VTCEM Residents & Faculty,

That was nice weekend weather for October…

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-Thanks to Faculty, Staff Admin, and Residents who helped to make HEENT Sim Lab for the residents last Thursday successful.

House Scoring

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-House Assignments: https://drive.google.com/file/d/1RyeevW45TS0D8Myk1bURlTIOSMeIYa1w/view?usp=sharing

-Standings:  House Clinton: 41, House Perkins: 38.5,  House Kuehl: 36.5, House Fortuna 35.5

Dear Doc Mystery Case Competition

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-Dr. Perkins’s Monthly Mystery Case 

-1st place: 50 pts,  2nd place: 25 pts, 3rd place: 15 pts, 4th place: 10 pts, 5th place: 0 pts

-Each House should designate one person who will submit the Dear Doc Mystery Case answers to Dr. Perkins.

General Program

-Temporary Resident Room Displacement: 10/19-10/21 – the ED Resident room will be undergoing some renovation/maintenance.  Please remove contents of your locker and remove any locks on the locker ASAP.  The 1S ED Admin Conference Room will be a temporary workroom for residents.-Epistaxis Learning Pearls:https://drive.google.com/file/d/1_cGm0K7yirqcGN8yuGpEsTP_zlzlnLBJ/view?usp=sharing
https://drive.google.com/file/d/1jNfNzyqY6vd_SQoLZhTTDwQufeBAycjP/view?usp=sharing

Ultrasound Peritonsillar abscess – Courtesy of Dr. Clinton:https://drive.google.com/file/d/12ElysHr-6MLypNj3j9d5wYEEc7dHji1L/view?usp=sharinghttps://drive.google.com/file/d/1WtSnoqOMYJvWmzjz4KLQ6kJz40bDBvLR/view?usp=sharing

-Residents – please note that a Mock ITE is being scheduled for early December 2020.  It is designed to simulate the content, pace, and conditions of the formal ITE being held in late February 2021.  ED Admin is currently coordinating a 5-day period during which a resident may complete the Mock exam in one sitting. More information to come.
-Dear Doc Concise Consults: https://drive.google.com/file/d/1tK5vjzdCN7OyV0gKL0Nejhw1a4pdVsZY/view?usp=sharing
-Courtesy of Dr. Janet Young – regarding CORD case submissions: https://drive.google.com/file/d/1f_8PDEB6FoHpUAzf70yOUgr3JN2rnYJe/view?usp=sharing

-Courtesy of Dr. Klemencic – Monthly LOA food box delivery, Tuesday Oct 20 10a-2p:https://drive.google.com/file/d/1Ynxge5wgKjiDzk60AVgLvPwdKiFdZ9GR/view?usp=sharing

-Update on Cures Act and Note Etiquette:https://drive.google.com/file/d/1Y6Pgb9Xg_UI5Llq6cBn0X68y-pSRtkoQ/view?usp=sharing
https://drive.google.com/file/d/1Sp6RlW-tI5DMDs3TjMLm48merAjAJxbi/view?usp=sharing

-E5 & E6 Retrofitting: https://drive.google.com/file/d/1TnOJ99RV2nRkkkkLteo1qlbtodTOagLn/view?usp=sharing
-Family Medicine: Please Call Family Medicine Resident 24/7 for any patient you plan to refer ED Obs – now through 10/30:https://drive.google.com/file/d/13u2DcFoRurbOCFoFGoduHb379FTXSuX2/view?usp=sharing
https://drive.google.com/file/d/1gy_YmXrGpbNRSDwaBgjabKKljVwG8OY7/view?usp=sharing

-Octreotide Shortage/Recommendations for Use:https://drive.google.com/file/d/111FiKyZE2S9sHZqCvwHrCH6P1G1q_Z4_/view?usp=sharinghttps://drive.google.com/file/d/1EklnFfznMpk1E_5qTbGzgqe8mwxNfYhB/view?usp=sharing

-Usability Study/Product Evaluation Opportunity:https://drive.google.com/file/d/1EZQ7m9SLSSvfxvYziG9_xWKxwcZzQiIJ/view?usp=sharing

