Residents published in JAMA

Our residents Christina Yek and Arjun Gupta published an article in JAMA this week, with an accompanying podcast! They highlight an incident of iatrogenic phenytoin toxicity at Parkland where an intubated patient received 3X the intended amount of phenytoin resulting in somnolence and delayed extubation.
The article describes how resident-initiated incident reporting sparked a root cause analysis, leading to process improvement and the implementation of systems-based solutions to prevent future recurrences.
We encourage our residents to keep up the good work reporting safety incidents in the work place! Every time you report an adverse event/ safety post, it creates opportunities for quality improvement. Recognizing areas to improve is the first step to improve.
Please save this google form to your phone, and report report report.

UTSWIM Case Report in the News

Another example of the amazing pathology we see at Parkland! A patient case in BMJ case reports has been making big news. Authors Nick Hendren, Senthil Sukumar and Dr. Glazer present a patient with significant alcohol use who went swimming in the Gulf of Mexico after a tattoo, and presented with Vibrio vulnificus sepsis.

Read the case abstract here.

This case currently has an Altmetric score of 450 and rising !! Several news outlets have featured it including CNN , Yahoo , Mens Health and DailyMail.

UTSW residents have had great success publishing with BMJ case reports (http://casereports.bmj.com/). They accept both clinical images and case reports, are fast reviewers, and publish weekly. UTSW has a “fellowship” with them, allowing for free publication (membership number is 849366 which is needed during submission). They have their own template and formatting requirements explained on their website and require their own consent form (they will not accept an article without consent on their form).

This patient was in the ICU for a long time- unfortunately he did not make it despite a 2-month hospitalization. Thanks to the superb team of IM residents that cared for him:
Thalvinder Sangha
Ruth Sacks
Allison Lange
Langdon Stone
Alisha Bent
Thomas Tielleman
Beth Batchelor
Omer Mirza
Jake Hutto
David Wang
Mark Weinreich
David Wang
Carlos Cardenas
Emily Bowen
Bryan Block
Christopher Chase
Stan Atkin
Christian Ngo
Nick Hendren
Senthil Sukumar

#parklandstrong

#FridayCaseChallenge

A case challenge for you on this rainy Thursday.

I will present the case step by step with additional information provided  every ~24-72h. Please leave your thoughts in the comments, or can submit to the anonymous link.

CASE: A 59yo with severe ischemic CM (most recent EF <20%) presents to CUH ED with DOE, orthopnea, bendopnea, and PND. He has had 3 hospitalizations in the last 4 months for heart failure exacerbations. His initial lab work is notable for normal K, CO2, AG, and creatinine, CBC is wnl, normal lactate, TSH. He is afebrile, BP 140/75, HR paced at 70, and satting well on RA. he has 2+ pitting edema b/l, JVP 15cm, +HJR, his extremities are moderately cool to touch. Overall he appears chronically ill but stable for the floor.

his EKG is belowADHF

His home medications are as follows

amiodarone 400 qday, furosemide 40mg BID, carvedilol 25mg BID, clopidogrel 75mg, pravastatin 10mg, diltiazem 30mg q6h, ranolazine 1000mg BID, ISMN 30mg BID, digoxin 125mcg qday, pradaxa 150mg BID

He is taken to RHC on HD1 with numbers below.

Hemodynamics:

Right atrium: 14 mmHg
Right Ventricle: 40/8 mmHg
Pulmonary Artery: 39/18/26 mmHg
PCWP: 20 mmHg

NIBP: 114/ 75/ 88 mmHg
Heart Rate: 60
PA sat: 47 %
Pulse Ox: 96%
Hgb: 14.6 g/dL

Assumed Fick: cardiac output 2.8 L/min, index 1.37 L/min/m2
Thermodilution: cardiac output 2.8 L/min, index 1.36 L/min/m2

Day 1 questions- What Stevenson profile is this patient? What are your treatment options and how do his RHC numbers inform your decisions? What would you do with his home medicines? What conditions make thermodilution less accurate? What kind of device does have in place?

If you have further questions of the patient’s history or initial presentation please ask as well

 

Quality Improvement Opportunities

Here are a couple of cool QI opportunities that can help you earn some $$$ as well.

1. AHRQ’s WebM&M
Submit cases of medical error/ patient safety to AHRQ’s WebM&M series. These cases are completely anonymous (no PHI, or information identifying the patient, institution or yourself). If selected, an expert will write a commentary on your case, and you will receive $300. Downside is that your identity is never revealed and you do not get credit/ a publication.
There is no strict deadline for this, but we never know when it will stop.
Please continue to report safety reports internally as well.
More information
Previous cases

2. ACGME’s Back to Bedside Initiative
This aims to empower trainees to develop transformative projects that combat burnout by fostering meaning in their learning environments and engaging on a deeper level with patients. The purpose of Back to Bedside is to support the development of innovative ideas, clinical practices, or policies that will improve physician well-being and foster a sense of meaning in work while increasing the time physicians have to spend in the care of their patients.
More information
Total funding: $10,000 per year renewable for up to two years.
Deadline for Proposals: August 5, 2017.