with polyethylene glycol electrolyte lavage solution (PEG-ELS) should be initiated if pills are seen on abdominal radiographs. PEG-ELS is given by nasogastric tube at a rate of 25 mL/kg/h in small children and 1 to 2 L/h in adolescents and adults. The end point of therapy is a clear rectal effluent. It is also useful to obtain an abdominal radiograph after completion of WBI to confirm the absence of pills. Active GI bleeding, ileus, and bowel obstruction are contraindications to WBI.6 (Pediatric EM 4th Edition)

Either a 50mg/kg ingestion of iron or a serum iron level of 500 are indicators of severe toxicity.

Even moderately poisoned children require meticulous supportive care to ensure a positive outcome. For patients in shock, large volumes of intravenous fluids and sodium bicarbonate are required to maintain fluid, electrolyte, and acid–base status.

Editor’s note: Dr. Carlson disagreed with the use of sodium bicarbonate. She felt sodium bicarb was not indicated for standard management of iron toxicity.

Chelation with intravenous deferoxamine is used for significant iron ingestions. Indications are the presence of significant symptoms or signs of iron poisoning, a serum iron concentration greater than 500 μg/dL, or metabolic acidosis.

Deferoxamine should be administered at a rate of 15 mg/kg/h. Administration of intravenous deferoxamine to patients with intravascular volume deficits risks nephrotoxicity. It is important to provide a bolus of crystalloid before initiating the deferoxamine infusion. The duration of chelation therapy is variable; there are no reliable end points.7 Serum iron determinations during the course of iron poisoning do not reflect clinical toxicity, and they are often unreliable during deferoxamine therapy.

Using a return of urine color to normal is not recommended as an end point for chelation therapy. It has never been validated, and pigmentation of urine (vin rose urine) is concentration and pH dependent. The most useful criterion for continued chelation is the presence of a metabolic acidosis despite satisfactory perfusion. This indicates the presence of non–transferrin-bound iron in the plasma. Deferoxamine is rarely required beyond the initial 24 hours after iron ingestion.

Hypotension is a potential side effect of intravenous deferoxamine therapy if it is given too rapidly. In a dog model, hypotension has been observed at infusion rates of 100 mg/kg/h. It is not reported at the usually recommended rate in humans, 15 mg/kg/h. Delayed pulmonary toxicity with symptoms resembling those of acute respiratory distress syndrome has been reported in patients who received prolonged chelation (>24 hours).8

Renal failure can be seen in ill hypovolemic patients. For patients undergoing chronic therapy, visual and hearing deficits, and Yersinia infections have been reported. (Pediatric EM 4th Edition)

Dr. Carlson comment: the TIBC level does not have a role in determining iron toxicity.

Case 3. 38 yo male with right arm pain. Patient fell from ladder and injured right arm. Patient has a laceration in area of injury. Xrays showed the injury below.

 Galeazzi Fracture, fracture of the distal radius with radial-ulnar dislocation. This injury requires surgical management.

Galeazzi Fracture, fracture of the distal radius with radial-ulnar dislocation. This injury requires surgical management.

Menon Global Health in New Zealand

It’s a big decision to go to New Zealand to do locums. You have to weigh the upsides and downsides for you and your family.

Downsides to going: You will make less money (@$100,000) and the cost of living is higher. Taxes are 30% in New Zealand and you also get taxed again in the US for whatever you make over $100,000. You obviously need to move far away. You will be placed in a rural environment because that is where they need the docs. You have to commit for at least a year.

Reasons to do this: You get to do something really cool. You get significant time off (6 weeks paid, 10 days paid holiday). You get to practice your craft in a different environment. You get to experience a different healthcare system and a different way of life.

The work: EM is a relatively young specialty in NZ. Because of that, consultants like anesthetists and pediatricians frequently get involved in your cases. NZ has a national formulary so medications are affordible for patients. Malpractice risk is quite low. No night shifts for attendings! There are no respiratory therapists. Hemodialysis is rare. The pain control culture is very different. Patients want very little pain medication. There is much less imaging than in the US. Getting a CT is kind of a big deal.

Hawkins/Pastore Global Health in Dominican Republic

Top 3 causes of death in Dominican Republic: Ischemic heart disease, stroke, road injury.

Our residents and faculty took part in this global Health experience through a faith-based clinic and surgery center (Institute for Latin American Concern) affiliated with Creighton Medical School and Advocate.

Visiting health professionals taking part in this global health experience live with local families near the clinic.

Drs. Hawkins and Pastore took back the awesome experience of living and practicing medicine in another country and a gratitude for what we have here in the US.

Ahmad Determinining Capacity and Leaving AMA

AMA myths debunked: Insurance does cover AMA dispo’s. You can give prescriptions to patients signing out AMA.

You as the physician can explore with the patient what factors are pushing them toward leaving AMA. Sometimes you may be able to address their concerns so they can stay.

AMA discussions do not need to be confrontational. You will be better served if you can be supportive and collaborative with the patient. Maybe think about it as managing/optimizing the AMA process instead of having a conflict with the patient.

Patients who have decisional capacity can not be kept against their will unless they are suicidal, homicidal, or psychotic.

