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Grand Rounds October 26, 2023

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8-8:30) How to have difficult conversations – Dr. Keith Baker, MD

  • Make sure you have the time for these conversation
  • Make sure you have someone with you when you break the news
  • Positioned in the room in an area where you can get out
  • Opening line “what do you know that’s going on” or “I am sorry I have some difficult news for you” or something
  • In a brief way step them through what actually happened
  • “ I am very sorry she or he has Died” you have to say it …. Then you stop talking
  • If you feel comfortably you can give family hug ect
  • “Is there anyone you need us to call for you”
  • “Do you want a chaplan here?”
  • “ if you have any questions we are here for you”

8:30-9) Who are the immunosuppressed?- Patrick Cheatle, MD 

  • Immunosuppressed
    • Autoimmune
    • Transplant recipients
    • Chronic conditions requiring steroids
    • Cancer patients
  • Immunosuppressive medications
    • Corticosteroids
    • Calcineurin inhibitors
    • Antimetabolities
    • Immunoglobulins
    • Ionizing radition
    • Biologic alkylating agents
  • Glucocorticoids- suppress antibody complement binding; inhibits synthesis of all inflammatory cytokines
    • Side effects:
      • increased susceptibility to infection
      • Impaired wound healing
      • Hyper glycemia
      • Htn
      • PUD
      • Psychiatric stuff
      • Osteopenia
      • Weight gain
  • Glucocorticoids withdrawal
    • Can suppress HPA but needs to be on it for over 3 weeks.
    • Wd symptoms looks like adrenal insufficiency
    • If they are on them over 3 weeks then they need a taper
  • Calcineurin inhibitors- tacrolimus, cyclosporine
    • Inhibit calcineurin suppress t and b cells
    • Most post transplant patients on it
  • Calcineurin inhibitors Side effects
    • Nephrotoxic
    • Htn
    • HyperK
    • Hypomag
    • Neuro shit
  • Antimetabolitis MMF
    • Inhibit proliferation of T and B lymphocytes
    • Chemo agents and organ transplants
  • Side effects
    • Bone marrow suppression
    • GI stuff
  • Immunoglobulins
    • Monoclonal antibody that binds to CD52🡪 targets lymphocytes for destruction
    • CLL and MS treatment
  • Transplant patients
    • Lifelong immunosuppression
    • Adverse outcomes are directly proportional to increasing age of the recipient and donor organ
  • Infections in transplant recipents
    • <1 month s
  • Rejection time lines A close-up of a medical reportDescription automatically generated
  • GVHD TX
    • Tx:
      • glucocorticoids; high dose
      • Calcineurin inhibitors
      • Empiric abx

9-9:30) Airway review – John Pester, DO 

  • Pester showed us videos of our intubations with the new glidescope gave us pointers on how to improve
  • ALWAYS HAVE EPIGLOTTIS IN THE VIEW if you do not see it then you went tooooooo far.
  • C collar patients- always use hyper angulated blade (S3)

9:30-10:30) Interactive Board Review – Rachel Patterson, MD 

  • Pictionary

10:30-11) Mentorship – Rebecca Jeanmonod, MD 

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  • Humanism – learning, science on how people learn and grow
  • Knowing – action – meaning
  • Humanism – fulfillment of purpose. 
  • What makes a good teacher – being an example, patience, empathy
  • Mentorship – beyond the classroom
  • Longterm, profession and personal growth, focus on development, dyad, subject agenda, informal, structured
  • Real, acceptance, empathy, needs assessment, goals,
  • Listen — ask —advise
  • Seeing potential
  • Support from below, place protection

11:00-11:30) EM Case Presentation – Daniel Greco, DO 

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11:30-12) TRIAGE – Chiefs 

  • Toxicology
    • Isoniazid toxicity: TRIAD
      • Refractory seizures
      • SEVERE metabolic acidosis
      • Coma
        • TX: B6
  • Radiology
    • A chest x-ray of a personDescription automatically generated
    • Kartagener syndrome-sinus inversous primary ciliary dyskinesisa ( infertility stuff and lung stuff)
  • Integument:
    • Close up of a person's mouthDescription automatically generated
    • Koplik spot- lesions on buccal mucosa consisting of pinpoint greys spots surrounded by bright red inflammation.
    • MEASLES aka rubeola
  • Ancillary
  • General
    • Endocarditis
      • Close-up of a person's handDescription automatically generated
      • A close-up of several images of human organsDescription automatically generated
  • EKG: 47yoM coming in with cc of nausea
    • https://litfl.com/ecg-case-035/
    • A graph with a number of linesDescription automatically generated with medium confidence
    • T waves in leads III and aVF appear to tower over the preceding QRS complex, and have a wide, “bulky” appearance. Such changes are consistent with hyperacute T waves (HATW) representative of hyperacute occlusion and evolving ST elevation
    • There is reciprocal ST depression in V1-3 and I
    • These changes are suggestive of hyperacute inferior OMI, likely due to occlusion of a dominant RCA given the lack of ST elevation seen in lateral leads. This ECG was faxed from the pre-hospital environment — by the time of arrival to an emergency department it is likely that we would see classical ST elevation evolving.
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