Peds Corner Peds Rescue Seizure Medications – Courtesy of Dr. Uherick and PharmD Kelly Mcallister
Midazolam INH – On the inpatient side, providers tend to lean towards using inhaled midazolam. It is easier to administer than PR diazepam. Dosing for Midazolam INH  is 0.2 mg/kg (Max 10 mg) split between the nares. There is a new commercial product made specific for intra-nasal administration, however, insurance companies are not covering it. Our inpatient Peds pharmacist has only had it successfully covered by insurance once. The pharmacists are sending patients home after educating them on how to draw up meds and use an atomizer.  
Diazepam PR – If a patient is already on Diastat PR (Diazepam PR), then sometimes inpatient providers will not switch them over because the patient is already used to it and has had success. The dose for Diastat PR is based on age and weight. Using the parenteral formulation (5 mg/mL): 0.5 mg/kg/dose, followed by 0.25 mg/kg/dose in 10 mins, prn (Max 20 mg dose). Rectal gel formulation: 2-5 years: 0.5 mg/kg PR; 6-11 years: 0.3 mg/kg PR; >= 12 years/adolescents: 0.2 mg/kg
Clonazepam ODT – Clonazepam ODT is interesting and specific to certain kids. It is not actually sublingual like one would think.  It is just a rapidly dissolving oral tablet (like Zofran ODT) that has the same pharmacokinetics as a regular tablet.  Kids just don’t have to swallow it.  Onset is close to 40 minutes, so it will not really help with an acute seizure.  Our providers tend to use it more for those patients who have cluster seizures.  If a kid presents with a respiratory infection and tends to seize often with those symptoms, pediatric providers will often start them on Clonazepam ODT for 3-4 days while they are symptomatic and then discontinue after symptom resolution.  There are several different dosage forms: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg. 

Fellowship News

Wilderness Medicine:

 Please email StephLareau@gmail.com with any questions.

WM Calendar
-Oct 19: Fellowship Journal Club 6p-10p:https://drive.google.com/file/d/1lhkS1VpBodS5dgIGb0yJZF95rqeTFt25/view?usp=sharing
https://drive.google.com/file/d/1X_x0yj836PaItVnmemIBmpGHiPl-HBUt/view?usp=sharing
https://drive.google.com/file/d/14SSj9M6DeNlUyo_VqKu5JW-aAtpYbDBG/view?usp=sharing
https://drive.google.com/file/d/1r5pc2XzZVy0rSCxyLkynCtY4Ta4gXepg/view?usp=sharing

-Oct 20: Joint WM/EMS Fellowship Scenario: 2p-8p(Residents welcome to join)
Nov 4: Fellowship Journal Club (virtual with WM Fellowships nationwide)-Nov 7-8: Mountain Shepherd Survival School (ask Dr. Justin Gardner at jgardner4028@gmail.com for more details)
WM PearlsCourtesy of Dr. Lareau:
Accidental hypothermia can be a huge problem in cold weather for patient populations who cannot get out of the cold weather or people who are outdoors and get stuck there (think exhaustion, trauma, slips and falls, or intoxication).  
Patients who become really cold often appear dead, however, there have been some very impressive case reports of heroic efforts to re-warm seemingly dead people with normal neurological recoveries.  One is a case of Anna Bågenholm, a Swedish ortho resident, who survived a body temperature of 56.7F after a 9 hour resuscitation effort involving cardiac bypass.  

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Rescuers working frantically to save Anna Bagenholm from a hole in the ice of a mountain stream.

Another case in which a patient was pulseless for at least 70 minutes after hypothermic arrest without CPR also had a full neuro recovery after resuscitation was initiated.  So remember you are not dead until you are warm and dead!

EMS:

EMS Pearls
-Not all prehospital time is equal: Influence of scene time on mortality: https://drive.google.com/file/d/1Iet4fzXoL-BcRJvb-V9yYejfgZB70Z6R/view?usp=sharing

Ultrasound:US Pearls-Necrotizing Fasciitis: https://litfl.com/ultrasound-case-092/

Academic 

Please read the following from the Program Director regarding the Academic Curriculum this year:

https://drive.google.com/file/d/19xRpkNg60QpJkmnSdUBUlDqQADmd-NvS/view?usp=sharing

-Overall curriculum: https://drive.google.com/file/d/16GE4pUmUOqFOW2xCXjXHcEMzhrx28rwN/view?usp=sharing

PGY1: Reading:Foundations 1 –  https://foundationsem.com/heent/Foundations 1 – https://foundationsem.com/immunology-dermatology/EM Coach – https://www.emcoach.org/ – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm 
Review Tests due 10/30:EM Coach F1 – Unit 16 HEENT, Unit 30 Immuno/Derm Rosh Tests: Foundations I – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm, Unit 3 – GI III
PGY-2/3: Reading:Foundations 1 –  https://foundationsem.com/heent/Foundations 1 – https://foundationsem.com/immunology-dermatology/EM Coach – https://www.emcoach.org/ – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm AliEMU – https://aliemu.com/courses/cutaneous2019/                   https://aliemu.com/courses/heent-2018/
Review Tests due 10/30:EM Coach F1 – Unit 16 HEENT, Unit 30 Immuno/Derm, PGY-3: F2 – Unit 16 HEENT 

Rosh Tests: Foundations I – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm, Unit 3 – GI III

Conference-Conference this week on Thursday will start at 7:30a with Multi-disciplinary Critical Care Case Conference followed by the VTCEM Residency Program Business Retreat.  -Below is a general idea of how the Business Retreat may go.  Please note that the location and timing has not been officially confirmed and may be subject to change.  More information to come early this week. 

