POTD: Mindfulness

 ·   · 

Have any of you ever read the EMRA Wellness guide? If your experience was anything like mine, I vaguely remember getting an EMRA box at the start of residency full of goodies and a ton of these little reference books. This is what I saw when I opened the box:

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcT80v8paanyyxRdN9EH9OxL7AMEZYNebVu7TQ&usqp=CAU

I remember thinking how handy these books were, that I was going to read each of them one by one to study from....until I opened the first one on antibiotics, became completely overwhelmed as a novice intern, and put them all away for the day.

One of the books I must have skipped over was the EMRA Wellness guide. I remember encountering a particularly rough month in my intern year, and began mindlessly googling information about emergency medicine wellness, to see how other, smarter people than I have learned to deal with the stressors of my future career. And that's when I found the digital edition of the wellness guide- and saw a very familiar name on the booklet:


( https://www.emra.org/books/emra-wellness-guide/cover/ , also comes as a free app you can download)

Geeking out when I recognized the name, I started reading. It's full of great, evidence-based knowledge and resources designed to understand and combat the stressors unique to EM physicians. One of the things that really stuck out to me was the chapter on mindfulness, and is the one I often recall on a busy shift.

What is mindfulness?

Mindfulness is "the basic human ability to be fully present, aware of where we are and what we're doing, and not overly reactive to or overwhelmed by what's going on around us." It is done by taking in the moment, intentionally, and without judgement. It is a method of quieting the mind by focusing on things one moment at a time, free from "the combinations of judgements, desires, and assumptions whispered by your inner voice." We practice mindfulness when we meditate, do body scans, and enjoy mindful moment practices. It's like hitting the pause button, taking in what you're sensing and feeling in that moment, accepting it, and responding without immediate reaction to a stimuli. 

Why practice mindfulness?

Practicing mindfulness helps in the moment and long term. In the short term, it quiets the mind, allowing you to put some space in between yourself and your actions, and gives us a chance to ground ourselves in the current moment. In the long term, mindfulness becomes less difficult and strange: you naturally may find yourself handling daily stressors better, staying calmer, and being able focus better without the constant brain chatter that exists in the reactive mind. Additionally, practitioners of mindfulness report improved insight into their personality and emotions, have deeper appreciation of the good things over the bad in their lives, and find themselves becoming less overwhelmed. Mindfulness can be practiced anywhere, does not take long, and trains your brain to react to stressors better after sustained practice.

What is the evidence?

The EMRA guide describes a few studies. In the first, volunteers were placed in an MRI scanner while being asked to focus their attention on the sensation of breathing. They were asked to hit a button if they felt their mind wandering, and then refocus their attention on the cycle of their breathing. The four phases identified were described as the cognitive cycle: mind wandering, then becoming aware of distraction, reorienting attention, and resumption of focused attention, where each corresponded to a different part of the brain activated and detected by MRI. Those more experienced at meditating simultaneously showed increased activity in the brain centers corresponding to increased attention and focus, but paradoxically had less activation, suggesting a continued state of meditation allowed subjects the ability to focus more but with less effort.

Additional studies showed that MRI scans taken after an 8 week course of mindfulness practice revealed that the amygdala, responsible for fear an emotion, shrank, as the prefrontal cortex, responsible for awareness, concentration, and decision making, became thicker.

Studies in mice demonstrated that when the pre-Botzinger complex was altered (a group of rhythmically firing neurons that affect the speed at which mice breathe each breath) the experimental group of mice with slower breaths were found to be much more calm than their control counterparts. This suggests that the change in breathing alone can help create a meditative calm.

And it's not just mice! Multiple studies with medical students and residents were performed where after adhering to a mindfulness curriculum reported decreased burnout and and increase to their overall wellness.

What are methods of practicing mindfulness?

Multiple different ways- some better suited to be practiced at home, while taking or walk, or more relevant to us- during a busy shift. Here a few examples recommended by the guide:

https://www.emra.org/globalassets/emra/publications/books/emra-wellness-guide/ch1/ch1_exercises_2.png

As my final POTD, I really hope you got something out of this month's emails! Thanks for all the feedback along the way!

-SD

Sources:

https://www.emra.org/books/emra-wellness-guide/ch1.-mindfulness-and-the-emergency-medicine-mind/

https://www.mindful.org/meditation/mindfulness-getting-started/

https://www.takingcharge.csh.umn.edu/what-mindfulness

https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040904/

https://www.emdocs.net/mindfulness-for-physician-wellness-and-even-your-patients/


 · 
Share

POTD: Leaving AMA

 ·   ·  ,

What is the best way to handle a patient leaving AMA?