Snip20181121_6.png


To proceed with an against-medical-advice discharge, assess the patient's capacity, with special attention to barriers limiting capacity. Alcohol use and psychiatric diagnoses are not absolute barriers to discharge against medical advice, with the exception of suicidal and homicidal patients. Document the patient's behavior that clearly demonstrates there was no impairment of capacity by intoxication or mental illness. Educate the patient about the risks associated with refusing to complete evaluation and/or treatment. Discuss the patient's reasons for leaving, because these often present opportunities for negotiation and convincing the patient to continue care.9 Use plain language and avoid medical terms. Given the medical-legal and patient risks of against-medical-advice discharge, make a substantial effort to convince the patient to remain but do not resort to threats. Incorrect statements such as "insurance will not pay for this visit if you leave against medical advice" may further damage the patient–provider relationship and discourage the patient from returning.26,27 Model documentation of an against-medical-advice discharge should contain the following elements21,28:

  • Documentation of capacity (ideally with examples and examination clearly noted)

  • Discussion of the risks reviewed with the patient including what diagnoses were being considered

  • Explicit documentation in the chart that the patient was leaving against medical advice and what treatments, procedures, and courses of actions were refused by the patient

  • Offers made of alternative treatments or courses of action

  • Efforts to involve family, friends, or clergy in the decision

  • Explanation of any potentially problematic entries in the chart such as nursing notes or abnormal laboratory values—for example, if the patient has an elevated serum alcohol level, document that the patient is clinically sober and has capacity, if true

  • Patient's signature on the against-medical-advice form, and if patient refuses to sign, document that fact

  • Documentation of treatment and follow-up provided

  • Documentation that the patient was told he or she is welcome to return at any time

While the most important part of documenting an against-medical-advice discharge is the discussion with the patient addressing the items above, having the patient sign an actual against-medical-advice form may help provide further liability protection in three ways: "1) it may terminate the providers legal duty to treat a patient; 2) creation of the affirmative defense of 'assumption of risk'; and 3) the creation of a record of evidence of the patient's refusal of care."29

When a patient leaves against medical advice, reasonable treatment should be provided as appropriate for the patient's medical condition and concordant with the patient's wishes. For example, provide antibiotics for infection, aspirin for chest pain, or stabilization for fractures. Tell the patient to return at any time. Provide a listing of resources for close follow-up and instruct the patient on signs and symptoms to prompt a return visit to the ED should the patient change his or her mind.9,21 (Tintinalli 8th edition)

Example of documentation describing patient’s decision making to sign out AMA: “It is my medical opinion that the patient appears to currently have capacity to refuse care. He is alert, able to reason through the information I am providing him and seems to understand the serious risks of refusing care up to and including death. He is able to communicate his refusal to me and does not appear to be actively suicidal or have worsening depression influencing his decision making capacity.”

Delbar Pancreatitis and Biliary Tract Disease

The level of lipase elevation does not correlate with severity of pancreatitis. CT imaging is not required for most cases of pancreatitis.

Treat pancreatitis with aggressive LR administration. Give 1-2 liters as a bolus then continue with a rate of 150-200ml/hour.

Patients generally need a total of 2.5 to 4 L of fluid over the first 12 to 24 hours.19,22 The specific rate of fluid delivery depends on the patient’s clinical status. In the situation of renal or heart failure, deliver fluid more slowly to prevent complications such as volume overload, pulmonary edema, and abdominal compartment syndrome. Crystalloids are the resuscitation fluids of choice. Normal saline in large volumes may cause a nongap hyperchloremic acidosis and can worsen pancreatitis, possibly by activating trypsinogen and making acinar cells more susceptible to injury.19,39 A single randomized study showed a decreased incidence of systemic inflammatory response syndrome in patients who received lactated Ringer’s instead of 0.9% normal saline.39 Regardless of which fluid is selected, monitor vital signs and urine output for response to hydration. (Tintinalli 8th edition)

Mild pancreatitis does not have organ dysfunction. If a patient has SIRS or organ dysfunction they have moderate or severe pancreatitis. The three most common organ dysfunctions associated with pancreatitis are renal, cardiovascular, and pulmonary.

Sonographic Murphy’s sign is 97% specific. So if the patient has tenderness with the probe over a gallbladder with stones, they have cholecystitis.

Choledocolithiasis and Cholangitis both need GI and Gen Surg on consult. Patients with cholangitis also need IR to get source control by placing a percutaneous drain.

Abughnaim Healthcare Disparities

Health Disparities= Higher burden of illness for a specific group

Healthcare Disparity= Difference in access to care and quality of healthcare between groups.

Social determinants of health include many things outside of the healthcare system such as housing, income, racism, pollution, social and family support, the legal system, etc.

Consider the social differential diagnosis for different complaints. Lack of access, need to provide childcare, poverty, side effects of medications, can’t miss work, need to serve as a care giver to another person, prison, and homelessness are just some examples.

 Some social determinants of health

Some social determinants of health

ED Care Managers can work through the social differential and figure out how to support a patient to improve their overall health and be able to be compliant with the treatment plan. Care Managers can arrange disposition from the ED to a SNF. They can arrange financial assistance. They can set up follow up appointments.