8:30-9:30a Transition to Lancerlot Sports Complex, 1110 Vinyard Road, Vinton, VA 24179

9:30-11a Complete Business Retreat Work Items

11a-1p Eat lunch/Ice-Skating

Scheduling-Block 4 and 5 shift scheduling complete. 

Oldies, but Goodies
-Please continue to report events, near misses, and unsafe conditions to SafeWatch or by calling 540-981-7233 (7-SAFE).

Interns/PGY-1s: Important Email Points

Reading:Foundations 1 –  https://foundationsem.com/heent/

Foundations 1 – https://foundationsem.com/immunology-dermatology/

EM Coach – https://www.emcoach.org/ – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm 

Review Tests due 10/30:

EM Coach F1 – Unit 16 HEENT, Unit 30 Immuno/Derm 

Rosh Tests: Foundations I – F1 – Unit 16 HEENT, Unit 30 Immuno/Derm, Unit 3 – GI III
Conference

-You should attend the upcoming VTCEM Business Retreat on Thursday, 10/22.  

Website: damonsdue.com

Email: rmhchiefs@gmail.com

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Stay safe.

Lu Ojeifo, MD

Chief Resident, VTCEM

540-525-9533

cc: Chief Resident, VTCEM, Dr. Cassie Schandel, 540-529-1180

Chief Resident, VTCEM, Dr. Zach Williams, 540-597-5495

VTCEM Residents & Faculty,

-Hope everyone is enjoying the Labor Day weekend. This week – we get back to business.

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“May your hands always be busy, 

May your feet always be swift,

May you have a strong foundation,

When the winds of changes shift.”

-Bob Dylan (Forever Young)

House Scoring

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-House Assignments: https://drive.google.com/file/d/1RyeevW45TS0D8Myk1bURlTIOSMeIYa1w/view?usp=sharing

-Current Standings:  House Clinton: 40.75, House Perkins: 38.5,  House Kuehl: 36.25, House Fortuna 35.25

Dear Doc Mystery Case Competition

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-Dr. Perkins’s Monthly Mystery Case is coming up this month.

-1st place: 50 pts,  2nd place: 25 pts, 3rd place: 15 pts, 4th place: 10 pts, 5th place: 0 pts

-Each House should designate one person who will submit the Dear Doc Mystery Case answers to Dr. Perkins.

General Program

 -Please read the following from the Program Director regarding  Conference, Recruiting, Program Evaluations, New Faculty Orientation, New Shift Evaluations:

https://drive.google.com/file/d/1VyVl5ryKXZB_K8-Pim5gYiOfjn0JhyzJ/view?usp=sharing

https://drive.google.com/file/d/1NXKAHfAa2RRDP9d2TbEr-Jw1E8NcUfhY/view?usp=sharinghttps://drive.google.com/file/d/1CpzF3puwqkfZnz_-A81cxGQJTwDRJJjs/view?usp=sharinghttps://drive.google.com/file/d/1zkXSrTKyQRC_RYE1Me91NALHndE3rvOO/view?usp=sharing

-Psychiatry face-to-face calls and consults:https://drive.google.com/file/d/1b1zKkxGRJgRuKOSu5ncUUaNqju0WeLSp/view?usp=sharing 

-Dear Doc – Best Practice in Working with Nursing to Provide Optional TEAM-based care for our patients:https://drive.google.com/file/d/1bcz4J0W0OTgPoilerg6ffsdTf2TV2BkA/view?usp=sharing

-Weekly Observation Round-up: https://drive.google.com/file/d/1En2iHqund8UtDRmPLTcPWWKl6pEjPGD5/view?usp=sharing
-VTC-EM Newsletter: https://drive.google.com/file/d/1UrtMmcbqhaLLfWKSZ_35vm7sZMXEW_W1/view?usp=sharing