Leaving AMA is not a benign action, both to the patient and the provider. Patients who leave AMA have higher rates of adverse outcomes compared to patients who have completed their medical workup and treatment, and are up to 10% more likely to sue their providers. It is estimated that 1 in 300 AMAs result in a lawsuit. Leaving AMA is a problem that continues to increase in frequency as the years go by; in 1992, 0.1% of ED patients left AMA, and now that number is close to 2% of all discharged ED patients.

Who is more at risk for leaving the ED AMA?

According to Kazimi et al, our most vulnerable patients are the ones leaving AMA. This includes patients with lower incomes, are African American, male, young patients, those with multiple significant comorbidities such as psychiatirc, substance abuse, and HIV in particular, those on public insurance, patients with no PMD, patients with poor social support, and unfortunately unsurprisingly, the uninsured patient comprised almost 1/3 of all AMA discharges documented in the study.

Why do patients leave AMA?

Often cited reasons include personal obligations (children at home, feeding cats, need to go to work), financial concerns, dissatisfaction with care and customer service, distrust of the medical system, wait times, and disagreements with staff.

What is the best way to handle someone leaving AMA?

The most important step is to first try to prevent the AMA discharge. Like the illnesses we treat medically as providers, prevention is key. First step is talking to the patient and figuring out what their reasoning for leaving is. Try to meet the patient where they are- their concerns and priorities may not always match ours. Oftentimes the patient (and the provider) do not realize what options are available that may fix their problem. We have an excellent team of social workers, case managers, substance abuse specialists, and patient reps that can help tackle specific reasons why the patient wants to leave AMA. Additionally, patients may not fully understand the extent of their illness. It is our responsibility as providers to present our reasoning for wanting the patient to stay, and try to find middle ground between our and the patient's goals of care.

But unfortunately, many AMA discharges are inevitable. What should we do when there's seemingly nothing else we can do?

ALIEM has a great article written about AMA discharges: there are 8 components of any AMA that in addition to discussing with the patient, must be documented. Here's a quick summary:

  1. Assess the patient's capacity. Assess sobriety, the patient's ability to communicate a choice, understanding, appreciation, and ability to reason.

  2. Signs and Symptoms: Patient and provider need to agree with their concerns: patient should acknowledge, for example, that their RLQ abdominal pain may be signs of appendicitis.

  3. Extent and Limitation of the Exam: Basically detailing that the workup thus far may be incomplete and not representative of the patient's potential illness; labs may be OK, but imaging may still be warranted to rule out appendicitis

  4. Current Treatment Plan: Discussed what the patient still needs in their workup/reasons for observation/admission, what medications they need, etc.

  5. Risks of Foregoing Treatment: patients should be informed of specific complications they may face, including death, infertility, loss of limb, vision, etc.

  6. Alternatives to Suggested Treatment: discuss with the patient alternatives to their current and most effective treatment plan.

  7. Explicit Statement of AMA and Why the Patient Refused

  8. Questions, Follow-up, Medicines, Instructions: Do what we can to limit bad outcomes for our patients. Even if the alternative treatment plan is sub-optimal, we are still doing all we can possibly do for the good of the patient. Help arrange follow up as soon as possible and coordinate with their existing doctors if they don't want to stay. Provide oral antibiotics if they do not want to stay for IV antibiotics.

Here's an example I found of AMA discharge documentation:

The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, though the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909809/

https://www.wikem.org/wiki/Against_medical_advice

https://www.uptodate.com/contents/hospital-discharge-and-readmission#H14129862

https://www.aliem.com/proper-way-to-go-against-medical-advice/

https://www.emra.org/emresident/article/lit-review-ama-discharge/

https://www.nuemblog.com/blog/ama

https://www.emra.org/emresident/article/lit-review-ama-discharge/

 · 
Share

Conference Summary 9-15-21

 ·   · 

Good afternoon all, and happy Wednesday! Today's conference was opened with an insightful and humbling case presented by Dr. Wilder.
 

Pediatric M+M With Dr. Wilder:

18 year old male presenting with “head bump.”

Complains of head bump at top of head, maybe related to trauma, but unsure. Tender to touch, +headaches. No LOC.

