Conference Notes Wednesday August 3

8 am: Cardiovascular Study Guide #3; Christine Kulstad: I was keeping Jeopardy score, so unable to provide notes on this outstanding S.G.

9 am: Ethics-Forms/End of Life; Dr. Shayla Garrett-Hauser

Advanced Directives

•Advanced directives are only operative if patient is unable to make and communicate the decision.

 Illinois POLST Form : took the place of the old Illinois Portable DNR form

•Has multiple sections with more options; is still a portable valid physician order It is illegal to generalize DNR designation beyond the coding condition. You cannot withhold other treatments based on DNR status

POA

•POA designates who will decide for the patient if they are unable to decide for

themselves

•This person can make any decision-from band-aids to withdrawing care, palliation

and hospice

•They are the legal equivalent of asking the patient

LET

•An internal form at Advocate hospitals

•It is a physician order consented to by the patient or their surrogate

•Gives additional guidance for very sick patients beyond the DNR

•It can be revoked by the patient, the agent or the surrogate

Withdrawal Withholding Care Form

•Life sustaining medical treatment health care surrogate act physician certification “double doc form”

•Asks 2 physicians to certify that pt has a qualifying condition: Terminal, Permanent unconsciousness, Incurable or irreversible condition

•Patient must lack decisional capacity

•Certifies a surrogate: in descending order of power: Guardian of person=POA, Patient’s spouse, Adult son or daughter, Either parent, Adult brother or sister, Adult grandchild, Close friend, Patient’s guardian of the estate The surrogate, who must sign the form, can withdraw or withhold treatment as specified

End of life facts:

•30% of Medicare dollars are spent in the last 1 year of life

•When they die: 75% of people are nonambulatory, 40% are cognitively impaired, 80% die in an institution, 20-30% die in an ICU

Principle of “Double Effect”:

•A legal/philosophical principle first proposed by Thomas Aquinas

•An action that has 2 effects, one is desired and the other is accepted-eg ok to give morphine to relieve pain at end of life understanding it may also cause respiratory depression.

Hospice

Can occur anywhere-it’s not a specific facility. It’s an insurance designation, and controls insurance dollars. There are specific designated hospice providers (eg Dr. Mien at ACMC)-most docs cannot admit to hospice. Palliative care is NOT an insurance designation, and any physician at ACMC can admit to any bed for palliative care. Palliative care is medical care focused on symptom control, enhanced quality of life, and maximizing functional capacity.

Hospice failing to control symptoms is one of the most likely reasons hospice patients are seen in the ED. Use the “ED comfort care” power plan to help with management.

10 am: Endocarditis; Dr. Logan Traylor

Risks: male, older, IVDU (repetitive bombardment with particulate matter/talc, ischemia from vasospasm), valvular disease (pressure gradients/turbulent flow), prosthetic heart valves, IV devices, Hemodialysis, HIV. Outside of USA, rheumatic heart disease #1 risk.

Epidemiology:

-- Native valves-usually left sided, initially marantic (nonbacterial vegetations) endocarditis. No big deal until transient bacteremia.....Strep viridans (slow) and Staph (fast). Fun facts: Strep bovis is assoc. with colon cancer. Also Enterococcus after manipulation of GU/GI tract. HIV: listeria, salmonella. 5 % will be culture negative (HACEK). IVDU=Staph.

-- Prosthetic valves: Staph epidermidis, Aspergillus, Candida albicans.

Valves: overall most common Mitral, second Aortic, third Tricuspid. IVDU more right sided, rheumatic more left sided.

Janeway Lesions-painless plaques “Jane is nice”, microabscesses

Osler nodes-“O is for ouch”

Clinical features:  Fever, chills, N/V, fatigue, malaise.  80% febrile on presentation (20% not febrile!).  Murmur 85% usually regurgitant.  Acute or progressive CHF in up to 70% of cases.   Have to think about this diagnosis to make it-frequently missed-ask about risk factors, listen for murmurs. 

MCA embolic stroke is the most common neurologic complications.

Can have many other embolic phenomena-retinal artery, mycotic aneurysms, pulmonary osteo.

If you see different infectious presentations/sites and can’t tie them together, think ENDOCARDITIS!

Most important test-blood cultures:  >/= 3 blood cultures, first and last at least one hour apart, 3 different sites.  Allows you to start antibiotics more quickly.  Unless HACEK, this should nail the diagnosis.  Also Echo, ECG, look for PR prolongation/other conduction abnormalities.   Also CXR, +/- CT, procalcitonin. 

Duke’s Criteria:  2 Major, 1 Major and 3 Minor, or 0 Major and 5 Minor...

Treatment:  Strong suspicion/acutely ill:  Vancomycin +/- gentamycin.

If stable may wait until blood cultures return.

Prosthetic valves get rifampin too, increased penetration of biofilm.

Prophylaxis:  previous endocarditis, unrepaired cyanotic congential heart diease, prosthetic valve/tissue in heart.  Do this if invasive dental procedures maybe tattoos.  Use Amox.

10:30 am:  M&M; Dr. Mark Bamman

“7 Deadly Sins”....lessons learned.  AKA the Bamman confessional.

Pride: 

First chest tube-supervision offered, deferred.  Next day with new hemothorax, likely from intercostal vessel damange.  

Afib/RVR-didn’t sync for cardioversion. 