-Information on Meals for Homeless on September 10th:https://drive.google.com/file/d/1LfQsLd93jX4sIVlBaTe7xidqw-PyOvpr/view?usp=sharing
-Sign-uphttps://docs.google.com/forms/d/e/1FAIpQLSc3UnCyJiQbcLIEK4-MXOZKqJw8TikG16b61YCDe8k6j_2ltA/viewform?usp=sf_link
-Please see the attached flyer about the upcoming Timothy A. Johnson Medical Scholar Lecture at VTC-SOM entitled title of “Personalized, Personalized Medicine: Lessons Learned from Chasing My Cure.”https://drive.google.com/file/d/1pU2GygJORXTocO5w9lfk-QhCZVy1WAx8/view?usp=sharing
-Zoom Link:https://virginiatech.zoom.us/s/96733590040

-Readings concerning the Intubation Hood Pilot:
https://drive.google.com/file/d/1XbPKJWxaygmEMAmSVHRRXTutHoj_9Uvd/view?usp=sharing

https://drive.google.com/file/d/14x1icuZYV2eUk0pZnn0GIEbwVEk6Rla1/view?usp=sharing

Peds Corner 

Courtesy of Dr. Uherick – A reminder of how our Pediatric Sepsis process works:

  • There is a trigger built in EPIC so when a pediatric patient is tachycardic or hypotensive and has a concern for infection, the nurses are prompted to answer a few more questions about abnormalities in mental status, perfusion, skin findings and risk factors.  
  • If one of those is concerning, the nurse is asked to initiate a “sepsis huddle.” A huddle has the attending go to the beside to make a clinical judgement on if a sepsis alert should be called. 
  • If a pediatric sepsis alert is decided upon, MEDCOM will send it out the overhead alert.  Doing this prioritizes resources to that patient such as nursing support and pharmacy prioritization. 
  • Unlike the adult alert, it does not start a bed identification process.    
  • There is a pediatric sepsis orderset to use for these patients.  Currently the orderset does not cover infants under 60 days, but we have an optimization in to add that which should be available soon.  
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Fellowship News

Wilderness Medicine: 

WM Calendar

Sept 10 at 6p Wilderness Medicine Journal club: Topic and location to be announced

Sept 14-27 is the VTCSOM Student WM elective rotation. Residents are welcome to participate and help teach. Please email StephLareau@gmail.com if interested.

        Elective calendar: https://docs.google.com/spreadsheets/d/1B6GYoRY17mNY1F4dR-LNYidk3WZT7CDkGQ6PYR60Ku8/edit?usp=sharing

Sept 15: Caving w/ Dr. Stanley. Location to be announced in subsequent emails.

Sept 16: Journal Club w/ students

Sept 19 or 20th 1-6p: The Advanced Wilderness Life Support course (AWLS) in Roanoke, VA will mostly be virtual this year. There will be an in-person component on . Resident cost: $250

Sept 21: Swift Water Safety Course/ Drowning Journal Club (all day)

Sept 24-25 Backpacking Trip (need volunteers to help with surprise scenarios)

Oct 2-4 River Trip: Expedition Medicine (local)

WM Pearls

-Courtesy of our Wilderness Medicine Fellow, Dr. Justin Gardner, below is the fourth in a weekly series of WM Pearls about snakebites and snakes in Virginia. 

-ED Management:

  • Mark the leading edge of erythema/tenderness/swelling as well as limb circumference above and below the envenomation for future comparison. This should be repeated every 15-30 min until local tissue effects stabilize. 
  • Wound infections occur in only up to 3% of pitviper bites. Routine prophylactic antibiotics are not recommended. 
  • Opioids are preferred for pain control. 
  • Obtain baseline labs on patient arrival: CBC, BMP, LFT, INR, PT/PTT, Fibrinogen, D-Dimer, Urinalysis, CPK. Labs are repeated every 4-6 hours. 
  • If severe abdominal pain or altered mental status develop, obtain CT imaging to assess for hemorrhage. 
  • Early surgery is contraindicated. Excision not routinely performed. However, necrotic tissue and hemorrhagic blisters may benefit from debridement 3-5 days after the bite.
  • Venom leads to superficial edema and subcutaneous inflammation, rather than in sub-fascial spaces. In rare cases where venom is deposited in subfascial spaces, antivenom can prevent and treat compartment syndrome. Fasciotomy is rarely indicated – favoring antivenom administration. 
  • If true clinical compartment syndrome develops, with objective measurement of compartment pressures, consult to surgical services is indicated. 
  • In critically ill patients, supportive measures and antivenom are mainstays of treatment.  Antivenom is the definitive treatment.  If hypotension persists despite IV fluids and antivenom, then vasopressors are recommended. 
  • Neurotoxic symptoms seen in bites from the Mohave rattlesnake can be profound.  Antivenom has relatively poor efficacy in reversing the pre-synaptic neurotoxicity seen in these envenomations.  Patients with paralytic features should be intubated early. 
  • Blood transfusions may maintain a normal Hgb/Hct, but will not reverse the coagulopathy.  Antivenom should be given and considered  the mainstay of therapy.  Transfusions given only in life-threatening bleeding or anemia refractory to antivenom. 