Vitals: T: 98.9. BP 129/92, HR 99, RR 20, SpO2: 99% RA

Got into fight with 14 year old brother 3 weeks ago, and hit head on shelf. No LOC, no vomiting.

Asking to go home. Unclear if there was language barrier or developmentally delayed.

 

Decided to have patient worked up as trauma

PECARN: to rule out non clinically significant TBIs, defined as death, NSG intervention, Intubation >24 hours, hospital admission >2 nights.

Using PECARN, for patients older than 2 years old:

  • GCS <15? Signs of basilar skull fracture? AMS? No.

  • Vomiting? LOC? Severe mechanism? Severe headache? Also no.

  • CT is thus not indicated.

What does GCS of 15 look like in a child?

  • Differences compared to adult/older child: Best Verbal Response

  • <2 years old: best is smiles, follows objects, interacts, then cries but consolable, inconsistently inconsolable, grunting and agitated

  • Also with Best motor response: Infants moves spontaneously or purposefully, followed by withdrawal from stimulus

But something didn’t feel right.

  • Speak to mom with interpreter. Find out lump has been growing for 3 weeks

  • Speaking again to patient, headaches sometimes associated with dizziness, persistent, worse at night

  • Patient at baseline

Physical exam: Bump noted on vertex of head. Behavior seemed delayed Neurological exam otherwise benign

Most of the time headaches in the ED are low risk, such as tension HA, migraine, dehydration

Can’t miss headaches: Meningitis, ICH, mass… Red flags: sudden onset, thunderclap, worse with Valsalva, worse in morning or night, age >50, age <5, HIV, significant FH; physical exam significant for focal neuro signs, Diastolic BP >120, Papilledema, AMS

Chances of significant pathology:

HA referred to HA clinic have significant neuroimaging findings: 1.2%

HA x 4 weeks, normal neuro exam: 0.9%

SAH with thunderclap HA: 43%

 

Worrisome Likelihood Ratio:

Waking from sleep from HA: LR ratio 98%

Ha with dizziness or lack of coordination: LR 49%, ….though CI 95% is 3-710.

Undefined HA: LR 3.8

 

CT performed.

Radiology replies with read: Mixed intracranial/extracranial mass, epidural extension above and compressing superior saggital sinus at vertex. Component of superimposed blood products difficult to exclude. No acute bleed. Suggestive of lymphoma/cancer

NSG consulted, labs ordered, explained preliminary findings to family

Recommended obtain MRI and follow up within 1 week…

 

 

Initial Labs: WBC of 129,000.

Hb 10.1. Plts 233

 

Oncologic Emergencies:

  • Hyperviscocity sx: elevated WBC >100,000, hyperproteinemia, polycythemia. Waldenstrom macroglobinemia, MM, and leukemia

    • Classic triad: mucosal bleeding, visual disturbnance, neuro sx, end organ failure

    • Tx: Lots of IVF, plasmapheresis, phlebotomy 2-3 units

  • Tumor lysis sx: high turnover of malignant cells

    • Severe metabolic derangement: metabolic acidosis, aki, hypocalcemia, hyperkalemia, hyperphosphatemia, hyperuricemia

    • Present after recent chemo treatment, radiation, or high dose steroids.

    • Have edema, hematruia, fatigue, weakness, or ams

    • Tx: Ca Glu if needed if hypocalcemia, allopurinol/rasburicase for hyperuricemia, IVF and acetazolamide for hyperphosphatemia, aggressive hydration

  • Hypercalcemia of malignancy

  • Febrile neutropenia

  • Mass effect

Hospital Course

  • Flow cytometry confirms B cell ALL, spiked fever 101.4, started on cefepime

  • Started on Intrathecal cytyrabine, LP, PICC line placed, induction chemo started

  • Transferred to floor

  • Complained of arm pain: US showed DVT, PICC removed, started on lovenox

  • Tachycardic: shown to have BL PE

Post admission:

  • Multiple LPs and Chemo treatments

Social Concerns surrounding new diagnoses

  • Potentially life changing, far reaching consequences

Bias in beginning of case

Lessons:

  • Broad and flexible differential diagnosis

  • Head trauma vs headaches

  • Who gets worked up?

