Conference Notes 2-11-2015

Paik/McDermott     Oral Boards


Case 1.   30 yo male patient presents with flu symptoms/cough for a few days.  He has a fever in the ED.   CXR  was normal.   Social history reveals that the patient is a laborer at a farm and was working moving hay.  CT chest shows no PE but patient has diffuse bilateral ground glass opacities.   Diagnosis is hypersensitivity pneumonitis (Farmer’s Lung).   Hypersensitivity pneumonitis is due to lung inflammation from inhaled antigens.  Common organisms are actinomyces and aspergillus.  Treatment is systemic steroids and avoidance of inciting antigens.   Long term, this  can lead to pulmonary fibrosis.


Case 2. 45yo male with headache and encephalopathy.   HR=115.  Pulse ox=94%  other vitals are OK.    Dexi=100.   Patient’s wife states the patient had been refinishing a bathtub in the bathroom just prior to the patient developing his current symptoms.  It was identified that the patient was using a varnish remover containing methylene chloride.   Patient has burns on his hands from the varnish remover. Methylene chloride gets metabolized to Carbon Monoxide.   It can lead to  delayed and prolonged CO level increases.   Methylene chloride and CO are both  neurotoxic and can cause encephalopathy.  Critical actions:  Patient was decontaminated with water shower.  CT scan of head was obtained but showed no acute abnormality.   CO level was 18%.  100% oxygen is all that is usually needed to treat the increased CO from methylene chloride.  There is no specific antidote.  Hyperbaric O2 can be used if the patient seizes or is in a coma.  Admit any patient with CNS or respiratory  symptoms.  There have been a few deaths recently in people refinishing bath tubs.


Case 3.  42yo male with bilat eye pain.  HR=110.  Vitals are otherwise normal.  Patient woke from sleep with bilateral eye pain.  Social history reveals that patient is a welder and did not wear eye protection at work the day prior.  Diagnosis is UV keratitis.   VA=20:40 in both eyes.   Treatment is supportive with pain control.  Pain  from UV keratitis can be severe.  The damaged cornea regenerates in 3 days.  Erythromycin ointment is suggested to act as a lubricant and antibiotic prophylaxis.  Evaluate the patient for FB, consider CT of orbits if they were working with metal.


*Welder’s (UV) Keratitis


There was a discussion on the use of topical anesthetics for UV keratitis.  Harwood felt that it was reasonable to give the patient a bottle of topical anesthetic for home pain relief.  He felt that the injury was self-limited and there was very little risk of prolonged inappropriate use of the topical anesthetic that could result in eye injury.   Elise and Christine said that if there was the ability to give a patient a very limited amount of diluted topical anesthetic for home use they would give that.   Other faculty members had some reservations about giving topical anesthetics.


Sandeep Jauhar          Guest Lecturer at IM Grand Rounds


Dr. Jauhar started out by discussing how he became disillusioned about the practice of medicine:

Physicians are not getting emotional sustenance from their practice.  

Physician debt drives many physicians to moonlight/work orethan they want to.  

The speaker discussed how in certain settings, referral patterns and diagnostic testing don’t help patients but instead generates income for physicians.

There is a crisis of confidence in the medical profession.   Medicine has become just another profession.   Doctors are insecure and not enthusiastic about their profession.    Many doctors would not encourage a young person to become a physician. 

It is alarming that physicians have such a negative self-perception and that society has such diminished regard for physicians.


There are 3 types of workers:

Knights:  Workers who strive to make life better for others.

Knaves: Workers whose only goal is to maximize profit

Pawns:  Passive workers who follow the rules of their work place and are not that autonomous

Doctors can fit into these three categories as well.

In the 1970’s doctors had transformed in society’s eyes from knights to more like knaves.  

Since the 1980’s,  physician income has diminished despite doctors seeing many more patients and carrying increasing debt from medical school.  Add to that issues of litigation and loss of autonomy, doctors are generally unhappy.   This unfortunately is leading to a shortage of doctors and poorer patient satisfaction/happiness.

Very few patients now have any long term, personal relationship with their doctor. 

Other professions such as lawyers and teachers are also unhappy.   Physicians however were always the noble exception to the waning idea of independent professionalism.   The time frame for this exception for medicine has ended. 

Dr. Jauhar than discussed how he won back his love of practicing medicine:

Go back to how you thought about medicine in medical school and residency.

Stay true to your beliefs.

Treasure the human experiences you have as a physician.

He found that he could experience much joy in the practice of medicine again.


Girzadas           In-Training Exam Zebras


I will send out a PDF of the lecture to all the residents.  


Jeziorkowski       Safety Lecture: Central Line Complications


Cardiac Complications

ž Ventricular dysrhythmias and bundle branch block

  • •       Cause by direct stimulation of endocardium
  • •       Prevented by limiting depth of guide wire and catheter insertion to less that 16 cm


Vascular Complications

ž Arterial puncture issually recognized by pulsatile blood flow and red appearance of blood

  • •       Can use US to confirm venous placement
  • •       Can get ABG and blood gas from your sample to compare
  • •       Can transduce the pressure and observe wave form


ž If a catheter/cordis is placed in the carotid, it should be left in place and vascular surgery consulted.  If you pull the catheter/cordis out immediately after placement there is a 6% chance of stroke.

žIf a catheter/cordis is placed in the femoral artery, you can pull that line.  Injury to the femoral artery can be contained with direct pressure for 15 minutes


Pulmonary Complications

ž Air bubbles noted as you are aspirating the syringe may mean you violated the pleural space

ž Always get confirmatory chest x ray for subclavian and IJ lines. Subclavian lines have the highest risk of complications.


Guide wire Complications

ž IR can remove a  lost guide wire

ž Guide wire complications are usually due to distractions occurring during the procedure.


We then discussed potential safety improvements when placing central lines in our ED.  A few that seemed fruitful were: Residents turning off their phones or handing over their phones to an attending during central line placement.   Putting up a stop sign on the room door so that no one interrupts the procedure. Having a procedure cart that can be brought into the room that has all the necessary materials and a stop sign that  could be placed in the doorway to limit interruptions.