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    Mohave Rattlesnake

EMS:

-Mechanical versus manual chest compression for out-of-hospital cardiac arrest: https://drive.google.com/file/d/1GkuNy-S1Yp3-FpewefOilIiuQ_XxXr2W/view?usp=sharing

Ultrasound:

-POCUS Aortic Dissection Case: https://litfl.com/ultrasound-case-016/

Academic 

Please read the following from the Program Director regarding the Academic Curriculum this year:

https://drive.google.com/file/d/19xRpkNg60QpJkmnSdUBUlDqQADmd-NvS/view?usp=sharing

-Overall curriculum: https://drive.google.com/file/d/16GE4pUmUOqFOW2xCXjXHcEMzhrx28rwN/view?usp=sharing

PGY-1: 

Reading:

Foundations 1 – https://foundationsem.com/pulmonology/

Foundations 1 –  https://foundationsem.com/infectious-disease/

EM Coach – https://www.emcoach.org/ – F1 – Unit 04-Pulm I, Unit 05-Pulm II

Review Tests due 9/30:

EMC Thoracic F1 – Unit 04-Pulm I, Unit 05-Pulm II

Rosh Tests: Foundations I – F1 – Unit 04- Pulm I, Unit 05- Pulm II, Unit 17- ID

PGY-2: 

Reading: 

Foundations 1 (Mandatory) & 2 (For conference credit or required if  <30% ITE performance) – https://foundationsem.com/pulmonology/

Foundations 1 (Mandatory) & 2 (For conference credit or required if  <30% ITE performance) –  https://foundationsem.com/infectious-disease/

EM Coach – https://www.emcoach.org/ – F1 – Unit 04-Pulm I, Unit 05-Pulm II

AliEMU (For conference credit) – https://aliemu.com/courses/respiratory-2019/

Review Tests due 9/30:

EMC Thoracic F1 – Unit 04-Pulm I, Unit 05-Pulm II

Rosh Tests: Foundations I – F1 – Unit 04- Pulm I, Unit 05- Pulm II, Unit 17- ID

Sim Lab

9/17/2020 1-4pSkills Labs

  1. PIGTAIL CATHETER        
  2. TUBE THORACOSTOMY      
  3. THORACIC ULTRASOUND

Cadaver/Anatomy (Pgy2-3)

  1. Thoracotomy
  2. Chest Tube
  3. Chest Anatomy/Dissection

Videos/Links 

https://www.ebmconsult.com/articles/chest-tube-placement-thoracostomy-procedure

https://www.ctsnet.org/article/technique-chest-tube-insertion

Conference– Note the upcoming 8th Annual Fall EM (Virtual) Conference on Thursday will start at 8a. There will be special alumni panel for residents from 12-1 PM. –https://drive.google.com/file/d/1D2RXhDhXrA9pLs_ADPlUX8O2Fdw8WeC2/view?usp=sharing

– Christie Neal will send out the Zoom link later this week.

Scheduling

-Block 3 shift scheduling complete. Block 4 shift scheduling soon coming.

Interns/PGY-1s: Important Email Points

Your September academic reading is:

-Foundations 1 only – https://foundationsem.com/pulmonology/

-Foundations 1 only – https://foundationsem.com/infectious-disease/

-EM Coach – https://www.emcoach.org/ – F1 – Unit 04-Pulm I, Unit 05-Pulm II

Your Review tests that are due September 30thinclude:

-EMC Thoracic F1 – Unit 04-Pulm I, Unit 05-Pulm II

-Rosh Tests: Foundations I – F1 – Unit 04- Pulm I, Unit 05- Pulm II, Unit 17- ID

-Please let Christie Neal know if you did not receive your EM coach or Rosh assignments.  Make sure you have logged into Rosh and EM coach and check to see your email/info is correct.

Conference

-You are required to attend the upcoming 8th Annual Fall EM Conference virtually on Thursday 9/10 that will start at 8a. There will be special alumni panel for residents from 12-1 PM. -Christie Neal will send out the Zoom link later this week.

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Website: damonsdue.com

Email: rmhchiefs@gmail.com

Stay safe.

Lu Ojeifo, MD

Chief Resident, VTCEM

540-525-9533

cc:  Chief Resident, VTCEM, Dr. Cassie Schandel, 540-529-1180

       Chief Resident, VTCEM, Dr. Zach Williams, 540-597-5495