Conference Notes 1-8-2014

New Year, New day of the week, so I am trying a slightly new format.  Based on the theory  “less is more”, I am going to try to make these a little shorter /more sustainable for me.  We’ll see how it goes.

Erickson/Schwab                       Oral Boards

I missed this excellent presentation , but the cases were

14 yo male withTesticular torsion.    Management was testicular u/s, pain control,  you can attempt  detorsion if the patient is having severe pain or the surgeon is delayed (Visualize opening a book.  Testicles are detorsed by rotating medial to lateral), and surgical repair is the definitive management.  

U/S of testicular torsion on left side

46 yo male with Lis franc foot injury.   If fx of the proximal second metatarsal is present or the middle cuneiform is not lining up perfectly with the second metatarsal you very likely have a lis franc injury present.  Also look at relationship between first metatarsal and first cuneiform

Lis Franc Fx/Dlx

65yo female  with  NSTEMI and flash pulmonary edema.    Treat with IV ntg and po ASA.   IV Lasix is second line additive treatment.

Sarah Maciolek          PED  APN Update

Sarah’s number if you have any pediatric patient safety issues you would want to bring forward  is 684-1782.   There are quarterly in situ pediatric simulations in the PED that include nurses, residents, and attendings.

Ketaneh/Lovell          Social Media

Largest HIPAA violation ever identified  happened on Facebook when a patient that frequented ACMC ED had a specific Facebook page that was created by a nurse from another hospital  about him.   This page was viewed by over 600 healthcare providers.  

Another example was a doc that was fired and fined for putting info about a trauma patient on Facebook.

28% of EM residency programs search facebook to get info on their applicants.

Any info you place on social media has to be general enough that the patient cannot be identified by the info in the post.

Don’t Friend patients on Facebook.   Don’t Friend people who in your workplace are in a subordinate position to you. 

Assume any text or post is publicly available forever.    Tweets are permanent.

Advocate Social Media Policy: HIPPA violations can lead to termination and legal action.  An unauthorized individual  can’t personally use Advocate’s Logo.   No ethnic slurs/personal insults/obscenity/harassment/inflammatory remarks allowed.  Advocate reserves the right to check an associate’s online profiles and content.

Beckemeyer question: Is it ok to text a  picture of a patient’s injury from the ED to a consultant.   Elise response: It is ok if the patient’s identity is protected.  Don’t put full facial view in the texted picture.  Also don’t give other identifying info in that text such as name or MR#.   When transmitting EKG’s be sure photo doesn’t include patient identifiers.    Girzadas comment: Be sure you document in the chart that the patient gave you permission to text the picture.     Elise comment: Even innocuous text or blog streams can inadvertently give identifying patient info.

Nick Ketaneh       Free and Open Access Medicine (FOAM) was discussed along with the use of Facebook and Twitter as sources of medical information  #FOAMed

Beckemeyer       Trauma in Pregnancy

Main Point:  Maternal resuscitation is the key to fetal resuscitation.

30 yo patient with gsw’s to head.   HR=120  BP=60/40

Physiologic  changes in pregnancy: HR increased, respiratory alkalosis, dilutional anemia, risk of IVC compression from uterus, increased pelvic vascularity making pregnant patients at risk for exsanguination from pelvic fx.   Increased risk of failed intubation.  GE sphincter is insufficient increasing risk of aspiration.  Increased minute ventilation and tidal volume but less functional residual capacity.  This makes the pregnant patient have less respiratory reserve.  Decreased chest compliance making bagging more difficult.

 IV access is better above the diaphragm in pregnant patients.  Access above diaphragm avoids the IVC compression problem with femoral lines or lower extremity IO access.


IVC Compression by fetus

Omi comment: Hypertonic saline was given to reduce cerebral edema and also avoid volume depletion from mannitol.    Hypotension could be due to bullet wound to head.  She has seen pt’s bleed severely from GSW’s  to head.  If bleeding is significant, suture/staple wound closed to tamponade bleeding.

Quick check for viability in the pregnant trauma patient:  Check if fundus is above umbilicus.  This grossly corresponds to 24 week gestation.   

The in-house phone number for the OB attending is 41-2005.

 Perimortem C-section: Start the procedure within 3 minutes of maternal arrest.  The procedure may aid maternal resuscitation by removing compression of IVC.   This procedure is best thought of as a resuscitative intervention for the mother and secondarily potentially life-saving for the child as well.    Toerne comment: This is a decision that has to be made rapidly.   If you delay, the window for success closes fast. 

Don’t stop CPR during the procedure.  Energy dosage for defibrillation is the same as in non-pregnant patients. Make a vertical midline incision, expose uterus , and make a vertical incision in the uterus.  Use scissors to extend uterine incision (Don’t cut the baby). Delivery baby and clamp cord.  Get procedure done within 1-2 minutes.   1 study showed no fetal survival if no fetal heart tones identified pre-delivery.   However lack of fetal heart tones should not impact your decision to perform perimortem c-section.  You should still do it for a fetus around 24 weeks as part of the resuscitation of the mom.  

Harwood comment:  Epi is a class C drug due to decreased blood flow to placenta.  You have to balance the risk between the fetus and the mom.  You could consider ED thoracotomy to perform open cardiac massage to improve cardiac output over external CPR.   Omi response:  Give epi in a pregnant patient with asystole or PEA.   The risk/benefit ratio favors giving it.  She voice a little discomfort with doing an open thoracotomy for cardiac massage if there is no specific intra-thoracic  injury to surgically repair.

Per ACOG, <5 rad there is no increase in childhood cancer.    CT abdomen gives 3.5 rad.

Lesser injured moms/fetus with trauma due to mvc or fall are monitored for 6-8 hours for contractions.   Harwood comment: A recent large study showed 4 hours was an adequate time period of fetal monitoring if no contractions or adverse fetal cardiac activity was noted in that time period.

Critical Care Equipment Lab