Wednesday Lectures, 11/19/2014

TTHM 6.1 PDR, EOLC, Contracts…

 

10a Contracts (DiRubbo)

Beware & Remove Noncompete Agreements!

Employee v Partnership (usually after 3 to 5 yrs) v Independent Contractor (IRS Audit Indemnity clasuse?)

Scheduling, Insurance, Term, Salary, Termination clause…

2080 hours ~40hrs x52wks… Holidays? Vacations?

Typical Max 1840hrs ~40hrs x46wks gives 4wks vacation, 2wks CME…

1500hrs better…

*Scheduling requirements, know liability!

Title 38 scheduling requirements require call!?

*Insurance ~ occurrence & claims made (tail, nose)

Claims made insurance cheaper initially & ramps up…

NYS Occurrence policy ~$15K

*EMR requirements

*Salary Base, Incentive?, Taxes, Benefits & relation

*Termination Cause: *Material Breach? Due Process “as accorded to other members of the medical staff” & No Cause termination (business reason, time frame)… & Time Frame? effective immediately?

*Potentially everything is negotiable, but keep in mind base salary negotiation is potential for strife! Keep large bonuses to yourself.  Know who you are negotiating with.  Be prepared to walk away from the table.  HR will do the negotiations.  Know what you’re worth.  Waiting & weighing options can work, but still risky.

Career Planning Guide for EM (EMRA)

IRS.gov Indepeendent Contractor Test…

“PracticeLinks.com”

Talk to Joslin about quality projects…

 

11a Ultrasound (Nicholas) Book by Dr. Ma & Mateer

AAA, US probe to pt’s right… Ao top to bottom intransverse plane; IVC compressible, bifurcation of Ao is around umbilicus.  90% of AAA bleeds are retroperitoneal.

Firm pressure may be needed to push bowel gas out of the way… start up by the heart & work down…

FAST cardiac view subxiphoid should show RV closest to probe, LA farthest away/deepest, lokk for pleural effusion

eFAST includes lung sliding Mmode for “sandy beach” (good, “Seashore”) v “bar code” (bad,”Stratosphere”)… Comet tails are normal artifact but increase in pulmonary edema.

 

12p RPL#4 Trepanation/Burr Holes (Deepak)

 

1230~230 Grand Rounds (Lapointe, Tox)…

Cannabinoids… & Synthetics!

Late 1800s, opium developed to morphine… Coca to cocaine… but THC not easily located…

MJ caught a bad cultural rap in the 1930s, 1940s…  1964s structure determined & Pfeizer started making derivatives CP 47,497 one of the first… none came to market…

1970 Controlled Substances Act (Nixon) c CSA schedules 1 to 5…

CB1 & CB2 receptors, tend to be inhibitory Gprotein mediated channels exist for endogenous cannabinoids…

~Anandamide… JWH018 (John W. Huffman, 1990s)

“Painful mechanism slide”…

Rimonabant… Sz & Suicidality… (inverse CB1 agonist)

New products, new delivery methods, new politics…

MJ not yet shown to be good medicine, but needs comprehension as drug.

THC concentrations increasing.

Vaporizers on the rise, better for the lungs…

Honey butter dabs oil, 98% THC… Butane labs

10mg starting dose for edibles… 4.20 bars have 180mg!… Starts working ~1 to 2hrs.

Hyperemesis only helped by hot water, only after smoked form?!

Zostrix Capsaicin creme ~ case series up to 18pts, consider other heating modalities.

TrypV1 receptor…

Analogue Act… “Not for human consumption”?…

Google Flu predicts flu outbreaks from trend data & similar trend data may be useful for Tox…

 

230p EOLC/DNR Issues (Prince)

Death Notification…

Gather (Data, Family, Social Work, Resources…) KNOW THE NAME!

Resources (SW, Spiritual Care) DO NOT GO ALONE!

Identify PT BY NAME, move to eye level; Identify what they know.

Educate, clearly, briefly, plainly, & use the word “DIED/DEAD”.

Verify, express condolences

… Space, Quiet, Questions…

INquire ~ Questions, Resources needed/requested

Grieving Process, Autopsy Details, Plan… Give condolences, support, Resources…

*DNR/DNI ~ Capacity ~ A&O? Understand options & consequences? Informed medical decision?

Form does not need pt signature, should be witnessed by 2nd provider & documented conversation in chart.  Be gentle yet honest.

