Let’s Talk About Resident Wellness

How do we change the culture of denial, secrecy, stigma and hopelessness surrounding seeking mental healthcare in residency??

Check out this powerful article from Dr. Elisabeth Poorman:

http://www.wbur.org/commonhealth/2016/08/19/depression-resident-doctor?utm_source=facebook.com

What do you think of her suggestions for battling depression amongst residents (near the bottom of the article)?

What can we adapt and bring to our own program?

 

Monomorphic vs. Polymorphic VT

Great job to those who answered our poll questions!

  1. What do you look at if called about possible NSVT and/or VT? Yes, all of the above. Look at QT duration, electrolytes (K and Mg), medications that prolong QT and low ejection fraction.
  2. The first image showed polymorphic VT, then post-cardioversion showed a normal QT –> making early ischemia or low EF much more likely – making the situation more dangerous. Please see below:

Screenshot 2016-08-19 10.21.28

ECG showing AV dissociation + capture beat + fusion beat

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AV Dissociation:  P waves appearing independently of the QRS complexes

Fusion beat: an impulse coming from above the atrioventricular node fusing with an impulse generated in the ventricle

Capture beat: reflect an impulse coming from above the atrioventricular node that depolarizes the ventricles when they are no longer refractory but before the next ventricle-generated complex

 

Continuous improvements!

UTSW physicians, residents and interns are always on the look-out for continuous improvement of their hospitals and patient care. Out of several months discussions, Parkland Hospital is implementing a new policy: Tele Monitor Tech will call Code Blue and then call the Telemetry hotline for these lethal rhythms:

  • Bradycardia 30bmp or less
  • Sustained VT for > 30 seconds
  • True Asystole

Great example of team work amongst physicians, residents, nurses and techs. Focusing on effective and safe patient-centered care!

But what do YOU think? For our HouseStaff:

  1. What do you look at if called about possible NSVT and/or VT?

2.  You see this rhythm on a telemetry strip:

ipej100184-01

and after urgent cardioversion, you see that the QT is normal:

ipej100184-02

#BeanBlock: we got Dr. Sambandam!

Today one of our superstar attendings joined us for lecture. Dr. Sambandam, nephrologist extraordinaire. 

The topic was Diuretics Resistance. He went over basic pharmacology of diuretics, mechanisms of resistance, clinical syndromes of resistance and management of diuretic resistance.

Just a few highlights with the powerpoint below:
– Bioavailibilty of torsemide and bumetanide >> furosemide
– Mechanism of diuretic resistance? Excess Na intake, ineffective dosing frequency, increased distal nephron transport
– Resistance but thinking noncompliance? signs include requirement for large doses of diuretic for GFR, requirement for large K replacement
– Renal insufficiency? Will need higher dose of diuretic as tub secretion is diminished and renal mass is reduced
– Natriuresis is directly proportional to GFR
– And so much more! Including slides like this:

Screenshot 2016-08-11 19.36.28

We Got This: As a Team

A recent Wall Street Journal article highlighted the importance for trainees – both interns  and residents to know when to call their Attending for guidance and help. The article describes how 4 hospitals developed guidelines to improve communications and decreased their proportion of critical events that weren’t conveyed to an attending from 33% to just 2%.

At UTSW Internal Medicine program, we support our trainees and remind them that Interns and Residents are encouraged and expected to inform their Faculty members in these following situations:

Events that require prior notification to attending physicians

  1. Procedures: Cardioversion, pericardiocentesis, thoracocentesis
  2. Therapies: Emergency dialysis, exchange transfusion, thrombolytic therapy, or initiation of mechanical ventilation if using 1) oscillation or 2) jet ventilation
  3. Events: End-of-life discussions, order of protective custody, or transfer of patient to higher level of care

Events that require concurrent notification to attending physicians

  1. BiPAP initiated on non-ICU patient for hypoxic or hypercapneic  respiratory insufficiency
  2. Code Blue/Unexpected Death
  3. Cardiopulmonary arrest/acute respiratory compromise
  4. Grievance
  5. Patient leaves AMA

Also our regular Patient Safety and Quality Improvement conferences are opportunities for us to learn as a system on how to care for patients even better.

More information on our Resident Website under Resident Manual: imweb.swmed.edu.

 

Current Concepts! Renal Autoregulation

Dr. Biff Palmer, nephrologist and clinician researcher extraordinaire has published a great piece in NEJM about renal autoregulation, creatinine, anti-HTN agents and renal dysfunction. Fantastic read!