If not comfortable with procedure, get help.

“Humility is not thinking less of yourself, it is thinking of yourself less” C.S. Lewis

Envy:

“Speed envy” when self-comparingto more senior residents.  Risk=cutting corners, incomplete history, will miss things.

Gluttony:

Diet and exercise-prioritize.

Anger:

“Anger is an acid that can do more harm to the vessel in which it is stored than to anything on which it is poured.”  Mark Twain

 “It isn’t the mountain ahead to climb that wears you out, it’s the pebble in your shoe.”  Muhammad Ali

Many daily system challenges in our ED

Anger towards patients.

Must learn to let it go, in order to preserve your humanity and longevity.

Lust:

Lust for “Dr. Done”.  Elderly woman with abdominal pain, CT read said SBO, missed incarcerated inguinal hernia...look at your own CT scans, careful/repeat physical exams.  Consider why diagnoses occur (look for underlying primary problem).

Greed: 

Greedy with Time.  

Consider service for others, beyond what brings you secondary gain.

“We make a living by what we get, but we make a life by what we give.”  Winston Churchhill

Sloth:

PICU extubation:  patient extubated, then received usual push dose sedation which led to oversedation and re-intubation.  Could have been avoided with clinical reassessment before giving meds?

Re-assess your patients, especially prior to interventions, going upstairs, going home, or if nurse says change in condition.

Procastination of reading/studying-you are cheating yourself; of administrative requirements-just makes it harder to complete.

“Diligence is the mother of good luck.”  Benjamin Franklin

11:30 am:  Health Care Disparities-Social Determinants of Health; Dr. Oyinkansola Okubanjo

WHO:  Social Determinants of health:  “conditions in the environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”

EG:  childhood asthma rates in children on the south side, access to public transportation, food deserts

Categories of Social Determinants of Health:

Economic Stability:  employment (access to insurance, PMD).  Employment associated with better health.  Blacks, Hispanics less likely to be in management positions.

Neighborhood, physical environment:  housing-time for EMS, smoke/CO detectors, mold, safety

Education:  language, literacy-tied into health, nutrition, employment

Food/Nutrition:  hunger in Chicago children, access to healthy options.  Food deserts correlate to areas where African Americans live.

Community and Social Context:  Diversity, Race (which is only a social construct) and discrimination, incarceration rates (normalized in certain communities)

Health Care system: insurance, provider availability, provider linguistic and cultural competency, access to health care, health literacy-pay attention to discharge instruction comprehension.

How Determinants Interact:  individual life style factors + social and community networks + socioeconomic, cultural and environmental conditions

Take home points:

-Determinants affect individual and community health directly and indirectly

-Different determinants affect different social groups

-Inequitable distribution contributes to health care disparities

-Increased knowledge of these determinants leads to providing better care for YOUR patients!

Next time:  Patient and Provider factors

12:00 pm:  Pulmonary Hypertension (PH); outside speaker Valerie Laroy, APN

Pulmonary artery hypertension-can be idiopathic or due to multiple underlying disease processes. Seen more in women, starts in small arterioles

Diagnosis with Right heart catheterization.

Pulmonary circulation:  low pressure system, low resistance, high capacitance, dynamic vascular bed. Pulmonary circulation has one fifth the pressures of systemic circulation despite the same CO as systemic circulation.

Usually several year delay from symptoms to diagnosis.  Presents with shortness of breath without hypoxia, tachycardia, fatigue, peripheral edema.  Late symptoms syncope, JVD, CP, hypotension, hepatomegaly, ascites, SOB

Patients asymptomatic until RV is affected.  How RV reacts to preload and afterload predicts outcome.

Treatment:  endothelin receptor antagonist (eg Opsumit), prostacyclin analog (eg Remodulin) and nitric oxide enhancement (PDE5 inhibitor-Viagra, Adempas).  PA pressures diagnose the disease, but goal of treatment is to remodel RV to maintain cardiac output.  Terminal treatment is therefore lung transplant, rather than heart transplant.  If you transplant a heart into patient with PH, heart will rapidly dilate/fail, death.

From Valerie Laroy (NP for PH team).  If a patient presents with PH diagnosis on PH meds, please call PH team on arrival.  They need to be on consult for the admission.   Type in “Pulmonary Hypertension” to perfect serve to identify who is on call.  If our PharmDs see the med list and identify a PH med, they will alert us.  PH meds are life saving-there are oral meds that must be continued in the ED, and pumps must stay on

Why do they present?  Fluid overload-need for diuretic assessment.  Site pain at site of infusion-possible infection.  These patients are usually baseline hypotensive.  If BP support needed, usually the preferred pressor is Neosynephine (avoid tachycardia).  Usually will go to MICU (preferred ICU), possibly 7W.  For admission, there is not a preferred admitting physician.  On the back of the patient’s IV or SQ pump (SQ pump is actually an insulin pump) will be a phone number for their specialty pharmacy-call this number for dose/rate.  NEVER SHUT OFF THE PUMP.  Inhaled meds have unique inhaler-it’s NOT our usually MDI.  Initial skin pain may not be infection-look for infectious sx beyond pain.

Testing:  Order BNP, need stat Echo

If respiratory failure, try CPAP first.  Intubation dangerous-PA pressures very high, anticipate code.   Anticipate need for pressors and inotropes.