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CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2013-14

http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx. CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2013-14. WELCOME TO CRITICAL CONCEPTS. ROTATION OBJECTIVES:

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CRITICAL CONCEPTS LSU SCHOOL OF MEDICINE SENIOR ROTATION 2013-14

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  1. http://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspxhttp://www.medschool.lsuhsc.edu/emergency_medicine/critical_concepts_rotation.aspx CRITICAL CONCEPTSLSU SCHOOL OF MEDICINESENIOR ROTATION 2013-14

  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: Case 1 JUNE 5, 2014

  5. When suddenly … “Is there a doctor on the plane? your picture here

  6. A 63 year old woman traveling alone in first began shouting incoherently and wandering around about ten minutes ago. Suddenly, she slumps forward and becomes unresponsive. The flight attendant hands 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.

  7. CLINICAL SCENARIOS: Case 2 JULY 1, 2014 When suddenly … your pager goes off …

  8. A 60 year old man admitted to the floor got up to go to the restroom. Suddenly, he fell back into bed and became unresponsive. The floor nurse goes out to find a code cart. You are able to feel a weak radial pulse at approximately 120 beats/minute and note a respiratory rate of 10 breaths/minute.

  9. CLINICAL SCENARIOS: Case 3 October 10, 2014 You are on your EM rotation on a busy night shift when …

  10. EMS brings in a 57 year old man who was an unrestrained driver in a rollover MVC with multiple cars. He was not responsive at the scene. Vital signs in the ambulance were HR 115, BP 100/60, and RR 10. All of the EM residents are busy working up the other cars’ passengers.

  11. WHAT NOW?? • What would your immediate actions be • In the air? • If/when this happens to you on your first day of internship? • If you are the first medical professional caring for an acutely ill/injured patient? • FOR EACH CASE - LIST 5 OF THE FOLLOWING: • Initial actions • Possible diagnoses • Management/treatment steps

  12. 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

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

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

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

  16. 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?

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

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

  19. 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

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

  21. 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

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

  23. 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”)

  24. 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

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

  26. 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!

  27. 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

  28. DON’T BE AFRAID … This is fun!

  29. 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)

  30. 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

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

  32. DIDACTICS WEEK • Please read assigned material on website prior to each session … come prepared to discuss! • Each of the 9 specialties has designed their own interactive module on what they perceive to be most important in managing their most critical or common emergencies • Each module requires a faculty/preceptor signature

  33. ICU ROTATION • You are an active part of the ICU team and expected to have direct patient care and documentation duties • You should participate 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”* *TICU students – please contact fellows for time/place to meet prior to starting the week

  34. 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

  35. CASE & PROCEDURE LOGS • During your EM block, please log all patient encounters and procedures that you observe, assist with, and/or perform into New Innovations • This is a way to begin to build your medical portfolio

  36. 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

  37. 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

  38. 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. Avegno for attendance questions

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

  40. NOW … ENJOY THE COURSE!

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