Conference Notes 6-6-2018

Tekwani        Medical Student Rotation Overview

Lovell      The Resident as Educator

2 Easy to use bedside teaching techniques:

1. 1 minute Preceptor: Get a commitment (get the student to commit to what they think is going on) , probe for supporting evidence (ask them how they reached that conclusion), teach a general principle, reinforce what was done well, correct mistakes (do this as kindly as possible), and identify next learning steps (suggest a topic to read further on).

2. SPIT=Serious,  Probable,  Interesting, and Treatable.   Have the student suggest 1-2 diagnoses for each of these categories that would fit the patient's presentation. This method is a quick way to build a broader DDX with a student learner.

Give feedback in as positive a fashion as possible.  Tell them at the beginning of your feedback:  "I am giving you some feedback now"

Remember, you are always "role modeling" to students

Send students to all codes and to interesting cases, rashes, or other significant physical findings.

Twanow       Myocarditis and Pericarditis

Myocarditis is most commonly a clinical diagnosis.  The diagnostic gold standard for myocarditis is endomyocardial biopsy which is rarely done.

Causes of myocarditis include viral infections, mycotic infections, RMSF, Chagas, Toxins, and medications.

Myocarditis can present as new onset heart failure, new murmur, new bundle branch block or heart block. Myocarditis can also present as persistent tachycardia, pericarditis with heart failure, arrythmias following uri, and unexplained heart failure.

Diagnose myocarditis with troponin, BNP, CXR and EKG. Echo is also important to make the diagnosis.  Inpatients can get Cardiovascular MRI which can also help to diagnose myocarditis.

In the ED, provide supportive care if needed with with pressors, anti-arrythmics, pacer, and anticoagulation.  Avoid NSAID's.  Cards may consider IVIG, ECMO, LVAD and other modalities.

Pericarditis can be caused by viral infections, TB, fungal, and parasitic infections.  Lupus, RA, and scleroderma can cause pericarditis. Neoplastic processes, post-MI, uremia, and radiation can all cause pericarditis.

Pericarditis classically has pain that is improved when sitting up.

 Pericarditis EKG. There is diffuse ST elevation and PR depression.  AVR has the opposite changes with ST depression and PR elevation.  If you see localized ST depression in the inferior, anterior, or lateral leads that  is not c/w pericarditis and needs to be strongly considered for STEMI criteria.

Pericarditis EKG. There is diffuse ST elevation and PR depression.  AVR has the opposite changes with ST depression and PR elevation.  If you see localized ST depression in the inferior, anterior, or lateral leads that  is not c/w pericarditis and needs to be strongly considered for STEMI criteria.

 Life in the Fast Lane reference

Life in the Fast Lane reference

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Dr. Lovell comment: Treat with ASA and Colchicine.  ASA has benefits over giving NSAID's.

 

(Tintinalli reference 8th ed.) Treatment of pericarditis depends on the cause.34 Most patients with idiopathic or presumed viral pericarditis have a benign course lasting 1 to 2 weeks. Symptoms respond well to nonsteroidal anti-inflammatory agents administered for 7 days to 3 weeks. Ibuprofen, 300 to 800 milligrams orally every 6 to 8 hours, may be preferred because of fewer side effects, limited impact on coronary artery blood flow, and large dose range. Colchicine, 0.5 milligram orally twice a day, may be a beneficial adjuvant and may prevent recurrent episodes.35,36 Hospitalization is not necessary in most cases, unless there is associated myocarditis, and follow-up or repeat echocardiography is not needed unless symptoms fail to resolve or reappear or new symptoms are noted.37 Indicators of a poor prognosis include temperature >38°C (100.4°F), subacute onset over weeks, immunosuppression, history of oral anticoagulant use, associated myocarditis (elevated cardiac biomarkers, symptoms of CHF), and a large pericardial effusion (an echo-free space >20 mm).38 In general, patients with these risk factors or with an enlarged cardiac silhouette on chest radiograph should be admitted for echocardiography to assess the extent of the effusion and degree of hemodynamic compromise and cardiac dysfunction.

Logan        Safety Lecture    New Stroke Pathway

Unfortunately I missed this excellent lecture but the new pathway is listed here.

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Chastain/Felder/Paquette       Efficiency Panel

The panel discussed many excellent tips on being an efficient emergency physician in our ED. I was only able to capture a few of them.

When you have multiple patients who are waiting to be seen, one way to prioritize them is: 1. Time dependent complaints like chest pain and stroke should be seen first, 2. Patients with abnormal vitals next 3. Then quick complaints that can be dispo'd quickly 4. While you are seeing those patients, put in lab and imaging orders on the lower acuity  patients with complaints like abdominal pain or weakness.

Maintain excellent communication with the nursing staff regarding your plan and discuss any roadblocks the nurses are facing.

If you are going to be delayed to see a new patient, ask the patient's nurse to go into the room and inform the patient you are delayed because of a critical patient.  When you finally get to that patient, apologize to them and explain why you were delayed.

Keep you communication brief with admitting and consulting physicians.

Utilize the care managers to help set up patient follow up and specialist appointments.  Care managers can help patients with limited healthcare access. The Care managers are stationed in the old telemetry room in the hallway to radiology.  You can leave them a message on their voicemail or slip a note under their door at night.  They will address the issue when they start their shift in the morning.

Ask a patient what their fears are, and/or what their hopes or expectations are for this ED visit.

Tran      Radiology Lecture

Unfortunately I missed this outstanding lecture.

Florek/Lorenz/Pastore/Robinson/Wing         Trauma Lecture

Unfortunately I missed this outstanding lecture.