CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2011-12

1. http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspxhttp://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx Twitter: @emednola FB: LSU-EM @ NOLA CRITICAL CONCEPTSLSU SCHOOL OF MEDICINESENIOR ROTATION 2011-12

2. WELCOME TO CRITICAL CONCEPTS ROTATION OBJECTIVES: • Provide all senior students with exposure to acute and critical care concepts in a variety of learning modalities.  • Review and reinforce diagnostic and management skills in common and/or critical disease entities and procedures encountered in a range of specialties. • Prepare senior students for their new roles as resident physicians with direct patient care and health care team responsibilities.

3. UNDERLYING PRINCIPLE • Every physician – regardless of specialty – should know how to manage acutely ill, undifferentiated patients with a variety of emergent conditions

4. CLINICAL SCENARIOS JUNE 5, 2012 / JULY 1, 2012

6. When suddenly … “Is there a doctor on the plane?/in the ward?” your picture here

7. A 63 year old woman traveling alone in first class/admitted to the floor began shouting incoherently and wandering around about ten minutes ago. Suddenly, she slumps forward and becomes unresponsive. The flight attendant/nursehands you a medical bag. You are able to feel a weak radial pulse at approximately 110 beats/minute and note a respiratory rate of 8 breaths/minute.

8. WHAT NOW?? • What would your immediate actions be • In the air? • If/when this happens to you on your first day of internship? • LIST 5 OF THE FOLLOWING: • Initial actions • Possible diagnoses • Management/treatment steps

9. MANAGEMENT OF THE ACUTELY ILL PATIENT • Based on the principles of identifying and treating the immediate, life-threatening conditions first • All other considerations come second • KEEP IT SIMPLE

10. PRIMARY SURVEY VITAL SIGNS = CRITICAL IMPORTANCE HR RR BP Temp Pulse Ox

11. PRIMARY SURVEY A – airway evaluation • Are there any signs of obstruction? • FB • Masses • Trauma • TONGUE

12. INTERVENTIONS • RELIEVE THE OBSTRUCTION before moving on • Finger sweep • Chin tilt/head lift or jaw thrust • Repositioning • Suctioning/hemorrhage control • FUTURE AIRWAY PROTECTION?

13. PRIMARY SURVEY • B – breathing, oxygenation & ventilation • Is the patient able to sufficiently oxygenate and/or ventilate? • Look for • Agitation/restlessness • Tachypnea/use of accessory muscles • Bradypnea/apnea • Breath sounds on BOTH sides • Tracheal deviation? • JVD?

14. PRIMARY SURVEY • Life threatening conditions requiring immediate intervention • Tension PTX • Flail chest • Respiratory failure/distress • Primary pulmonary issue • Consequence of underlying disorder

15. INTERVENTION: • Assisted oxygenation/ventilation through • Supplemental O2 (how much & how?) • Proper bag-valve-mask • Non-invasive positive pressure ventilation • Intubation (RSI)

16. PRIMARY SURVEY • C – circulatory status • Assess for PULSES (bilaterally) and heart tones • Any obvious bleeding? • Other s/s: • MS changes • Cool, pale extremities • Capillary refill • BP/HR – shock index

17. PRIMARY SURVEY • Life threatening conditions requiring immediate intervention • Shock states: • Hypovolemic? • Cardiogenic? • Distributive? • Obstructive? • Active hemorrhage

18. INTERVENTION • Venous access (large bore/CVC) • Administration of blood or fluid products in rapid boluses • Target to specific types of shock: • Cardiogenic – inotropes, BP support, procedures • Sepsis (distributive) – EGDT, source control • Obstructive (PE/tamponade) • Anaphylactic – epi, antihistamines

19. PRIMARY SURVEY • D – disability assessment • Mental status/level of consciousness • Gross neurologic exam • Pupils • GCS if trauma

