Last guest conference notes, Dan’s back in country soon. This week back to Christine Kulstad.

 

8:00-9:00- Oral Boards- Felder vs Wise

Case 1- Thyrotoxic paralysis. Critical actions- treat hypokalemia and thyrotoxicosis. This is rare disorder with painless muscle weakness- this is a subcategory of periodic paralysis. Usually in SE Asians, more often men, usually young adults. Respiratory and bulbar muscles are not affected, and arrhythmias are uncommon. Weakness is proximal > distal, legs >arms. All symptoms resolve after treatment.  Treat with potassium, but high dose can cause rebound so give lower initial than you might think. Propranolol will move potassium into serum where it is lacking (total body potassium is fine, just shifted into muscle cells during attacks), dosing is 1 mg q10 to max of 3 mg/kg. Treat hyperthyroidism as usual. Have patients avoid high carbohydrate meals, fasting and heavy exercise as they can precipitate episodes. Chronic potassium supplementation is ineffective.

Case 2- Toxic shock syndrome from skin abscess. Treat sepsis as usual, drain abscess. TSS is caused by either Staph aureus or group A strep. Was associated with tampon use in past, now more with wound-packing or skin infections. Staph will rarely be found in blood cx (GAS does yield + blood cultures). Symptoms arise from exotoxins that staph produce- commonly see fever, hypotension, skin manifestations. May also have chills, malaise, v/d, sore throat, headache. DDx of ill young patient with rash- TSS, RMSF, meningococcemia. Treat with clindamycin and vancomycin. Remember to treat septic oral boards patients with EGDT as you would in the ED.

Case 3- FB aspiration in a child with prolonged cough. Found with air trapping on decubitus x-rays. May also see atelectasis, mediastinal shift, pneumonia.  If FB is left long enough, air in alveoli will be absorbed causing atelectasis. Infection often develops- first pneumonia and then pulmonary abscess and bronchiectasis are possible. Take-home point: do more evaluation (at least xrays) in child with prolonged cough.

 

9:00-10:00- EMS Study Guide- Motzny (and How to Survive the Zombie Apocalypse)

Triage: When triaging during a disaster, green is walking wounded. Remember triage is dynamic and will require reassessment.

START and SAVE are 2 triage systems. SAVE (secondary assessment of victim endpoint)- determines who will benefit significantly from austere field interventions. Patients who will die if not treated in field (vs those whose fate will not change if treated because too critical or not that bad). START (simple triage and rapid treatment) uses a quick assessment of respirations, perfusion, and mental status. Assess respitations first, if repositioning airway dosen’t fix it they are black/dead. If it does or breathing more than 30- red (immediate rx). If not, check radial pulse. If absent, red. If normal, check MS. If patient can respond they are yellow. Otherwise red.

Disasters: Internal disaster- catastrophic problem in the hospital (power failure and generator failure). External or just a disaster is defined by the capacity of the surrounding hospitals to deal with patients. E.g. 40 victims in a rural area is a disaster while 100 in a large urban area is not.

JCAHO requires a hospital’s disaster plan to be activated twice a year for accreditation.

Communications is consistently identified as a problem during disaster drills. Causes can be failure of equipment and unclear terminology, chains of commands. The first step when you are notified of a disaster is to verify the information (before activating the disaster plan).

Mass gatherings are defined as 1000 people in one site for a common purpose. The most common complaint of patients at a mass gathering is dermal injury (cuts/scrapes).

Medical control from the EMS physician is indirect and direct. Direct is real-time contact with paramedics, whether over the radio or at the scene. SMO (standing medical orders) give indirect guidance for many common problems. Physicians cannot assume control of a scene if unknown to EMS UNLESS you have proof of licensure.

HAZMAT command centers should be set up uphill and upwind. Many toxins are heavier than air (so go uphill), if lighter than air they will soon rise above your head. When dealing with patients with significant chemical exposure, eyes take precedence in decontamination. No procedure (including airway) should be done without decontamination unless you are wearing the appropriate protective gear (HAZMAT suit) and then get decontaminated yourself.

Weapons of mass destruction include chemical, biologic, nuclear, radiologic, and explosive agents. Biological agents classified as Class A agent of concern by CPC are smallpox, anthrax, plague, tularemia, viral hemorrhagic fevers, botulism- all the agents that you think of as really bad. Others are class B if they could be used but not effectively or not that toxic (e.g. salmonella).

Radiation- alpha, beta, and gamma. Alpha particles will not penetrate skin or clothes, only dangerous if ingested. Beta goes a couple of centimeters (lead protects). Gamma goes all the way through (like xrays) and will give whole body irradiation. The good news is you don’t have to decontaminate gamma since its still going. The earliest indicator of radiation injury is lymphopenia. 

Hypoxemia and hypoperfusion are not caused by helicopter EMS transport generally because they don’t fly very high, can factor in fixed wing aircraft transport (planes). Decreased air pressure in planes can 1) increase fluid rates in medications given in glass bottles as gas expands 2) increase pressure of pneumothorax increasing the size 3) tracheal cuff on ETT may pop (use saline instead of air). If you are approaching a helicopter, avoid the rear.

NIMS (National Incident Medical System) standardized terminology and procedures. It states material managment is logistics section responsibility. For more info, www.fema.gov/emergency/nims

10:00-10:30- Discharge Instructions- Kiernicki-Sklar

Don’t make the mistake of thinking discharged patients are not sick or someone’s problem. CRICO 2011 benchmarking report summarized 200k EM malpractice cases, they found #2 cause of malpractice cases related to missed/delayed diagnosis (majority of cases) was development of discharge plan.

Think of d/c instructions as sign-out to the patient. Other functions as a patient care summary, contract with patient (if patient doesn’t follow instructions and suffers harm, care contract is breached).

Patients don’t remember verbal instructions well, make sure you write down important information too.

Mnemonic to remember how to provide good d/c instructions. WTF DR DC?

W- What we did or didn’t find. Include incidental findings (lung nodules, elevated BP).

T- Treatment/tests that are still needed (have BP rechecked, have a stress test in 72 hrs, have sutures removed). Include risks of non-compliance.

F- Follow-up required. Timed f/u when undifferentiated abd pain (24-28 hrs), significant wound checks (1-2 days), chest pain (72 hrs). Stress that patient needs to call to make appointment (or if specific time arranges). Make effort to contact f/u physician in high-risk cases.

D- Drug warnings- legally it is your responsibility to provide warning and check for allergies/interactions.

R- Restrictions. Things that may worsen a current or undiagnosed condition (undifferentiated CP and exertion, seizures and swimming/bathing/driving). Not only could patient sue you, but 3^rd party could (driver who seized and hurt someone else).

D- Diagnosis. Don’t feel need to make a diagnosis when it is not clear (abdominal pain vs GERD). Two reasons, easier to sue for misdiagnosis in case 2 and causes anchoring bias in physician who next sees patient.

C- Comeback (what to return for). Highlight specific concerns based on that patient’s problems, don’t assume that they will read all the pages of the pre-formatted d/c instructions. Include contingency plan if f/u cannot be arranged (patient can always return to ED as last resort and should be encouraged to do so).

?- Final checks. Re-check vital signs, reassess pain. Use simple words (6^th grade level), and avoid medical terms and abbreviations.

Brief discussion of AMA- think of as informed non-consent. Must discuss and document 1) risk/benefit/alternatives 2) Pt has decision making capacity 3) Patient has understanding of #1 4) patient can ask questions and get answers. Give them good discharge instructions and any treatment they will accept.

10:30- Musculoskeletal Exam- Hands-On Skills Station

You had to be there