Just a few points:
– with chronic HTN and chronic renal disease, the intraglomerular to MAP (or renal perfusion) curve becomes more linear – and anti-HTN therapy can lead to decreases in intraglomerular pressure for chronic renal disease patient that would not affect a normal person. See Figure 1.

Picture11111

– Chronic renal failure, even small declines in the glomerular filtration rate will lead to an increase in the serum creatinine  concentration
– In many patients, this initial decline in renal function will either improve or resolve with long-term control of the blood pressure.
– Allowing blood-pressure control to deteriorate in order to prevent a rise in the creatinine concentration can harm the very patients who benefit most from tight blood-pressure control, which has bee proved to slow the progression of chronic renal failure.

NEJM Creatinine and BP

http://www.nejm.org/doi/full/10.1056/NEJMra020676

 

#FridayImageChallenge

ANSWER: You were correct! The thrombus is in the RA. There is a large free floating thrombus in Right Atrium. Left ventricle ejection fraction is 202-25% with severely depressed RV function. Bi-atrial enlargement with RV dilation. Example apical 4 chamber view on TTE shown below.

4_chamber

Quick Learning Points:
Right sided heart thrombi (RHTh) in 2 types:
– Type A thrombi: worm-like shape, extremely mobile and likely arising from lower-limb veins–> mortality of 28-44%
– Type B thrombi attach to the atrial or ventricular wall indicating that they are probably of local origin. –> mortality of 4% (lower risk than Type A)
* Either can obstruct Right Ventricle filling + emptying or migrate to pulmonary arteries.

Surgical thromboembolectomy has been the treatment of choice in the past, however with RCT lacking – many have presented prospective studies showing good outcome + rapid improvement with t-PA (classically indicated for proven PE w/ cardiogenic shock). Heparin alone may not be adequate as some studies have shown. Catheter-based interventions also an option for those unable to undergo surgery or t-PA.

A Quick Read on the Topic:
http://content.onlinejacc.org/article.aspx?articleid=1132395

****************************************

64 year old male smoker, no history of COPD or CHF who presented with 3 days exertional dyspnea and pleuritic chest pain. Echo is done and what do we see?

The One, The Only – Dr. Brad Cutrell!

Our own phenomenal Dr. Brad Cutrell, UTSW ID faculty extraordinaire joined us for our Back-2-Basics series and delivered a lecture to remember! And refer to over-and-over again. Antibiotic Strategies + Pearls!

Only just a few highlights:
– HAP and VAP considered separate entities in new guidelines; removal of HCAP
– Consider PseA in patients w/ Bronchiectasis or COPD + frequent steroids/antibiotics, chronic alcoholism, recent hospitalization in last 90 days
– MDR risk factor: IV Abx use in prior 3 months!
– Anti-Psa for HAP: 2 drug coverage if prior IV abx last 90 day, structural lung dz (e.g. CF), septic shock or MV need
– colony threshold (≥ 105 cfu/mL) is NOT an indication for treatment of asymptomatic bacteriuria

Enjoy!

 

#FridayImageChallenge

#Answer: You were correct! Atelectasis from mucus plugging of R mainstem bronchus. This patient had severe oropharyngeal dysphagia. The position of the trachea is crucial in formulating a differential for a unilateral lung white-out. Here it is pulled towards the white out, indicating a resorptive atelectasis (also with pulmonary hypoplasia and intubation of bronchus). A pleural space process (effusion, hemothorax) will push the trachea away, while it will remain largely central in a primarily parenchymal (pneumonia, edema) and pleural/chest wall (mesothelioma, tumor) pathology.

Image and write-up credit: Arjun Gupta

A man in his 60’s admitted for myeloma chemotherapy develops acute onset shortness of breath. CXR 12 hours prior (Fig 1) and now (Fig 2) are presented.

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Fellowship Applications: July 15th

Good luck to those applying for fellowships today!

Try to certify/submit your applications today (July 15) – even if all your uploaded LOR from your letter writers have not been yet released by ERAS-EFDO. You can assign those letters once they’ve been released.

Remember you have to pay the fees and only then will your application be released. Confirm this under the “Programs Applied to” tab.

Let the Chiefs know when your interview dates will be – we can help!

All the best,

UTSW Internal Medicine

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