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Archive for May, 2006

Airway Management of the Septic Patient

Very Abbreviated conversation between Matt Denny and Scott Weingart:

Matt: I’ve been reading a few articles arguing against using etomidate, even as a single dose for induction, on the grounds that it suppresses cortisone production. The alternatives were giving steroids to all such patients post etomidate, or using alternative agents such as thiopental or dexmedetomidine. What’s your take on all of this?

Scott: dex not a good induction agent. thoipental induces hypotension, so you must dose accordingly. i use ketamine for my sepsis inductions. etomidate is fine if the patient is going to get empiric steroids anyway, i.e. your patient already on vasopressors. etomidate may result in a patient getting placed on pressors a few hours earlier than they would without it. does this have clinical relevance now that we supplement all patients on pressors, who knows. It is a confounder for all of Annane’s work on the value of steroids in septic shock.

Etomidate in Sepsis:
http://eresources.library.mssm.edu:2968/?sid=Entrez:PubMed&id=pmid:15764790

Written by phil

May 30th, 2006 at 8:02 pm

Posted in Pearls

Notes on Teaching in the ED from SAEM Spivey Lecture

Recommended Reading
Creative Medical Teaching – Neal Whitman
The Courage to Teach – Parker Palmer

TEACHER Mnemonic

T – Teaching in the ED
E – Enthusiasm
A – Appropriate Feedback
C – Centerdness (on learner)
H – Helpful
E – Elevates to be Independent
R – Role Model

Teaching in the ED

What do EM residents want?
– attentive
– enthusiastic
– approachable
– communicative
– “takes time to teach”
– “teachable moment”
– “tailors teaching to learner”

– Have to teach quickly for learner to remain “with you”.
– 1-2 focal teaching points; avoid teaching too much
– be armed with information
– assess level of learner

Step 1. Get a Commitment
Step 2. Probe for supporting evidence
Step 3. Provide an Educational “Hit and Run”
Step 4. Positive Feedback
Step 5. Correct Mistakes
Step 6. Identify Learning steps

Enthusiasm
– The Dr. Fox effect

Appropriate Feedback
– give effective feedback
– avoid saying “good job”
– praise in public, perfect in private
– deposit into emotional bank account -> makes corrective feedback more meaningful

Centerdness (on learner)
– who are you?
– where are you from?
– what service?
– did you get lunch? bathroom?

Helpful
– professional intimacy

Elevates to be Independent
– consider who inspired you to become independent in the ED

Role Model

Written by phil

May 27th, 2006 at 11:13 pm

Posted in Lecture Notes

Sepsis Protocol

Written by phil

May 25th, 2006 at 5:30 pm

Posted in ED Guidelines,Sepsis

Sinai ED Clinical Resources

Sinai specific resources that we use both frequently and infrequently to make your shift go a little bit smoother.

Resus Room
– Resus Criteria
Critical Care Supplies
Ultrasound Documentation
– MI Team Activation: see info here. When in doubt, call AMAC.
– STROKE Team Activation: Call AMAC who will notify Stroke, CT, Lab.
Central Line Documentation: be sure to document Maximal Sterile Barrier use.

Methadone Clinics
– Harlem East Life Plan 2369 2nd Avenue (212) 876-2300

Disposition and Follow-Up
– (800) MD SINAI: Physician Referral Service to Faculty Practices and the following:
– IMA
Settlement Health: Sliding Scale
Boriken Neighborhood Health: Sliding Scale
EHOPP: No health insurance, >22 yo, and Residents of East Harlem
– Metropolitan Psych Clinic
GYN Referral Guidelines
LWBT AMA and ELOPED Patients

Specific Patient Issues
– Sickle Cell -> Page Heme Fellow on admission/ ?every visit
– Hemophilia PTs -> Masterlist of Factor deficiencies in Attg Office
– Sexual Assault (Code 11): Call SW and then AMAC to reach SAVI and the SAFE examiner on call.


Expediting Admissions
– surge criteria
– TO BE CLEAN –> Call transport at 44443 to ensure they know bed needs to be cleaned

Phone Numbers
– AMAC – 43611
Restaurants

ID Approval
– Hours: 9 am – 6 pm. (Fill out form after 6pm)
– If ID unavailable -> call pharmacy to release drug

What About…
– PT/OT
– When do I send a patient to Psych ED?
– ED Policy Manual

Written by phil

May 23rd, 2006 at 2:40 pm

Posted in Pearls