  • Pretest probability and LR

  • Incorporating specialists

  • Remaining Systematic

  • Overcoming bias and the socioeconomic implications of a diagnosis

  • Undifferentiated vs differentiated sick kid

 

Pediatric Soft Tissue and Skin Infections with Dr. Gonzalez:

History: Very important in these diagnoses

  • Immune status, pmh, MRSA risk factors

  • Surgery/trauma

  • Medications and allergies

  • Travel history/geographic locale

  • Animal exposure

  • Lifestyle/ hobbies

PE:

  • Site of infection

  • Purulent/nonpurulent

  • Color/size/texture/shape/scale

  • Systemic Symptoms

 

Impetigo: Classic honey crusted, facial region, can look varied in different people

Bullous: can have bullous lesions, fluid underneath, can inoculate different areas

Ecthyma: impetigo, but on deeper level in tissue. Classic cigarette burn appearance. One of child abuse mimics

  • Consider culture. Mupirocin or retapamulin for mild impetigo

  • Dicloxacillin or cephalexin for mssa

  • PCN for strep

  • Doxy, clinca, Bactrim for mrsa

  • Oral abx recommended during outbreaks psgn, helps prevent spread in the community

Purulent STI:

  • Purulence, fluctuance.

  • Abscesses, furuncles, carbuncles, infected cysts

  • Cause by staph, less likely strep

  • Consider culture

  • I+D

  • Add oral abx to cover staph with systemic symptoms

  • Consider MRSA coverage especially if worsening on initial oral abx, immunocompromised or shock

  • Consider decolonization regimen if recurrent

Cellulitis/Erysipelas

  • Most often caused by staph or strep

  • Consider other agents in immunocompromise, post surgical, trauma

  • Erysipelas aka st anthonys fire, is SUPERFICIAL and is usually GAS as cause

  • Cultures only recommended in immunocompromised, immersion injury, animal bites

  • Mild- cover strep- pcn, Keflex

  • Moderate ie with systemic symptoms: add MSSA coverage

  • Severe or with risk for MRSA: add something like Vanc

  • Very severe: broad spectrum such as vanc and meropenem or zosyn

  • Adjunctive tx:

    • Elevate

    • Treat underlying skin issues like eczema

    • Consider prednisone

    • Consider prophylactic antibiotics with recurrent cellulitis

Necrotizing Fasciitis

  • Aggressive skin and soft infection

  • Often starts below level of skin. Classic signs of warmth, redness, etc, not often seen

  • Pain out of proportion

  • Systemically ill patients

  • NEED surgical consultation for debridement, borad spectrum abx

  • Add clinda if GAS

  • Aggressive supportive care

Pyomyositis, also a deep infection:

  • Cultures

  • Imaging with MRI

  • Vancomycin, +/- gram negative coverage in immunosuppressed or open wound

  • Cefazolin, nafcillin, or oxacillin for mssa

  • Surgical consultation

Animal Bites:

  • Consider prophylaxis in immunocompromised, hand face, wounds, severe wounds

  • Infected wounds need coverage of aerobic and aerobic eg augmentin

  • Tetanus

  • Rabies prophylaxis as needed

  • Avoid suturing

  • Know your local antibiogram!

 

Pox Virus/Molluscum

Ringworm

  • Can get one or multiple lesions

  • Well appearing child

  • For capitus: need oral treatment

Tinea Versicolor

  • Hyper or hypopigmentation

Warts

  • Parents confuse with FB

  • Black dots, can be painful

  • Verrucal or flat in appearance

  • Duct tape, salicylic acid, derm

HSV

Gingivostomatitis

  • Fever, irritable, dehydration because of pain of PO

Herpes eye infection

  • Need oral treatment, ophthalmology

Whitlow

  • Can spread to other parts of body

Eczema Herpeticum

Herpes Simplex infection in babies

Scabies

  • Itchy, do others in the house have it, when is it most itchy (usually when they go to bed)

  • Low threshold to treat- permethrin cream, household cleaning/instructions

  • Classically involves web spaces fingers

  • Likely will need to treat everyone in home

Head Lice

  • Otc meds, household cleaning/instructions

  • Likely will need to treat everyone in home

 

Approach and management of the agitated patient with Dr. Strayer:

What patient defines EM?

  • Undifferentiated agitation, classically brought in by EMS or police

  • An immediate threat to themselves and others

  • Requires use of dangerous maneuvers including chemical and physical restraints

  • Could be drunk or dying

  • Simultaneous control, resuscitation, and risk stratification

Mild agitation:

  • Anxious but normal speech, persistently redirectable, responsive to engagement

  • Verbal de-escalation

  • Nonpharm interventions: food and water, symptoms control

Moderate

  • Most common

  • often disruptive, often requiring calming meds

  • distinguished by being intermittently assessable. Can usually get a bit of history. Can usually figure out dangerous or non dangerous cause

  • Usually related to alcohol

  • Prioritize safety over speed and efficacy

  • Often observed in unmonitored bed. Can be dangerous if received meds for calming, and then placed in unmonitored bed.

