mssmem.com

I forget…what did that email say? oh yeah, its at mssmem.com

Archive for July, 2009

VNS Referrals

Good morning, just a reminder. If it is off hours, and you think that your pt would benefit from VNS services, you may print out a consultation form write your concerns on it, and leaving it under the door of the social worker. The VNS will review the case in the morning.
VNS would rather too many referrals rather than too few.
thanks
meika

Written by phil

July 29th, 2009 at 12:44 pm

Fourth Year Role

Start of shift:

1. Check airway equipment, including diffcicult airway supplies
2. Check difficult airway stock list (list near airway supply) against current inventory- ask tech or Resus Nurse to restock missing items
3. North zone signout
4. Confer with charge nurse, IBEX Pulsecheck, and BedBoard Overview- introduce yourself, touch base on ED bed situation, # admitted patients, # available ICU beds, etc.
5. How many patients are in for a stress test today?

During shift:

Supervise all junior residents, meaning hear cases primarily when you can, otherwise just get a bullet (assessment and plan) from the resident on cases they’ve presented to attending

When you start falling behind in hearing about cases or seeing patients you’ve heard about, defer presentations to the attending, catch up with attending afterwards

Know all North Resus pts- well enough that you would be able to speak to a MICU consult about them

Know the bare bones of the South Resus patients- who’s really sick, who could leave the Resus area if a bed is needed

• When the junior residents become saturated with patients, and the department gets busy:
1. Board round with them on their patients (have them click “My patients” in IBEX); help them determine the next few critical actions they need to perform
2. Cherry pick patients to pick up primarily- clear admissions, call-ins who need orders entered, etc.
3. Confer with attending if other options would improve department flow

Board round with attending a few times per shift (just for a few minutes each time) to get on the same page about eval and dispo for each patient- this is a good way to get the gist of patients you were previously unaware of and see the departmental ‘big picture’

At Signout:

• -Sign out to incoming senior
• -Take part in attending change of shift as needed

Notes on Resus:

• -Know the North Resus patients well- the EM-4 should be actively supervising their care (bring junior residents in to the case), or care for them primarily if no juniors are available
• -Know key issues/dispo status for South patients

Charting:

Reiterating the attending assessment and plan may not be useful; however, Seniors should write a brief progress note in the Doctors Notes section on patients they are supervising/following (ie. Response to treatment, PCP contacted, etc.)

Codes:

The EM-4 should run the codes, assigning other roles according to staffing and need (airway, central line, etc.). If an EM-3 is primarily caring for a coding patient, the EM-3 could then take on the role of running the code and assigning roles (leaving the EM-4 to assist with airway, or whatever is needed).

Night Shifts:

Depending on staffing and volume, several options are possible:

1. EM-4 supervises the North Zone, attendings focus on hearing South Zone cases directly from South junior residents and EM-4 supervises North juniors
2. EM-4 sees patients primarily, but periodically round the board with attending to keep abreast of overall department flow and cases

Know This

The fourth year should know the answers to these questions (or know how to find out quickly) on any given shift:

1. Who can come out of Resus?
2. If CT can take a patient right now, who goes next?
a. -Or- How many patients are waiting on CT and Ultrasound? In what order should they go?
3. How many admitted patients are boarding in the ED right now?
4. Which patients have been in the ED the longest without a disposition, and what are they waiting on?

Written by phil

July 27th, 2009 at 5:52 pm

Posted in Residents

Protected: Affiliates Contact List 2009

Written by reuben

July 25th, 2009 at 7:46 pm

Posted in Contacts

Travel and CME Reimbursement

Dear Faculty,

As the new academic year begins, I wanted to remind everyone of the travel policies for CME reimbursement. Your $2,200 annual cme allocation runs from July- June. CME funds not used within this time frame will be forfeited as we can not carry funds over from year to year. All travel must be submitted in advance by the traveler. The procedure starts with an online TRAVEL REQUEST which must be submitted in advance of travel. (A week at the least to go through the approval process)

1. Log on to http://www.mssm.edu/finance/
2. pick on-line procurement system
3. your username will come up: type in your password or pick Login or Password help. You will be given instructions.
4. Once you login to Sinai Central go to
5. Finance
6. Transactions
7. New
8. Travel Request
9. Fill in all information starting with Name of Traveler.
10. Your request will need an approval; once it is approval you will receive email notification.
11. When you return from travel you submit a travel voucher (following the above instructions) which generates your reimbursement.

