• Secondary Trauma/Moral Injury¹

• Intro to EDH¹

• Room 9 Follow up with Dr. Whitford
  1. -Thyrotoxic Periodic Paralysis is an extremely uncommon but high mortality condition (80-100%) complication of thyrotoxicosis
  2. -Replete potassium aggressively. Avoid steroids if possible. Can give propanolol in conjunction for those patients refractory to potassium repletion
  3. VV ECMO for patients primarily with ARDS or inability to oxygenate/ventilate. VA ECMO for patients in acute cardiogenic shock

• Social Work in the ED

– Common misconceptions is that social work in the ED is able to find housing for homeless patients

– Social work is able to pay for some low cost medications for patients and help with some DME during business hours (things like ostomy supplies not covered)

– Also can help with transportation to substance use disorder clinics

• Survival Guide to the Peds ED

– Complete your notes on time (within 24 hours). Recognize sick vs not sick. Utilize complaint order sets to your advantage

-Heme/Onc, NES admit to themselves. Very select pediatricians will admit to themselves. Only fellows and attendings call to give report on PICU patients

-FiO2 50-60% and 2L/kg for HHFNC in kids is threshold for PICU

-Pay attention to vaccination status. Certain febrile neonates will automatically get an LP and septic workup compared to other kids

-White hot is a febrile chemo patient.Red hot is a febrile neonate

-Straining does not mean constipation in newborn population. Be careful about putting words toxic/lethargic/irritable in note unless you’re intubating, performing LP, or resuscitating. Describe in your note and paint picture of what kid looks like (high fiving, smiling, interactive, etc)

• Cardiac Pacing¹

-Indications: unstable bradycardia, SSS with frequent pauses

-Can do both transcutaneous and TVP. Start with TC pacing but prep for TV pacing. Can place pads anterolateral or anteriorposterior

-TC pacing: Select pacer function, select rate (typically around 70), set current and look for capture. Can increase current until you get capture by 10 mA equivalents. If youre getting to 120 mA without capture, consider replacing pads. Capture will look like QRS complexes on tele after each pacer spike. Make sure you have mechanical capture as well (palpable pulse, BSUS)

-TV pacing: Set up on generator has three knobs: rate, output, and sensitivity. 80/20/20 is typical initial set up for asynchronous pacing.

-TV pacing: First step is placing Cordis (preferably R IJ). put sterile sheath on pacer wire and have non-sterile assistant attach connecting cables to generate. insert the swan pos and neg pins then insert swan into cordis and go to about 20 cm and stop. then you inflate balloon, and advance until you get capture. once you get capture, decrease output until you lose capture and then incr to lowest effective output.

• How to Break Bad News²

– Be aware of the setting and perception of family members when you are delivering bad news. You want to know what they already know before you talk to them. Invite them to explain how much they want to know

-Don’t use medical jargon. Allow time for frequent pauses. Use chaplains and their services, they will typically tell you ahead of time who is in the room and what/how much they know

1. ↩︎
2. ↩︎

Healthcare Disparities in the ED:

• -amongst persons experiencing homelessness (PEH), the rates of mental illness and substance used disorder is disproportionately higher compared to the non-PEH group
• – Implicit bias still affects medical care in the US today; black individuals are less likely to receive urgent triage score or to be admitted to the hospital for their complaints.
• – It has been well studied that patients receive better care and have better health outcomes when cared for by doctors who share similar identities in race or gender
• – Try to use preferred names and pronouns. Don’t ask intrusive questions or perform intrusive exams when not indicated. Be compassionate.
• – healthcare costs associated with undocumented immigrants (UI) largely felt by the ED. EMTALA applies to UI as well as documented immigrants.

• How to Give and Receive Checkout:
• – A TOC occurs when >2 providers exchange info about a pt. Happens more than you think
• -In a TOC, be clear, brief, timely and complete. Check your bias. Give the oncoming residents time to ask questions
• – Use IPASS mnemonic when transitioning care between providers
• – Check out your sickest patients first
• – Consult with a purpose and a specific request/question

I posted this paper and it’s revisited update on room9er about 3 years ago. July is always a good time for it!

Here is the original paper.

Here is the update.

The fundamentals do not change much!