Conference Notes 12-20-2012

VIJAY    ANO-RECTAL DISEASES

Thrombosed external hemorrhoids: elliptical incision.  Thrombosed hemorrhoid should be firm, tender, and purple.   Bleeding should be minimal.   You will express clots from your elliptical incision.  Sitz baths following procedure.

Anal fissure: Tx with sitz baths, stool softners, cautious nitroglycerine topically, anal hygiene.

Rectal FB:  Try passing foley beyond fb and slowly pulling fb out of rectum.

KATANNEH   STATUTORY RAPE

Consensual sexual  relations between individuals that would be legal except for their age.

Statutory rape is linked with increased suicide and lower academic achievement in victims.

In Illinois any sexual contact involving a person less than 17 and accused is 5 years older.

We are required to report if we suspect that the child has been a victim of abuse. This does not include a consensual sexual relationship with a boyfriend or girlfriend.  You could get sued by parents however.

If the older person is responsible for the younger person’s welfare such as a teacher, you have to report that. 

BARTGEN   M AND M

Osteomyelitis of sternoclavicular joint.

Metacognition=thinking about how we think

Decision making strategies: Heuristic or pattern recognition.   Systematic or hypothetico-deductive or Bayesian is reliable but slow.   Algorithmic method is used for high risk time dependent scenarios like codes.  Worst case scenario rule out method.  

Biases:

Pattern recognition suffers from anchoring and confirmation bias

Rule out worse case scenario suffers from value induced  bias.  This bias is expensive an we overutilize resources.   Decsion rules help with this bias

Hypothetico-deductive method suffers from premature closure bias.

Bias defenses:  awareness of biases, stay skeptical, question your diagnosis, consult in uncertain situations

 

Identify risky discharges: abnormal vitals, elderly, poor access to care,  patients that had another recent evaluation, patients that worry you, high risk complaints,  communication errors, rare problem.

71% of bounce backs had a resting tachycardia on the first visit.

Address abnormal vital signs with additional thinking, testing, observation, and arranging follow up.  Read the notes in the chart from nurses and other staff and EMS. 

Specific, clearly written discharge instruction are your last defense against bad outcomes.

LAMBERT  U/S GUIDED VASCULAR ACCESS

U/S decreases your time required to do a central line and decreases complications as well.   It also works well for perioheral lines.

Gotta use a high frequency linear probe to do vascular access.  It has better resolution in the near field.

Can use tegaderm to provide sterile coverage on the probe if you can’t find a sleeve.

To see needle on screen it has to be in a 1.5mm cut of the probes beam.

Keep indicator on the probe to the procedure performer’s  left.  The probe indicator should also be in same direction as the dot on the screen. 

Keep probe perpendicular to skin.  For right IJ, the probe should be just superior to clavicle with medial edge of probe near medial end of clavicle.

Make sure IJ collapses with probe compression.

The Sonosite machines in our department have a soft ware enhancement that greatly highlights the needle on U/S.  You have to be in the vascular program to use this feature.

When you tent the vessel with the needle, Mike recommends making a jab with needle to puncture thru the vessel.  If you tent to far though you can jab thru the back wall of the vessel.  So jab just when you begin to tent the vessel.

For peripheral lines use the basillic vein.  It is the largest vein above the elbow.   You will need a longer angiocath due to the distances involved.

Bedside U/S for DVT

Best view of the CFV is at or below the great saphenous junction with the CFV.   If patient has clot to both vessels, Mike recommends consulting vascular as this is a higher risk scenario.

Pop on top=popliteal vein is more superficial than popliteal aretery.

DVT study you need to visualize the CFV and make sure it compresses and visualize the popliteal vein and make sure it compresses. Get a 5cm sample of views at both sites.   Make sure the clip you save shows complete compression at both sites.

Augmentation: Seeing back flow in the popliteal or CFV with calf compression does not rule out dvt.   It just means that the vessel is not completely occluded. 

LAMBERT  VASCULAR  ACCESS LAB