Remember you must submit all receipts with the travel voucher

YOU MUST submit your:
1. Boarding Passes (no exceptions)
2. Hotel Bills with credit card ledger
3. All meal receipts ($65.00 a day limit for meals)
4. Taxi, bus, and/or car service receipts

Everything you want to be reimbursed must have a paid receipt and you must submit the original receipt with your travel voucher. All travel vouchers are audited by finance and will not be reimbursed without all documentation. For individual questions, please speak with Rene Patton. I have also attached the institutional travel policy guidelines for futher clarification. Thanks!

Written by phil

July 15th, 2009 at 5:25 pm

Posted in Finance

Sinai Wilderness Medical Society

Admin

Co-Director, Residente Virdis Montis and all around Outdoor Guy: Dr. Hill
Co-Director, Treehugger and Climbing Guru: Dr. Hahn
Co-Director, Farily Consistent Recycler: Dr. Andrus
Resident Representative and ski/snowboard/tele instructor: Dr. Oishi
Secretary of Spaghetti: Dr. Bruns
Members: Dr. Bentley, Dr. Strayer, Dr. Truong

Resources

Wilderness Medical Society

Upcoming Events

2009 Summer Retreat
2010 Winter Retreat – Dalton NH

Past Events

2009 Sinai WMS Winter Retreat
– Attendees: Dr. Andrus, Dr. Hill, Dr. Hahn, Dr. Strayer, Dr. Oishi, Dr. Bentley
– Activities: Skiing/snowboarding/Telemark Skiing/Snowshoeing/Snow Hiking
– Lecture: How not to settle Cataan (Dr. Hill)

2008 Sinai WMS Winter Retreat
– Sinai WMS established
– Attendees: Dr. Andrus, Dr. Hill, Dr. Hahn, Dr. Bruns, Dr. Oishi, Dr. Truong
– Activities: Skiing/snowboarding/tele/snowshoeing
– Lecture: Thermodynamics of snowpack (Dr. Hill)

Written by phil

July 15th, 2009 at 5:14 pm

MountSinai.org Website

MountSinai.org Website
1) My name doesn’t appear in the Find-A-Doctor list or the information there is incorrect. What do I do? Simply fill out and submit the “Find-A-Doctor” application. You will also need to choose one or more items from this list of clinical interests.

2) My publications aren’t listed in Find-A-Doctor, what do I do? Send a list of your top ten (most recent/most important) publications to kristen.morales@mountsinai.org and webfeedback@mountsinai.org.

3
) How do I add an event to my “events” page on the Patient Care or Education Pages? Simply email the request to webfeedback@mountsinai.org.

Written by phil

July 15th, 2009 at 5:01 pm

Posted in Admin

Publications

Books


Manual of Emergency and Critical Care Ultrasound

Bret Nelson MD FACEP RDMS
Director of Emergency Ultrasound
Mount Sinai Hospital
Mount Sinai School of Medicine

(Find it at Amazon)


Evidence-Based Emergency Medicine

Scott Weingart MD FACEP RDMS
Director of Emergency Critical Care
Elmhurst Hospital
Mount Sinai School of Medicine

(Find it at Amazon)


Neurologic Emergencies: A Symptom Oriented Approach

Andy Jagoda MD FACEP
Professor and Vice-Chair of Emergency Medicine
Mount Sinai Hospital
Mount Sinai School of Medicine

(Find it at Amazon)

Written by phil

July 15th, 2009 at 4:59 pm

Posted in Sinai Publications

English – Russian

Written by phil

July 15th, 2009 at 4:57 pm

Posted in Translator

Blood: a practical guide to the (gi) bleeding patient

Resources:

Powerpoint Lecture

One Page Summary (pending)

NG Tube Insertion

References:
http://www.jeffmann.net

http://www.emcrit.org

Michael D. Witting, ‘You Wanna Do What?!’ Modern Indications for Nasogastric Intubation, Journal of Emergency MedicineVolume 33, Issue 1, , July 2007, Pages 61-64.

