POTD: Where do I go?

Today’s POTD is going to be about where to find certain locations in the hospital. Some of these places might not be as relevant most of the time but it’s helpful to know on the very busy days to expedite patient care or inpatient rotations. It’s also helpful to know where the clinics we send our patients to most often are (like dental and ophtho) so that we can give proper instructions for follow-up. I know there’s no map to help orient yourself but hopefully it’s a little helpful. :) 

Dental Clinic - 4802 10th avenue, 2nd floor

The same building as our conferences, also on the 2nd floor but just past Schrieber auditorium

Ophtho clinic 902 49th street

On 9th ave at the corner of 49th street

Blood bank - 4802 10th avenue, 3rd floor → Once you exit the stairs, make a left at the end of the hallway

The same building that we have conference, on the 3rd floor; easiest way to access it is by going outside the hospital (even though there is a way of going through the hospital but can be confusing / takes longer)

This is helpful for off-service rotations where they need emergent blood transported and sometimes no one else is available

Lab - 4th floor → use elevators between resident’s lounge and kitchen

this one is mostly really important to drop off CSF studies so that there’s no delay in processing 

Go through this door, down the corridor

Ultrasound - 3rd floor → use elevators (set of 4) near resident’s lounge 

Operating room - 4th floor → use elevators that are just past KRB

Gives an idea of where to go for the anesthesia rotation 

MICU - 7th floor

Use the elevators past KRB

SICU - 8th floor

Use the elevators past KRB

PICU - 6th floor

Use the elevators between the resident’s lounge and kitchen 

CCU - 2nd floor

Use the elevators between the resident’s lounge and kitchen

POTD: "Leak" out for those chest tubes!

Today we’re going to talk about what to do when it seems like the chest tube is not functioning properly. (Everything here applies to any type of chest tube placed, not just large bore).

The biggest thing to take away from this is how to manage an air leak and only clamp the tubing when necessary and for a few seconds (not routinely and not for extended periods otherwise it can cause a tension pneumothorax).

Let’s start by talking about how you can tell the chest tube is functioning properly (aside from drainage and confirmed CXR). 

You should see tidaling occur (as seen in graphic below) which demonstrates the water in the chamber moving according to a patient’s respirations. 

There are multiple things that can indicate the chest tube is not working appropriately so let’s talk about what you would see and how to approach some of them.

There may be an air leak which you can find by looking for constant or intermittent bubbling in the water-seal chamber. (it is common to have some bubbling upon initial placement of the chest tube but watch for constant and a large amount of bubbling). 

To find the source of the air leak, clamp the chest tube (only for a few seconds) starting from where it enters the chest and moving toward the pleur-evac. If the bubbling stops when you clamp the chest tube where it enters the chest, the problem is more likely internal and the chest tube might need to be completely replaced. 

If the bubbling stops when any site more distal, along the tubing, is clamped, the tubing might need to be replaced. 

If the bubbling stops close to where the tube enters the pleur-evac, the chamber itself might need to be replaced. 

Subcutaneous emphysema at the site of the chest tube dressing could indicate a worsening air leak within the chest cavity and potentially even development of a tension pneumothorax so immediately obtain an x-ray to assess progression. 

Drainage may stop → check for any kinks in the tubing and reposition the patient so they are upright. Always make sure the pleur-evac is below the level of the patient to allow proper drainage.

If the tubing accidentally gets disconnected, clamp the chest tube at the site closest to the dressing only briefly until the tubing can be replaced OR place the distal end of the chest tube in a bottle of sterile water so everything can continue draining until the equipment is replaced. 

The list of things that can go wrong with a chest tube is never-ending but I wanted to mention some of the more common ones we may see while the patient is still in our ER. 

Here’s another video to help with visualization (more helpful around 10:40 mark): https://www.youtube.com/watch?v=YOpzcWc3yrw&t=1139s

~~

https://www.ncbi.nlm.nih.gov/books/NBK594490/#:~:text=If%20drainage%20suddenly%20stops%20in,blockage%20in%20a%20dependent%20loop%3A&text=Assess%20the%20drainage%20system%20and%20the%20client.&text=Inspect%20for%20kinks%20and%20straighten,connection%20with%20the%20collection%20device.

https://opentextbc.ca/clinicalskills/chapter/10-7-chest-drainage-systems/

https://www.perplexity.ai/search/when-is-it-191OyTWbRqSV3.KHzmoORg#0

POTD: IO needles: the back~bone~ of EM

Hi everyone and welcome to our new interns! (And cheers to our new senior class and new resus residents! 😍) I’m Ambica and I’ll be the admin resident for the month. Part of this includes writing POTDs aka pearls of the day. For my first POTD, I’m going to talk about using IO needles for a crashing patient and I’m highlighting in blue the biggest take-aways.

It’s helpful to obtain IO access for a crashing patient because the placement can be safe and quick to place (<60 seconds) and can deliver medications at basically the same rate as an IV (which takes more time to place). There’s also a lower risk of bloodstream infections. It’s also been found to have a higher first pass success rate compared to placing a crash central line. 

Here are the optimal locations for needle placement (there are more but I’m listing the common ones and to quickly measure, just use fingerbreadths in place of cm):

- Proximal humerus - greater tubercle, about 2 cm above the surgical neck; helpful if arm is adducted but this is hard to do with chest compressions or the LUCAS machine on; due to the depth, typically should use yellow IO (45 mm) **not preferred in pediatric patients < 6 years old

- Proximal tibia - about 2 cm inferior to the patella and 1-2 cm medial to the tibial tuberosity; preferred option for obese patients

- Distal tibia - 2-3 cm superior to medial malleolus 

- Distal femur - 1 cm superior to patella and 1-2 cm medially

Hold the needle at a 90 degree angle for all insertions except for the proximal humerus location where you hold it at a 45 degree angle

Which size needle do I use? 

- Pink - pediatrics aka infants / toddlers

- Blue - most commonly used for adults and larger pediatric patients

- Yellow - patients with more subcutaneous tissue 

When can I NOT place one: 

1. Fractured bone proximal to IO insertion - absolute contraindication 

2. Recent IO attempt at that site within 24 hours - absolute contraindication 

3. Overlying skin infection

4. Burns

5. Prosthetic limb

6. Underlying bone disease like osteogenesis imperfecta

Here’s a link for an EMRAP video on how to do the procedure. 

https://www.youtube.com/watch?v=KHXSfh2ZRDM

~~

Ambica

https://rebelem.com/dont-forget-about-the-io-in-the-critically-ill-patient/

https://naemsp.org/2023-1-4-iv-vs-io-does-your-site-of-access-matter-in-cardiac-arrest/#:~:text=%5B6%5D%20In%20terms%20of%20flow,rates%20at%20the%20humeral%20site.

https://litfl.com/intraosseous-access/