Looking at wellness: "Happiness and Resilience in the Life of an Emergency Physician"

Today’s POTD will be focused on wellness.

I will attempt to briefly summarize an amazing piece on “Happiness and Resilience in the Life of an Emergency Physician” from ACEP Wellness Guidebook. But more importantly the piece is written by our amazing and hardworking wellness advocate Dr. Arlene Chung in collaboration with Dr. Rosanna Sikora and Dr. Laura McPeake.

The first paragraph is talking about defining happiness and resilience. My favorite quote is “Engagement and meaning appear to be the strongest contributors to living a happy life” and that “You can strengthen happiness and resilience by practicing”. But at the end of the day it is very individualized and we, ourselves “ must choose what is most meaningful in our lives along the way to be happy”. 

The part that I would like to draw your attention to are the suggested specific strategies by the authors that can help to build resilience in the practice of emergency medicine:

Writing a journal or recording oral narratives. 

Transforming your traumatic experiences into a written or recorded piece will not only help you to cope with difficult emotions but also put the situation in perspective and even learn from it. 

Meditation or mindfulness exercises. 

Mindfulness can be as simple as taking in a deep breath and exhaling very slowly, resulting in a parasympathetic charge of feeling peaceful and settled.

Peer mentoring.

Discussing stressful events with a supportive and empathic colleague is some of the best medicine that we have, and if our emergency medicine atypical humor is involved, all the better. Humor is a great coping strategy. 

Niche development. 

“Research has demonstrated that physicians who have developed a niche within emergency medicine have lower rates of burnout, better career longevity, and more career satisfaction.” This one is specifically very important for the senior class. Thinking about what can improve your clinical practice after graduation (and I am not only talking about fellowship) but rather looking into different areas of interest that can potentially become your niche.

Education. 

I’ve heard teaching is rewarding and improves doctors satisfaction :)

Personal coaching. 

Develop a mission statement and a career plan and the examples that authors suggest: personal organization, time management courses, and learning to say “no” to obligations outside your mission statement.

Focus on empathy. 

Consider books, workshops, and podcasts. Connect with your family, friends, and co-workers outside of the fluorescent lights of the emergency department. 

Take care of your own needs. 

We need to take care of ourselves before we can care for others. Remember to MOVE your body: “A jog a day keeps depression away.” Make time for what you enjoy. Place it on your calendar and treat it like a shift.

Limit stressful downtime.

Balance your high-stress activities with low-stress activities. 

Please read the full article at ACEP emergency physician-focused wellness guide 

https://www.acep.org/globalassets/sites/acep/media/wellness/acepwellnessguide.pdf

Variceal Bleeding

Active Gastroesophageal Varices bleeding

Background: 

Gastroesophageal varices bleeding is associated with a mortality rate approaching 20-30%.  

Bleeding from varices stops spontaneously only in 50% of patients

Evaluation: 

History: 

Prior complications, medications, fever, abdominal/chest pain, vomiting, melena, syncope/pre-syncope, hematemesis, cause of cirrhosis, prior interventions on varices, weights.

Exam: 

Evaluate hemodynamic status immediately (consider use of beta blockers). 

Look for signs of chronic liver disease – spider angiomata, palmar erythema, jaundice, ascites (shifting dullness, fluid wave, etc.), coagulopathy (petechiae, purpura), ENT exam (pharynx), CV, pulmonary, extremities, mental status.

Labs: 

ECG, CBC, coags, renal function, VBG/lactate, Ammonia level, electrolytes, LFTs, type and cross, fibrinogen, CXR and EKG 

Management: 

First obtain bilateral IV access (large bore advised), monitors, supplemental oxygen. Wear personal protective equipment. 

Airway: 

This is one of the most difficult airways to management due to shock state, difficulty with visualization, rapid desaturation with sedative/paralytic, and extensive blood loss.

Use NG tube to decompress stomach (remove the ticking time bomb). 

May use metoclopramide 10 mg or erythromycin 250 mg IV to assist in moving blood through GI tract

Place in Trendelenberg if vomiting (keep blood out of lungs).

Bleeding and Circulation:

Hemostatic Resuscitation: Do not rely on PT/PTT/INR to assess coagulation status. Consider use of TEG instead. May need to start MTP

Consider pRBCs if Hb <7 g/dL (goal of Hb between ≥7 g/dL (70 g/L) and <9 g/dL). If pt received >6 units of pRBCs in <3 hours check serum ionized calcium concentration (due to citrate binding of ionized calcium) 

Platelets – if initial platelet count is < 50,000/microL 

Prohemostatic products – consider fresh frozen plasma, PCC on case by case basis, cryoprecipitate targeting fibrinogen 150-200 mg/dL. Consider to use TXA 1g IV. 

Target resuscitation end points of mentation, capillary refill, MAP, urine output. 

Source Control: Emergency GI and IR consults. 

May use erythromycin or metoclopramide to improve view for EGD. 

Use octreotide 50 mcg IV bolus, 50 mcg/hr IV infusion (or vasopressin with nitroglycerin), which is associated with decreased products transfused. 

Be ready with other devices: Sengstaken-Blakemore, Minnesota, Linton-Nachlas tubes.

https://www.youtube.com/watch?v=Yv4muh0hX7Y

Prevent and Treat Complications: 

Infection associated with 25-65% of upper GI bleeds from varices (UTI, SBP, pneumonia):

Ceftriaxone 1 g IV or cefotaxime 2 g IV associated with NNT of 22 to prevent death and NNT of 4 to prevent infection. 

Albumin also useful in patients meeting certain criteria (Cr 1.5, BUN > 30, bilirubin > 4)

Consider NG tube placement for stomach decompression (Whether placement of a nasogastric tube can help prevent aspiration has not been well studied)

Beware of renal failure and encephalopathy, which are further complications.

References: EMCrit, EMDoc, UpToDate

ECG: What about U waves?

What is the U wave? 

Small 0.5mm deflection following T wave: and best seen in V2 and V3 

Usually in the same direction as T wave 

Usually better visible at slow heart rates < 65 bpm

Grows bigger as HR decreases

Usually < ¼ of the T wave voltage, if much bigger (or >2mm)- its abnormal

Where is it coming from?

May be Purkinje fibers repolarization

May be some kind of after-potential

No one really knows

Abnormal U waves:

Prominent U wave - >1-2mm or 25% of the height of the T wave

Common causes: 

Bradycardia

Severe hypokalemia.

Hypocalcaemia

Hypomagnesaemia

Hypothermia

Raised intracranial pressure

Left ventricular hypertrophy

Hypertrophic cardiomyopathy

Drugs associated with prominent U waves:

Digoxin

Phenothiazines (thioridazine)

Class Ia antiarrhythmics (quinidine, procainamide)

Class III antiarrhythmics (sotalol, amiodarone)

Hypokalemia

U waves associated with left ventricular hypertrophy

U waves associated with digoxin use

 Inverted U waves:

A negative U wave is highly specific for the presence of heart disease

Common causes of inverted U waves

Early MI

Coronary artery disease

Hypertension

Valvular heart disease

Congenital heart disease

Cardiomyopathy

Hyperthyroidism

Inverted U waves in a patient with NSTEMI 

References: UpToDate. LITFL, ecg.utah.edu, ecg weekly