POTD: Mentorship

Some History:

The term mentorship is derived from Homer’s epic, The odyssey. Mentor was the name of a character that guided Telemachus on his journey to find his father Odysseus. Today a mentor means a wise and trusted counselor or teacher. Whether directly or indirectly, mentorship is pervasive in our culture and crucial to the advancement of society.

Mentorship is a key factor in promoting and maintaining fulfillment in medical practice. The mentor-mentee relationship benefits both parties in different ways. Mentors benefit from the altruistic success of helping others achieve their goals. Mentees benefit in the sense that they establish a person they can rely on for advice, suggestions, and coaching. Senior colleagues who share similar interests in clinical practice, research, administrative or community service serve as the best mentors. Mentors are role models who also act as guides for students and residents in both their personal and professional development.

 When should physicians start seeking out a mentor and how?

·       Mentors should be established early on in residency and even throughout medical school training when students find their niche and interests.

·       The best way to start a mentee-mentorship relationship is reach out to someone with a specific request that shares similar interests. These will naturally then develop into a mentorship.

·       Many national organizations (eg. EMRA) also offer mentorship and pair mentees with mentors of similar interests.

·       Establishing a mentor does not need to be a formal process many times this occurs informally

·       The best way to find a mentor is to find people you admire in your field or someone in a position that you might envision yourself in one day

 What qualities or traits should mentees look for in a mentor?

·  Find a mentor who you feel you can connect with and will inspire you and support you throughout your journey

·  A mentor should be someone that can celebrate you as an individual during the best of times and someone that can also help you overcome roadblocks

·  The key to mentorship is feeling comfortable with your mentor

 Can you only have one mentor or is it ok to have multiple mentors?

· It is good to have a few mentors as each mentor will likely have their own expertise. For example someone that is a great clinical mentor may be different then someone you may want to approach to help mentor you in research vs someone who can help guide your career path

 What is the Mentees role?

·      Mentees should take initiative in driving their relationships with mentors.

·      Be proactive around scheduling meetings and identifying topics of discussion with your mentor

·      The ability to critique oneself and make changes on the basis of advice and probing from a mentor is important to a mentee’s development

 Want to get involved in Mentorship here are a few places you can sign up to be a mentor for medical students:

·      https://medicalmentor.org/join-us/

·      https://www.emra.org/students/advising-resources/student-resident-mentorship-program/

“ A good mentor is a tremendous asset in this complex profession, so search for one. Once you have found one, cherish his or her time and wisdom. Mentors, in addition to teaching through words and deeds, show us care and respect and empower us to confidently approach the myriad complications inherent to the human condition.” Dr. Ahmed Mian

Go out there and find your mentors!

Sources:

·      https://www.nejmcareercenter.org/article/physician-mentorship-why-it-s-important-and-how-to-find-and-sustain-relationships-/

·      https://pubmed.ncbi.nlm.nih.gov/29691796/

·      https://www.jacr.org/article/S1546-1440(10)00385-6/pdf

·      https://www.prospectivedoctor.com/the-importance-of-mentorship/

·      https://www.prospectivedoctor.com/the-importance-of-mentorship/

POTD: Blunt Cerebrovascular Injury

Todays POTD will be a trauma topic we frequently talked about at Shock Trauma but less frequently at Maimo.

 Blunt Cerebrovascular injury (BCVI): refers to a spectrum of injuries to the cervical carotid and vertebral arteries secondary to blunt trauma.

 Why is this Important?

If left untreated, patients with BCVI are at increased risk for stroke. Mortality may reach as high as 43%. Rare diagnosis which makes it even more important to consider evaluating for in all of your trauma patients that meet criteria and have the associated risk factors .

 Pathology:

The injury is caused by longitudinal stretching and injury to the vessels. Acceleration and deceleration can cause rotation and hyperextension of the neck, stressing the craniocervical vessels. This will lead to disruption of the intima. The intima tear then becomes a source of platelet aggregation that has a potential to cause downstream effects such as an embolic stroke or vessel occlusion

 Risk Factors:

·      High energy transfer mechanisms

·      LeFort II or III fractures

·      Mandibular fractures

·      Complex skull fracture/basilar skull fracture/occipital condyle fracture (most common risk facture)

·      Closed head injury with GCS < 6

·      Cervical spine fracture, subluxation, or ligamentous injury at any level

·      Near hanging with anoxic brain injury

·      Clothesline type injury or seat belt abrasion with significant swelling, pain, or AMS

·      Traumatic brain injury with thoracic injuries

·      Scalp degloving

·      Blunt cardiac rupture

·      Upper rib fractures

 Signs/Symptoms:

·      Arterial hemorrhage from neck/nose/mouth

·      Cervical bruit in patient < 50 years old

·      Expanding cervical hematoma

·      Focal neurologic defect

·      Neurologic defect inconsistent with CT head findings

·      Stroke on CT or MRI

 Diagnostics:

• ·      Standard of care CTA (80% sensitive and 97% specific)

• Should be considered when patient has one or more of the risk factors or signs and symptoms

• ·      Can also do MRI or arteriography but this is time consuming and labor intensive

 Grading Scale:

1.     Grade 1: Intimal irregularity or dissection < 25 % of luminal narrowing noted

2.     Grade 2: Dissection or intraluminal hematoma with > 25% luminal narrowing, intraluminal clot or visible intimal flap

3.     Grade 3: Pseudoaneurysm

4.     Grade 4: Complete occlusion

5.     Grade 5: Transection with active extravasation

 Management:

·       Antithrombotics (heparin) or Antiplatelets (aspirin, Plavix) 

·       Operative repair

·       Endovascular stenting

·       Grade 1 and 2 injuries: single antiplatlet agent (aspirin 81 or 325mg)

·       Grade 3: dual antiplatelets or therapeutic anticoagulation (heparin drip with PTT at goal)

·       Grade 4 and above: Dual antiplatelets or therapeutic anticoagulation as well as operative or endovascular intervention

·       Many low grade injuries heal within 7-10 days therefore early repeat CTA is recommended. Otherwise treatment may need to be continued for 3-6 months.