Order of consent priority: 1)guardian/HCP; 2)spouse or domestic partner; 3)adult child; 4)parent; 5)sibling; 6)other family member or friend with knowledge of pt wishes…

*Palliative Care is NOT necessarily Comfort Care! (although can include comfort care discussions…)

*Minors, Emancipation, & Consent ~ vary state to state…

Wednesday Lectures, 11/05/2014

10a PDR (Kloss) Geriatric Abdominal Pain

Geriatrics are 65plus, 12% of population, to 30% by 2030!
Abdominal Pain in this age group requires SG 30% of the time & relatively higher M&M!
Decreased barriers to infxn, decreased physiologic reserve… think “2nd childhood”…
Decreased pain perception & dementia can be complicating factors, delay care…
Fear of losing independence, higher comorbidities…
NSAIDs & Polypharmacy issues…
“Atypical is Typical” ~ dt poor localization, less likely tachy dt Bblockers…
Infection > obstruction > PUD > UTI…
10% of Appy happens >60yo, more likely to rupture; Mortality up to 5% from baseline <1%.
1/2 do not have fever or Leukocytosis & exam findings may be nonfocal; Guiac may be wnl.
(*1/3 of all lawsuits involve signedout pts…)
Syncope increases risk…
Diverticulitis (simple) can be treated OutPt c Abx: Cipro, Flagyl…
Perforated diverticulitis? May be more serious…
Biliary Dsx more commonly stone related in elderly vs EtOH related in younger pts…
Cases… Cases… Cases…

11a PSQ (Shaw) Geriatric Abdominal Pain, mild anemia…

Transition of care c labs pending or refused? Needs documentation!
Policy exists CM M03 such that Pt may take own home medication.
http://www.upstate.edu/policies/documents/intra/CM_M-03.pdf
Looking into EPIC addenda…

1200p TLLT (Rosenfield)

Apnea & Nasal Oxygen in ED Intubations ~ Clinical Controversy
2012 Weingard? Physiology… “Apneic Oxygenation” ~ passive NC (?) helpful?
http://www.ncbi.nlm.nih.gov/pubmed/22050948
http://www.ncbi.nlm.nih.gov/pubmed/23836064
Preoxygenation > Apneic oxygenation! …might as well preoxygenate with NC, as long as it doesn’t delay care… & 20* Reverse Trendelenburg also good.
“RSI” is a NO BAG technique by definition, btw!

1230p TLLT2 (Rosenfield)

Review of the Ear
Impaction… Cerumenolytics, Irrigation, Manual Removal… ALL the same?
Color, Position, Lighting, Entire TM, Translucent v opaque
Pars flaccida bulges early in AOM, followed by purulent collection, protrusion can lead to rupture!
NNT 20 Pain relief
NNT 33 Perforation prevention
NNT 11 AOM unilateral to bilateral spread prevention
NNH 14 (Harm is rash or diarrhea or emesis, already Viral Sx???)
http://summaries.cochrane.org/CD000219/ARI_antibiotics-for-middle-ear-infection-acute-otitis-media-in-children

130p Journal Club (Cherrington)

Tox UEM Awareness Rothman
**Press Ganey scores between Narcotic & NonNarcotic Pain Rxs? <http://www.sciencedirect.com/science/article/pii/S0196064414001206?via=ihub&gt;
No specific correlation identified, so don’t just give analgesics for Press Ganey.
**EGDT for Septic Shock… “ARISE” study
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380
In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days. (Funded by the National Health and Medical Research Council of Australia and the Alfred Foundation; ARISE ClinicalTrials.gov number, NCT00975793.)

230p Radiologic Emergencies (Cooney)

http://emergency.cdc.gov/radiation/countermeasures.asp
Alpha Beta Gamma Neutron
http://www.frankswebspace.org.uk/ScienceAndMaths/physics/physicsGCE/images/penetration.jpg&gt;

EXPOSED is NOT the same as CONTAMINATED!
*Exposure depends on Time, Concentration of energy, Shielding (Distance dissipates)

http://emergency.cdc.gov/radiation/countermeasures.asp
http://emergency.cdc.gov/radiation/countermeasures.asp

http://en.m.wikipedia.org/wiki/3_Mile_Island
http://en.m.wikipedia.org/wiki/Radiation_effects_from_the_Fukushima_Daiichi_nuclear_disaster
http://en.m.wikipedia.org/wiki/Neutron_bomb
http://en.m.wikipedia.org/wiki/Dirty_bomb “Expose Many, Kill Few”
http://en.m.wikipedia.org/wiki/Geiger_counter
http://en.m.wikipedia.org/wiki/Mass_decontamination
http://www.ncsu.edu/ehs/radiation/forms/alara.pdf
http://www.remm.nlm.gov/ext_contamination.htm
Psychological impact of radioactive material exposure not to be underestimated…

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