Sharara AI, Rockey DC. Medical progress: gastroesophageal variceal hemorrhage. N Engl J Med 2001;345:669-681.

Bernard B, Grange JD, Khan EN, at al.. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-61.

Sixth ACCP Consensus Conference on Antithrombotic Therapy,Chest 2001:33S-34S.

Lankiewicz MW, Hays J, Friedman KD, Tinkoff G, Blatt PM. Urgent reversal of warfarin with prothrombin complex concentrate.
J Thromb Haemost 2006; 4: 967–70.

J Trauma. 2008 May;64(5):1177-82

Written by phil

July 15th, 2009 at 4:51 pm

Posted in Lecture Notes

Intubating Laryngeal Mask Airways (ILAs)

Hi all,
Recently, there was a case where an ILA was used as a rescue device, but nobody, including anesthesia, was familiar with how to transition this device to an endotracheal tube .

Joe and I discussed this in May 2007 when we first bought these devices.

Here is a review:

The ILA  is a device specifically designed for ease of ET tube placement.

After the ILA is placed and the pt is reoxygenated, ET tube placement can be accomplished by either:

Placement of the bougie (I prefer using the straight end), and then placement of the tube over the bougie with the ILA still in place.

or

Placement of the intubating stylet with an ET tube over it through the ILA, which allows direct visualization of the cords through the ILA.

In both cases you need to remove but not lose the 22 mm adapter from the top of the ILA

please watch these two videos:

http://cookgas.com/assets/Movies/ILA_ASASeq_Small.wmv

http://cookgas.com/assets/Movies/Cookgas.wmv

the videos also show how to remove the ILA after ET tube is placed and confirmed.

One key move that Rikki and I learned was to make sure the patient is paralyzed during these maneuvers or you might wind up with a face full of GI bleed blood, ummmmm GI bleed blood.

ask Joe or I if you have any questions

Scott Weingart, MD FACEP
Division of Emergency Critical Care
Department of Emergency Medicine
Mount Sinai School of Medicine

Written by reuben

July 9th, 2009 at 8:44 pm

Posted in Airway

Rotating Students: July 2009

Written by reuben

July 9th, 2009 at 8:41 pm

Posted in Students

Therapeutic Hypothermia

Intro: The induction of Mild Therapeutic Hypothermia has been proven to improve mortality and neurological outcomes in survivors of cardiac arrest. This effect is achieved by decreasing cerebral oxygen consumption, suppression of free radical reactions, a reduction of intracellular acidosis and inhibition of excitatory neurotransmitters. The Critical Care community at the Mount Sinai Hospital and Mount Sinai school of Medicine are dedicated to providing this therapy to our patients.

Project Hypothermia: Therapeutic Hypothermia has been provided to appropriate survivors of cardiac arrest at Mount Sinai since April 2008. Mount Sinai is now part of the GNYHA/FDNY/REMSCO city wide initiative to provide this therapy to survivors of cardiac arrest. As part of this effort we are collecting QA data as part of our agreement to collaborate with NY Project Hypothermia. In addition to the standard cooling procedure for our patients you will be asked to complete a very brief form. For your convenience the full protocol, ED worksheet, shivering protocol and QA form are provided here:

Resources:

Lecture: available Navigating the cool waters of hypothermia.