Classic: Haldol 5, Lorazepam 2

  • If fine, but slow and unreliable

  • Often needs redosing

Best option for treatment is to assess patient, obtain history, and treat underlying problem

  • Psychosis

  • Ethanol intox

  • Withdrawal

  • Cns stimulant intox

  • Delirium

Droperidol

  • Most effective

  • Safest

  • QT concerns but mostly nonsense

  • Dosing is 5-10mg IM (or IV)

    • Absorbed well in the IM route compared to Haldol, fast, more potent

Midazolam

  • Reliably and quickly absorbed intramuscularly

  • Good for alcohol withdrawal, seizures

  • Think of the M as standing for IM

  • Lorazepam is slow

  • For monotherapy for disruptive without danger

    • 5-10mg

    • Monitor for hypoventilation. Has real potential to cause harm

    • Put patient on a monitor if receiving 3mg or more IM midazolam in span of 1 hour

    • Any patient receiving 10mg or more of IM midazolam should be monitored in resus

  • Faster than Haldol, but narrow therapeutic window

Severe Agitation

  • Immediate threat to self or others; combative, violent, uncontrollable, especially if concern for concomitant dangerous medical condition like trauma

  • Code white

  • Uncommon

  • Excited delirium: Delirium and danger to themselves and those around them

  • Disruptive vs delirious:

    • Screaming and thrashing, disregard for futility, pain, fatigue

    • Cannot engage

    • Incoherent

    • Fluctuating sensorium

    • Abnormal vitals- don’t fight for vitals

    • Err on treating the patient first

  • Need adequate force to safely approach patient.

  • Put face mask O2 on the patient for O2 delivery AND because it controls spit.

  • Relieve dangerous restraint holds. Err on using chemical restraints and NOT physical restraints. Focus on sedation.

  • Chemical restrains given IM, not IV. Prioritize safety. IM can be given through clothing

    • Speed and efficacy trump concern for over sedation

  • Treatment for uncontrollably violent, severe agitation patient, can use dissociative dose ketamine

    • Requires PSA monitoring

  • Used especially if worried about dangerous underlying condition that needs to be treated

  • Litmus test for ketamine: if this patient ended up intubated, does that seem like appropriate care?

  • Treat underlying condition

  • Keep broad differential when working up causes of agitation

 

 

Mood and Thought, Neurotic and Factitious Disorders with Dr. Kurbedin

28 year old male, unknown pmh, brought in by neighbor for AMS. “not acting right” over last week

Vitals WNL, NAD, going through stack of papers, laughing to self

Primary survey fine

Obtained more history: usually highly functional. Recent patients apartment with nothing in fridge, messy apartment. Patient states he feels fine. “I’ve been hand selected by the CIA to find a terrorist.” Hears the voice of God, has some headache, lost weight. Cannot perform ADLs. Should obtain social history when able. Denies drug use. No pmh or meds.

Does he have capacity? Not being able to take care of oneself

SI? HI? AVI?

Try to rule out other diagnoses when examining psychosis.

Try talking to family to obtain collateral information. Also check other hospital records. Family history.

Any increased risks of suicide, such as gun at home?

This guy is not a safe discharge. Will need psychiatric services.

 

Physical exam positive for psychomotor agitation, difficulty sitting still, pressured speech, denies SI, reports plan to capture and use appropriate force to subdue the terrorist, is asked, normal memory and attention. Otherwise PE benign.

 

Acute Psychosis:

  • Characterized by derangement of personality and loss of contact with reality causing a grossly disorganized mental capacity

  • Need to rule out can’t miss diagnoses. Need to keep a broad differential.

  • Get labs: bgm, cbc, bmp, vbg, alcohol levels, tsh, psych drug levels, lfts, salicylate levels, acetaminophen, urinalysis, utox, ct head

 

Avoid these meds in elderly:

BATMAN

Benzos, anticholinergics, tricyclic antidepressants, muscle relaxants, antiepileptics, and nitrofurantoin

 

Depression in the ED

  • Screening tool PHQ-2 may be useful

    • During the past month, have you been bothered by feeling down, depressed, or hopeless?

    • During the past month, have you been bothered by little interest or pleasure in doing things?

