Conference 8-15-2018

Ahmad      Difficult Conversations

Before you start a difficult conversation with a patient, have a plan. 

SPIKES:   Set an expectation,  Perception, Inform, Knowledge, Empathy, Summary.

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Lovell comment:  The times of delivering bad news are incredibly important to our patients and their families.  We need to work on this skill to provide compassionate care to our patients.

Empathy is a critical virtue to being able to give bad news to a patient or family in a compassionate fashion.

Beware of traps:  Bias,  Ancillary staff perceptions of the patient,  Fatigue. 

Expect the unexpected:  Families may have intense emotional reactions, or indifference, or anger.

Know your audience.  Deliver your news with consideration of the patient's or family's healthcare literacy, culture, and their sensitivities.

When telling a family that a loved one died, use the words dead or died.  Don't use passed away.   To soften the blow,  use compassionate phrases right after you use the word dead or died.  "I am so sorry for your loss"  "You have my deepest condolences"   "You did everything you could"  

Delivering Bad News Workshop

Small group discussions of ED specific scenarios that required the emergency physician to deliver bad news.

Gerity       Endovascular Treatment of Stroke

 Modified Rankin Score

Modified Rankin Score

MRI Cerebral Blood Volume and Blood Flow measurements can be used to predict the degree of ischemia of brain tissue .

 CBF correlated with degree of ischemia

CBF correlated with degree of ischemia

 VAN Positive is Defined by unilateral arm weakness plus yes to any of the following:  visual disturbance, aphasia, or neglect.  If a patient is VAN positive, they need CTA of the head and neck in addition to CT head.

VAN Positive is Defined by unilateral arm weakness plus yes to any of the following:  visual disturbance, aphasia, or neglect.  If a patient is VAN positive, they need CTA of the head and neck in addition to CT head.

Lovell     2018 ACGME Resident Survey

Dr. Lovell reviewed this year's ACGME Resident Survey.

Humphrey     Bites/Stings/Envenomations   Wilderness Medicine

The risk of infection from a dog bite is @5%.  Prophylax with Augmentin ("dogmentin")    Dog bites are at risk of capncytophagia infection.

Tigers kill more humans than any other mammal except humans. Tigers have killed over a million people over the course of history.

Domestic cat bites have a higher risk of infection than dogs.  Pasturella multocida infection is a risk of cat bites.  Treat with Augmentin.

The black widow spider usually only bites defensively.  The bite of a black widow spider is painless but within hours patients can develop muscle cramps, diaphoresis, and hypertension. 

Cleansing of the bite site is reasonable. Pain and muscle spasms can generally be controlled with liberal doses of opioids and benzodiazepines.22 Although IV calcium has been advocated to relieve symptoms, a retrospective review of patients with Latrodectus envenomation indicated that this treatment is ineffective.22 For severe envenomations, admission may be required for continued analgesia. The most effective therapies for severe envenomation are parenteral opioids and Latrodectus antivenom.

Administration of Latrodectus antivenom often causes rapid resolution of symptoms and can significantly shorten the course of illness. Even in severely symptomatic cases of Latrodectus envenomation, patients can often be discharged from the ED after a short observation period when antivenom is administered. Successful treatment of latrodectism with antivenom has been described even with administration 90 hours after envenomation.23 Antivenin Latrodectus mactans is not contraindicated in pregnancy. (Tintinalli 8th ed)

Brown recluse spider bites cause a necrotic skin lesion.  Less commonly patients can develop coagulopathy and thrombocytopenia.

Patients with systemic symptoms following a bite warrant hospitalization. Various treatments have been advocated for brown recluse spider bites, including antihistamines, antivenom, colchicine, dapsone, hyperbaric oxygen, surgical excision, steroids, and topical nitroglycerin. None of these therapies have clear benefit, and most wounds from the brown recluse are self-limiting and heal without any medical intervention.  (Tintinalli 8th ed.)

 Brown Recluse Bites are over-diagnosed and this decision rule helps avoid misdiagnosing another illness as a Brown Recluse bite.

Brown Recluse Bites are over-diagnosed and this decision rule helps avoid misdiagnosing another illness as a Brown Recluse bite.

Bark Scorpion sting  There is antivenon for scorpion bites.

New antivenin for crotalid bites has been developed called Anavip. The Anavip structure has 2 FAB fragments bound together.  There is slower renal clearance of this molecule and longer activity in blood stream. This results in less late term recurrance of coagulopathy from venom.