Damon's Due

VTCEM Residents & Faculty,

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

“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

-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

-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.

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.

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

PIGTAIL CATHETER
TUBE THORACOSTOMY
THORACIC ULTRASOUND

Cadaver/Anatomy (Pgy2-3)

Thoracotomy
Chest Tube
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.