20. INTERVENTION • Prompt imaging as warranted (trauma – hemorrhage or fracture; medical – CVA/mass) • Prompt Neuro specialist involvement if appropriate • Reversal/supportive care if toxidrome • Consider likelihood of airway protection (“GCS less than 8 = intubate”)

21. PRIMARY SURVEY • E – FULL exposure • Every inch of the patient is surveyed and documented for obvious life threats • Occult traumatic injury • Infectious sources • Rashes/skin changes • Medications/patches

22. INTERVENTIONS • Imaging/tests/treatment based on findings • Removal of any offending agent

23. After stabilization … • Brief, targeted HPI/PMH etc. (“AMPLE”) • REASSESSMENT OF VITAL SIGNS and success of any intervention • Detailed testing • Longer-term treatment and management • Secondary survey: FULL PHYSICAL!

24. GOALS • … in the care of the undifferentiated patient: • Identify life-threatening processes • Immediate stabilization • Consideration of most serious and most likely diagnoses • Initiation of definitive treatment and care • Utilization of all available resources when appropriate

25. DON’T BE AFRAID … This is fun!

26. ROTATION HOUSEKEEPING • Course structure and expectations; • 1 didactics week • 2 EM weeks • 1 ICU week • You are expected to be an active participant in all parts of the course, and a full member of each team • (consider yourselves acting interns)

27. YOUR GOALS • What should you get out of this? • Expanded skills and knowledge base from 3rd year • Application of those skills/knowledge to more complicated/critically ill patients • Increased exposure to/experience with common and emergent procedures & interventions • More sophisticated understanding of disease complexity & health systems management

28. WHO WHAT WHERE WHEN • Most of you are here: • We want to move you here: REPORTER HOW WHY WHAT NEXT? INTERPRETER MANAGER

29. DIDACTICS WEEK • Please read assigned material on website prior to each session … come prepared to discuss! • Each of the 8 specialties has designed their own interactive module on what they perceive to be most important in managing their most criticalor common emergencies • Each module requires a faculty/preceptor signature

30. ICU ROTATION • You are an active part of the ICU team and expected to have direct patient care and documentation duties • You shouldparticipate in family and team discussions of care plans • Details will differ between ICUs • Information on where/when to report to ICUs – see CC website under “Didactics Schedule & ICU Information”

31. EM ROTATION • Again, you are expected to have direct patient care responsibilities as part of the EM team • Please read the assigned EM readings during your 2 week block • While on the EM portion of the rotation, you are expected to attend EM student lectures and labs

32. SOCIAL MEDIA • Another part of the curriculum! • Information available on the website – there are several ways to have this information “pushed” to you • This content is testable!

33. CASE & PROCEDURE LOGS • During your EM block, please log all patient encounters and procedures that you observe, assist with, and/or perform into E*Value • If you have forgotten your logon/password … please let Dr. Avegno know • This is a way to begin to build your medical portfolio

34. RESPONSIBILITIES • BE ON TIME … for all sessions, rounds, and shifts • Adhere to the school honesty policy at all times • Be properly supervised in all educational and clinical settings and duties

35. EVALUATION METHODS • Final grade is based on: • End of rotation on-line exam, derived from: • EM and specialty-specific reading (all online on website) • Social media content • Didactic session lectures and labs • Professionalism assessment during clinical rotation • H/HP/P/F system • Either component can be remediated if necessary

36. ATTENDANCE POLICY • Students may miss 2 days of the rotation FOR INTERVIEWS ONLY: • During EM block – may miss 1 ED shift and one “free”day • During ICU block – if 2 ICU days are missed, they must be remediated the weekend before or after (in order to have a full week of ICU) • DIDACTICS DAYS MAY NOT BE MISSED • Please contact Dr. English or Dr. Avegno for attendance questions

37. FORMS • Please turn in evaluation form to Jennifer Jeansonne, course coordinator, upon completion of the rotation (room 615)

38. NOW … ENJOY THE COURSE!