Video: Hypothermia – Getting it Done at emcrit.org

REFERENCES

2002 Studies – the big ones:
Hypothermia after Cardiac Arrest Study Group, (2002). Mild Therapeutic Hypothermia to Improve Neurologic Outcome After Cardiac Arrest. New England Journal of Medicine, 346 (8), 549-556.
Bernard, S., Gray, T., Buise, M., Jones, B., Silvester, M., Gutteridge, M., Smith, K. (2002). Treatment of Comatose Survivors of Out-Of-Hospital Arrest with Induced Hypothermia. New England Journal of Medicine, 346 (8), 557-563.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112[Suppl I]:IV-84-IV-88.
Burns, S. (2001). Revisiting Hypothermia; A Critical Concept. Critical Care Nurse, 21 (2), 83-86.
Ginsberg MD. Hypothermic Neuroprotection in Cerebral Ischemia. In Primer on Cerebrovascular Diseases. 1997:272-275.
Ginsberg MD, Sternau LL, Globus MY, Dietrich WD, Busto R. Therapeutic modulation of brain temperature: relevance to ischemic brain injury. Cerebrovasc Brain Metab Rev 1992; 4:189-22.
Holzer M, Bernard SA, Hachimi-Idrissi S, Hypothermia for neuroprotection after cardiac arrest: systematic review and individual patient data meta-analysis. Crit Care Med. 2005 Jun;33(6):1449-52.
Nolan J, Morley P, Vanden Hoek T, Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advanced Life Support Task Force of the International Liason Committee on Resuscitation (ILCOR). Resuscitation 2003;57:231-235.
Mayer SA, Sessler DI. Therapeutic Hypothermia. New Tyork: Marcel-Dekker, 2005.
Polderman KH. Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality – Part 2: Practical aspects and side effects. Intensive Care Med 2004; 30: 757-769.

Cooling with IV Saline
Bernard S, Buist M, Monteiro O, Induced Hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report. Resuscitation 2003;56:9-13.
Kim F, Olsufka M, Longstreth WT, Pilot Randomized Clinical Trial of Prehospital Induction of Mild Hypothermia in Out-of-Hospital Cardiac Arrest Patients with a Rapid Infusion of 4 °C Normal Saline. Circulation 2007;115;3064-3070.
Polderman K, Rijnsburger E, Peerdeman S, Induction of hypothermia in Patients with various types of neurologic injury with use of large volumes of ice-cold intravenous fluid. Crit Care Med 2005;33:2744-2751.

Shivering Management
Alfonsi P, Sessler D, Dumanoir B. The effects of meperidine and sufentanil on the shivering threshold in postoperative patients. Anesthesiology 1998;89:43-8.
Doufas AG., Lin CM., Suleman MI., Dexmedetomidine and meperidine additively reduce the shivering threshold in humans. Stroke 2 003 May;34(5):1218-23.
Mokhtarani M, Maghoub A, Morioka N. Buspirone and meperdine synergistically reduce the shivering threshold. Anesth. Analg. 2001;93:1223-9.
AHA 2005 Guidelines

Physiology of Hypothermia

Polderman KH.  Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37:7:S185=S294.

Cooling Device Manufacturers:
Alsius Corporation (Irvine, CA; maker of endovascular cooling catheter systems
Innercool Medical (San Diego, CA; maker of endovascular cooling catheter system)
EMCOOLS (Austria; maker of external cooling blanket)
Adroit Medical(Loudon, TN; maker of internal and external cooling devices)
MTRE Advanced Technologies – link from Adroit Medical
Life Recovery Systems (Alexandria, LA; maker of external cooling system)
Medivance, Inc. (Louisville, CO; maker of external cooling system)
Radiant Medical (Redwood, CA; maker of endovascular cooling catheter system)

Hypothermia Research:
The Hypothermia Network
Center for Resuscitation Science (University of Pennsylvania)
Emergency Resuscitation Center (University of Chicago)
European Resuscitation Council
Safar Center for Resuscitation Research (University of Pittsburgh)
The Hypothermia After Cardiac Arrest Registry (European Registry Site)
Food and Drug Administration (FDA) consideration of hypothermia

Written by phil

July 6th, 2009 at 7:03 pm

Posted in Hypothermia

email forwarding

Here’s how to forward your email from mssm.edu to your preferred address.

Go to imail.mssm.edu and sign in. Ask the Library (212) 241-7091, ext 47091 for help if you’ve misplaced your login info. You will see this:


Select “Options”. You will see this menu on the left of your screen:

Choose “Settings”. At the bottom of the list of settings, you will see the “Mail Forwarding” Options. Make sure that “Enable Forwarding and Don’t leave copy on server” are selected. Enter your destination email address and “Save Changes”.

Written by phil

July 6th, 2009 at 6:53 pm

Emergency Department Pharmacists Protocol

1. Continuity of care

The Emergency Department Pharmacists’ primary mandate is to facilitate care of the long-stay ED patient, from the standpoint of medications. As such, they will assess patients, patient records, and orders put in by the admitting team–starting with the patients who have been in the department the longest, and working their way down by length of stay. They will identify important medications that the patient needs (anti-rejection meds, antiepileptics, antihypertensives, anticoagulants, etc) while awaiting inpatient beds. They will enter their recommendations into IBEX in accordance with the EDP medication policy (see appendix 1).