 References:

·      https://www.emra.org/emresident/article/blunt-cerebrovascular-injury/

·      https://rebelem.com/blunt-cerebrovascular-injury-bcvi-universal-imaging-for-all/

·      https://jss.amegroups.com/article/view/3790/html

·      https://radiopaedia.org/articles/blunt-cerebrovascular-injury?lang=us

·      https://www.east.org/education-career-development/practice-management-guidelines/details/blunt-cerebrovascular-injury

·      https://www.aliem.com/guideline-review-east-blunt-cerebrovascular-injury/

POTD: Tinea Pedis (Athlete's Foot)

This PODT is inspired by a recent case I had in while working in Peds and is something we may encounter often in the summer. This is a perfect example of a fast track compliant that we may have not seen a lot of during COVID.

The patient was a young male in his 20s who works in construction and wears heavy boots and socks for about 8 hours of the day in the heat. He presented with 1 days of sloughing of the skin of both of his feet with discharge.

 Lets discuss Tinea Pedis (Athlete’s Foot):

 Tines pedis is a dermatophyte infection of the skin on the foot.

 Etiology and Risk Factors:

• Usually occurs in adults and adolescents and is rare prior to puberty

• Infection is acquired by means of direct contact with the causative organism

• Commonly seen in patients who have a history of walking barefoot in locker rooms or swimming pool facilities

• Also commonly seen in patients who wear occlusive footwear

Predisposing factors to consider

• Diabetes Mellitus

• Immunodeficiency, Systemic corticosteroid use, or use of immune suppressive agents

• Poor peripheral circulation or lymphoedema

• Excessive sweating (hyperhidrosis)

 Who would have know that there are different types of tinea pedis?

•  Types of Tinea Pedis:

  • Interdigital tinea pedis: Manifests as pruritic erosions or scales between the toes, most commonly in the third and fourth digital interspaces

    • More severe form of this is known as Ulcerative tinea pedis. This is generally associated with secondary bacterial infection

  • Hyperkeratotic (Moccasin-Type): Characterized by diffuse hyperkeratotic eruption involving the soles and medial and lateral surfaces of the feet.    

  • Vesiculobullous (inflammatory-type): Pruritic, sometimes painful, vesicular or bullous eruption. Medial foot often affected 

Management:

• Topical antifungal therapy is treatment of choice for most patients.

  1. Example of topical antifungal: Azoles, Allylamines, Butenafine, Ciclopirox, Tolnaftate, and Amorolfine. Recommended to apply once or twice a day for four weeks. (Refer to references for dosages and frequency)

  2. Beneficial and more effective for patients to use the suspension formulation of these medications

• Systemic antifungal agents are primarily reserved for patients who fail topical therapy

  1.   Terbinafine 250mg per day for 2 weeks in adults

     1. Most check LFTs prior to administration and patients need to follow up and have LFTs checked while receiving treatment

     2. Peds dosing:

        • 10 to 20kg: 62.5mg/day

        • 20 to 40kg: 125mg/day

        • Above 40kg: standard adult dosing

  • Itraconazole 200mg per day for two weeks

    •   Peds dosing:

      • 3 to 5 mg/kg per day

  • Fluconazole 150mg once weekly for two to six weeks

    • Peds dosing:

      •   6mg/kg once weekly

• ·Ulcerative Tinea Pedis;

  •   Always treatment with systemic antifungal agents in addition to topical antifungals

  • Make sure to add in addition to your antifungal an antibiotic such as Keflex

  • Outpatient podiatry follow up should be given to patients

• Prevention

  • Use of sock with wick-away material

  • Use of desiccating foot powders

  • Tx of hyperhidrosis if there is history of moist feet

  •   Tx of shoes with antifungal powder

  •   Avoidance of occlusive foot wear

 We diagnosed our patient with ulcerative tinea pedis. We started the patient on Terbinafine, Ciclopriox, and Keflex and arranged for podiatry follow up. Our patients case was unique in the fact that the patient had bilateral involvement normally this occurs unilateral.

 References :

·      https://www.uptodate.com/contents/dermatophyte-tinea-infections?search=tinea%20pedis&source=search_result&selectedTitle=1~103&usage_type=default&display_rank=1#H2658711829

·      https://www.uptodate.com/contents/image?csi=18b425c8-5b1f-4694-a039-5bc8aa27c160&source=contentShare&imageKey=PC%2F76148

·      https://wikem.org/wiki/Tinea_pedis

·      https://www.aafp.org/afp/2014/1115/p702.html

·      https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=109447903&bookid=1658

·      https://dermnetnz.org/topics/tinea-pedis/