  • SIGECAPS

    • Needs to have 5 more more symptoms x 2 weeks. One sx has to be depressed mood or anhedonia. Sx cannot be related to drug use

  • Most important part of eval is assessment of suicide risk.

    • ASK ABOUT FIREARMS

  • Get psych consult for SI, plan, past SI attempt, substance use disorder, irritability/agitation/aggression, significant PMH

  • Antidepressants can take weeks to months to take effect, so not started in ED typically

  • Needs psych consult and needs follow up

 

55 year old male, h/o htn and dm, CC chest discomfort and SOB, starting 1 hour ago. +palpitations and weakness. Tachycardic. Patient states he has symptoms before and was diagnosed with anxiety.

Vitals tachy 122.

What to do for this guy? Work him up. NEED to rule out other dangerous causes of symptoms like ACS and PE.

Anxiety in the ED

  • Anxiety remains most common mental health diagnosis

  • Nonspecific symptoms common

  • Treatment:

    • Psychotherapy is effective as medication for GAD and PD with CBT having best evidence

    • Benzos in ED for symptomatic treatment, but does not improve long term outcomes

    • Give PO

 

Medical causes: 1st presentation of sx occurs >40, possible fluctuations of consciousness, and autonomic instability

Anxiety: 1st presentation of sx occurs between 18-40, FH of anxiety, patient is concerned about losing control and occurrence of recent/anticipated life event

 

 

Substance Use Disorders with Dr. Turchiano

Case 1: drunk patient received in sign out, is still metabolizing, but isn’t ready to go yet.

When trying to wake him up, he’s confused.

HR: 101. Normal O2 sat. Afebrile.

FSG 97. Draw labs. Hang fluids. Hang banana bag.

Full reassessment: Has bruise on forehead. Prior head CTs show volume loss.

Should still scan the patient’s head. à normal, unchanged from previous

Alcohol level is now 0.

Wernickes: thiamine deficiency causes diffuse brain injury

Thiamine is vitamin B1. Alcohol prevent GI absorption and is nutrient poor.

Three things that define wernickes: oculomotor findings, ataxia, confusion

Treatment: Thiamine 500mg IV TID, needs admission, needs magnesium

 

 

Case 2:

43 year old male coming to north wall- EMS states he knocked over all chips in bodega and doesn’t want to leave. Tachy to 130, hypertensive. Diaphoretic, trying to get out bed.

Needs sedation: give IM benzos. Give another 5mg IM, but keep on monitor.

Patient seems calmer. Repeat vitals with tachy again.

FSG: 112, EKG sinus tach, blood work. Lactate for 6, otherwise normal.

Delirious, tremulous.

Concern for alcohol withdrawal

Valium. Likely will need high doses. Possibly phenobarb. Redose as intervals to achieve desired effect.

May need propofol and intubation

There is likely to be an underlying medical condition alongside/that may have precipitated withdrawal. Keep a broad differential and perform a thorough workup.

 

CQR With Dr. Dhanraj

  • Confirm patient’s info in chart whenever possible, especially when patient wants to AMA/needs follow up

  • Do not take AMAs personal, the best treatment may be “suboptimal” if that is the most the patient is willing to do; such as in the AMA’ing patient requiring admission and IV abx, but at least agreeing to an Rx for oral ABX.

  • Document these interactions in depth and as much as possible

  • Have low threshold to work up cardiac syncope in patients with significant cardiac history.

  • Bedside sonography is a cheap and easy bedside test. Should have low threshold to use.

  • Be careful giving benign diagnoses to patients in the ED, such as gastritis or costochondritis. Every patient should be given thorough return precautions and what to expect and look out for.

 

 

Live on NY with Dr. Levin

  • Consult LiveOnNY within one hour of

    • Every death

    • Mechanically vented patients meeting any of these conditions:

      • Absence of two or more brain stem reflexes

      • GCS </=5

      • Family discussion of withdrawal ofd life sustaining therapies is anticipated

    • Call 1800 GIFT 4 NY

    • 1800 442 8469

  • DO NOT initiate conversation with family about possible organ donation. This can be a conflict of interest. Direct them to LiveOnNY and introduce them as the team best equipped to discuss such matters.

  • Need neurological testing and apnea test. These are the bare minimum tests.

    • If unable to do either, may be able to perform ancillary tests

  • Have LiveOnNY involved as early as possible

Thank you all!

Enjoy the rest of your Wednesday!

-SD

 

 · 
Share