In cases where orders have been entered into TDS by the inpatient team, the pharmacist shall transcribe the important medications into IBEX when appropriate. In this case no co-signature is needed, as a physician has already ordered the medication in a different system. Similarly, TPN orders entered by ED pharmacists do not require co-signature; the pharmacist will ensure that the original paper order has been scanned into the chart.

The pharmacist shall enter all TDS orders for long-stay patients into the pharmacy information system (WoRX).

ED pharmacists may find it clinically necessary to clarify certain patients’ allergies and/or home medications prior to reconciliation by the admitting team, on ED practitioner request or to ensure continuity of medical care as above. Clarifications to a patient’s current medication list in IBEX as entered by the triage nurse may be made as appropriate. The pharmacist may document the sources that informed the clarification, including patient/family interviews, medication bottle and content inspections, computer records and outpatient pharmacy contacts. The pharmacist’s role is to supplement the existing medication reconciliation process in the ED, not to replace it.

2. Symptom Relief

Unaddressed pain and other symptoms–one of the major effects of overcrowding–underlie much morbidity and many patient complaints. The ED pharmacists will inquire with patients regarding treatable symptoms and recommend key medications (for example: tylenol, morphine, zofran, reglan, pepcid, nicotine patch) as they perform their assessments. The role of the pharmacist is to supplement and not to substitute the role of the physician or nurse in monitoring patient symptoms.

3. Core Measures

Pharmacists can screen chest pain patients for aspirin and beta blocker orders and dyspneic or febrile patients for antibiotic orders. Where potential deficiencies exist, the pharmacist will make recommendations for the treating MD.

4. Participation in resuscitations

Pharmacists are ACLS certified and can anticipate and assist the team with the preparation and delivery of medications used in resuscitations and cardiac arrests–especially where more complicated drips are called for (amiodarone, tPA). Pharmacists may also be able to facilitate the preparation of RSI meds.

5. Drug Information

Pharmacists are available to address medication questions that arise and will usually be able to provide information regarding drug selection, dosing, indications, contraindications, interactions, monitoring and drip preparation in a clinically relevant time frame.

6. Error Reduction

The EDP will expedite medication order processing by screening for incorrect orders; for example, alerting novice (and veteran) IBEX users of faulty syntax in their orders, changing non-formulary medications to formulary (e.g. Novolin to Humulin), or adding a patient weight to LMWH orders. This will improve the accuracy of ED documentation and reduce turnaround times when medications have to be sent from pharmacy. Medication-targeted laboratory tests may also be recommended if not ordered, for example, partial thromboplastin time for a patient on a heparin drip, fingerstick for a patient on insulin, etc.

The EDP will change particular medication orders for the purposes of conforming to the ED and hospital formulary and resolving other problem orders (form-route mismatches, missing units, wrong units, etc) according to the order clarification and substitution protocols (see appendix 2). In these cases the original order will be cancelled by the EDP with a note that the order is changed per protocol, and a new order is entered by the EDP with the same ordering physician; co-signature is not necessary.

7. Patient counseling

EDPs can discuss with the patient any medication the patients receive in the ED or have been prescribed at discharge.

The role of the ED Pharmacist is in evolution and will be revised to best meet the needs of all concerned parties.

Appendix 1: Medication Policy

Policy for medication orders involving Emergency Department Pharmacists

1. The emergency department pharmacist (EDP) will enter his/her recommendations into Picis PulseCheck (IBEX) in the Med SVC section.

2. The EDP will approach a treating MD and review his/her recommendations.

3. The treating MD will sign the order using the Co-Sign function in the Med SVC section.

4. The RN will then pick up the order and administer the medication.

Appendix 2: EDP Order Clarification & Substitution Protocols

http://spreadsheets.google.com/pub?key=r2tbu4GCqzxZWAjeqm-3Rkg&output=html

Written by reuben

July 1st, 2009 at 9:41 pm

Posted in Pharmacy