Missed Foreign Bodies in Wound
Stenoclavicular Dislocation -
Pt seen with normal 12 lead ECG. D/C'd home. Returned within 12 hours with a STEMI.
Core concept - LISTEN TO YOUR PATIENTS - history is everything - no amount of clinical decision rules can trump this.
Case 2 - Ludwig's Angina
- Ludwig’s angina is infection within the sublingual/submandibular potential space, isolated by superficial fascia. Infection demonstrates rapid progression with posterior deflection of the tongue, obstructing the airway.
- Airway management, ENT consultation and IV antibiotics (penicillin + metronidazole, clindamycin or ampicillin/sulbactam) are the necessary steps for management of Ludwig’s angina.
- Mucositis is a common side effect of most chemotherapy and head/neck radiation regimens that is associated with significant morbidity.
- Severe mucositis carries 75% risk of serious co-infection and 9% risk of associated mortality.
Ehler's-Danlos and Aortic DIssection
- Ehler’s-Danlos Syndrome, an inheritable collagen vascular disease, is associated with hyperextensible skin and hyperflexible joints; many subtypes are at risk for arterial aneurysm, dissection or rupture at young ages.
- Management of acute aortic dissection or perforation includes vascular surgery consult (for emergent intervention) and decreased BP/sheer stress with IV nicardipine or esmolol.
Thanks to Dr. Troha's diligent efforts, we will be initiating a new protocol to help streamline the decision making and coordination of care for patients with small PEs, Submassive PEs, and Massive PEs.
Step 1: Risk stratification
- Obtain BNP, troponin, perform echo and assess vitals
Step 2: If massive or submassive, call out Code PE. Pull Code PE pack that contains treatment algorithm and lysis checklist
Step 3: Administer heparin
Step 4: Assess bleeding risk using lysis checklist
Step 5: If decision is made to give IV lysis, stop heparin drip during infusion
Step 6: If decision is made to administer catheter-based lysis, contact interventionalist on call
1. Billing is fairly algorithmic and requires good communication to coders about the work done.
2. Documentation for coding is not always the same as documentation for good care.
3. Avoid all rubber stamp, Copy/Paste maneuvers, and “Dragonisms” if you can. Be thorough and vigilant!
4. Medical Decision Making drives the chart complexity and reflects the care you give.
Case 1: Inferior shoulder dislocation and traumatic pneumothorax
When Evaluating Complex Patients:
- Always regroup and reassess. It is okay to start over from scratch.
- Ensure work up is complete for life threatening pathology before patient leaves the ED
Inferior Shoulder Dislocation:
- High incidence of vascular and nerve injury. You must document a thorough exam!
- Reduction via hyperabduction with traction-counter traction or convert to anterior dislocation and then reduce.
Occult Traumatic Pneumothorax (i.e. visible on Chest CT but not on supine CXR):
- Supine CXR has sensitivity of ~50%
- Supine Ultrasound has sensitivity of ~90%. We should be doing FAST with thoracic windows on all patients, especially those with no plans for CT Chest
- Know/ Reference our trauma guidelines!
- No hard and fast guidelines in regards to management. Needs a chest tube if progresses (visible on CXR or if patient has respiratory distress).
- Most still feel positive pressure ventilation with occult PTX deserves a chest tube... although debated.
Case 2: Black Dot Poison Ivy
- Treat contact dermatitis with high potency topical steroid (ex. Clobetasol) for 2 weeks.
- If treating with PO steroids remember needs tx for 2-3 weeks with taper.
- Don’t forget adjuncts: Zanfel, Ivy Block (Research supports usage of both).
Case 3: Hx of Devic disease with missed posterior circulation stroke
- Know your limitations and don’t develop tunnel vision.
- A thorough CN II exam involves visual acuities, visual fields, light reflex and color testing.
- Optic neuritis typically has pain with eye movement (92%) and impaired color vision (Red first).
Background on Costs of Care in the US
· Health Care expenditure consumes 17.7% of US GDP, almost twice the average of other industrialized nations at 9.3%.
· Heath outcomes indicators are no better in the US than in other industrialized nations.
· Unnecessary medical tests and procedures are estimated to cost $700 billion/year in the US, 5% of GDP.
· Approximately 2/3 of US bankruptcies are due to medical bills.
Defining Value in Health Care
· Value = (Outcomes/Cost)
· Outcomes are dependent on results, not the volume of medical tests and procedures we order/perform.
· Costs are dependent on the volume of medical tests and procedures we order/perform.
· To increase value, we must improve outcomes, while being mindful of the volume of medical tests and procedures we order/perform.
Cost-Effective Care Strategies in the ED
· Utilize validated clinical decision rules (CDR) such as the Canadian Head CT Rule, and basic published guidelines such as the ACEP “Choosing Wisely” List of Top 5 Things Physicians & Patients Should Question.
· CDR and publish guidelines are only effective in reducing costs if available to Physicians at time of order entry. Thus, electronic medical records should integrate decision support tools as part of the flow of order entry.
· Cost transparency & Physician Cost Sensitization have been shown to help reduce costs of care when the Physician knows the cost of the interventions they are ordering.
· Utilize Lean Methodology to improve workflow, eliminate waste, and improve outcomes.
· Diagnostic laboratory testing/ imaging, as well as admissions are important uses of resources; remember this during your daily practice.
· Physician practices are established in Residency and are difficult to modify after completion.
· Learning to be a good steward of health care dollars is an important part of medical education and will continue to have an ever increasing impact on our practice; take costs of care into consideration with every patient encounter.
Case 1 - S/P Arrest w/ STEMI
Case 2 - Ear Pain and Facial Palsy
Case 3 - Ataxia and Headache after Rollercoster Ride
Change in Mental Status and Abnormal Laughter
Abdominal Pain in Pt who has MS and Drinks Everyday
Change in Mental Status
Pupura on Ears of Pt
1. Infectious disease still is a large contributor to morbidity and mortality in developing countries, but cancers and heart disease are on the rise.
2. In a resource challenged environment, efforts should focus on empiric treatment when confirmatory diagnostic testing is unavailable.
3. In addition to malaria, consider dengue fever in your differential for fever in the returned traveler. Management is supportive care.
4. Mortality remains high for pediatric congenital heart disease in a large portion of the world where surgical intervention is unavailable.
5. Always confirm the location of a newly-diagnosed pregnancy and be aware of the complications and risks involved in post-partum ABDOMINAL pregnancy.