8:00 am M&M by Drs. Wiseman and Stander

Case 1
A case of N/V/D.
Learning points:
1. In patients with long-standing N/V/D it may be helpful to obtain UDS
2. Females with abdominal pain must have pelvic exam no matter what. It’s the right way to do!
3. Self-swabs for GC/CT are subpar, and pelvic exam with cervical swab need to be done
4. With patients with non-specific sxs for few weeks, HIV testing may be helpful

Case 2
A case of ambulatory dysfunction
Learning points:
1. When an elderly patient presents to ED and there is no previous workup done/not documented, MD may consider doing screening labs regardless of chief complaint in select cases

Case 3
A case of respiratory distress
Learning points:
1. Never discharge patients with abnormal vital signs
2. Remember that combination of homelessness and mental disease have a very high morbidity and mortality

Case 4
A case of drug overdose
Learning points:
1. If you as an ED resident believe that the patient needs a higher level of care and you are getting a pushback from the admitting team, this needs to be escalated to an attending to attending discussion
2. Using beta-blockers in methamphetamine toxicity is not a good idea due to unopposed alpha action

Case 5
A case of SOB
Learning points:
1. Be liberal checking a blood gas on patients with COPD/asthma that you are admitting for SOB, as hypercapnia is a common factor in their deterioration on the floors.

10:00 am Pediatric Endocrine and Metabolic Emergencies by Dr. Shakir Hussain

Endocrine emergencies:

1. DKA

Definition: blood glucose >200, pH <7.3, bicarb <15, evidence of ketoacids in blood or urine
Common presentation of new onset DM
Occasionally present as euglycemia
Pathophysiology: insulin deficiency pushes glucose up in blood, resulting in polyuria, polydipsia, weight loss, enuresis. Stress response (glucagon, cortisol, GH, catecholamines), results in ketosis, acidosis, resp alkalosis
Cachexia, dehydration, gaunt appearance
Tachycardia, Kussmaul breathing
Altered MS – watch out – 1% have clinical cerebral edema
GI sxs: N/V, gastroenteritis, constipation and fussiness
Labs: accucheck, VBG, chem-7, urine dip, beta-HB
Tx: IV access, start IVF 10 cc/kg over 1 hour prior to giving Insulin, NSS is preferred
Hydration/hydration/hydration: IVF drop blood glucose well, and improves sxs as well.
Do not give bolus of Insulin!!! Insulin gtt only 0.1 U/kg/hr!!!
Monitor el/lytes
Watch for AMS: if you believe it’s cerebral edema, give Mannitol 1 mg/kg over 10 min without imaging
Symptomatic treatment

2. Diabetes Insipidus

Hypertonic dehydration
Normal UO, dehydration and hyperosmolar state
Multiple causes: deficiency of ADH or unresponsive to ADH
In ED: Recognize dehydration and treat it!
Diagnostic criteria: Elevated serum osmolality >300, hyperNa >145, dilute urine osmolality <600
Tx: volume resuscitation NS 20 ml/kg, DDAVP for central, but nephrogenic do not respond to DDAVP, they respond to thiazide diuretics

3. Hypoglycemia

Irritability, somnolence in small kids
Definitions: glucose <50, for newborns and infants <45
Correction: juice
Rule of 50: 2 ml/kg of D25, 5 ml/kg of D10 or 1 amp of D50!
If on Insulin pump, then correct hypoglycemia and disconnect the pump
Once it’s corrected, start searching for the cause: infection, malnutrition, sepsis, adrenal insufficiency, insulin overdose, beta-blockers, etc
Urine for ketones, beta-HB

4. CAH (Congenital Adrenal Hyperplasia)

Inborn errors of adrenal steroid biosynthesis
Ambiguous genitalia
Acute presentation: lethargy, V, weight loss or gain, may be in shock
Salt wasting crisis is common 2-5 weeks of life
HyperK, hypoNa, low bicarb
Get labs and accucheck
They are hypovolemic
Treat as acute adrenal insufficiency: volume resuscitation, IV Ca for membrane stabilization, stress dose of steroids (hydrocortisone is preferred). Insulin is contraindicated due to the danger of hypoglycemia!
Hydrocortisone:
< 2 yo, give 50 mg IV/IM
> 2 yo, give 100 mg IV/IM
Symptomatic treatment

5. SIADH

Opposite of DI, excessive ADH secretion, volume overload with dilutional hypoNa
Most are asymptomatic until Na <125
AMS, weakness, seizures, volume overload
Causes infections, chemotherapy, hypoxia of brain, trauma, pneumonia, etc
Tx: id hypoNa, give 3% NaCl bolus 3 mg/kg. Asymptomatic – aggressive IVF.
Symptomatic treatment

Metabolic emergencies:

1. Unknown realm
   mom states something is wrong, but cannot specify
   This is a common presentation of metabolic emergencies
   Abnormal newborn screen: not feeding well and vomiting
   Neonate does not appear well, but does not have fever
2. Inborn errors of metabolism
   Single gene defects: affect carb, fat, protein metabolism, so toxic byproduct buildup that causes sxs
   Most are autosomal recessive
   May have multiple trips to healthcare providers
   Sxs are usually after initiation of feeds
   Poor feeding, vomiting, weight loss/gain, hypothermia
   May have abnormal tone or seizures, tachypnea or cyanosis
   May present septic
   May present as unexplained bleeds – workup for child abuse
   Their risk of dying is very high
   Metabolic acidosis with gap: get VBG, hypoglycemia, hyperammonemia
   Keep them NPO, start D10
   Lytes, CBC with diff, ammonia, LFTs, coags, ketone bodies, urine for organic acids
   Imaging: CT head, CXR, Abdominal X-ray
   Their first presentation may be SIDS, and Dx of IEM is on autopsy
   Your job in ED: suspect IEMs, stabilize, and get them to specialist
   If > 5 yo: may present psychotic/neurologic sxs, abdominal pain/V, rhabdomyolysis

11:00 am "Feedback: getting it and giving it" by Dr. Sharon Griswold

Part 1: Giving feedback

Principles of giving good feedback: your feedback matters
Types of feedback:
- Direct – immediate, you state what you need to be done immediately
- Reflective
- Formative – active learning, practice, SIM. It’s a feedback for learning
- Summative – tests, evaluations
- "High stakes" – board exams
It’s hard: involves feelings (negative feedback hurts) + facts (different versions of truth) + identity (especially MDs)
Great book: Difficult conversations by D. Stone
Great TED talk: Brene Brown’s list of when it’s ok to give feedback "Listening to Shame".
Ground rules:
- Everyone is well intentional and wants to do their best
- Don’t shame/blame/simple answer (lazy, stupid, arrogant, etc)
- Professionalism slips (do not give feedback if you are too hungry, angry, lonely, tired)
- Healthcare is rough

Focus on behaviors, not people!

Start with observation: I saw, I thought, I noticed, I observed, I heard, etc
Advocacy: I thought, I liked that, I appreciated that, I am concerned, I felt uncomfortable because…
Reflection: Your thoughts? I am wondering if you can tell me more! Can we talk about that?

Meaningful feedback:
- Shift cards
- Setting intentions
- CCC (clinical competency committees)
- At the end of the residency PD must declare trainee competent for independent practice

Delayed feedback does not work as well.
Non-specific feedback is not helpful.

Part 2: Getting feedback

Know your tendencies
Disentangle the "what" from "who" and impact from intent
Sort toward coaching
Unpack the feedback
Ask for just one thing
Engage in small experiments

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

 
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