TTHM 9.4 (3/4/15) Program Director Rounds
10a ~ How ED Docs Think (Paolo)
Quick Decisions on very limited information
Acquire knowledge (horizontal) vs vertical knowledge by analogy.
Simple Probability & Bayesian Probabilities… IF … THEN … to get odds…
Experience & Environment & Emotion affect decision making.
Forward Driven (data) > Backward (hypothesis) Driven
“Thinking Fast, Thinking Slow” (Croskerry, Type 1 “Intuition”, & Type 2 “Analytical” decision making) “Blink” (Malcolm Gladwell)
Heuristics ~ methods of processing information
Like ACLS… IF/THEN Algorithm medicine.
Errors based on Heuristics, Individual Bias, & Perceived risks…
“Framing Effect” of Biased option presentation, difficult to identify & reduce…
Think about your own biases!
1045a ~ Epiglottitis Case Presentation (Mangano)
Keep the differential broad & utilize available resources (i.e. Anesthesia @ CGH)
11a ~ PSQ (Martini/Shaw/Adcock/Weidman)
12p ~ EPIC Tips (Michael Longo)
My Dashboards useful for internet resources
New Themes! ED Map coming in April. PSY paperwork can be found by searching “forms” under orders menu!
1230 ~ TLLT (Kinariwala)
Platelet Transfusion on AntiPlatelet Therapy (Clinical Controversy) in setting of Traumatic ICH
Neurosurgery recommends reversal. Neurology does not, within same institution.
Clopidogrel ADP antagonism…
One Unit Plt TF raises Plts count ~30K, & estimated half will be functional?
ASA & Plavix not well associated c increased Trauma Mortality, unlike Coumadin!
Platelet function testing can be sent to lab, but no POCT & probably not super useful.
?Desmopressin to increase Plt fxn?
*Efficient H&P… Sensitivity, Specificity, LR Review…
130p ~ Journal Club (Pryor)
*ARISE trial: does EGDT reduce mortality at 90 days vs “standard care” in Australia/New Zealand, Hong Kong… NO Significant Difference, no additional benefit.
Perhaps now because standard of care reflects pieces of EGDT in community practice (including early Abx, IVF resuscitation, Cultures, Lactate, Pressors & Monitoring prn…)
*Intra Arterial treatment of acute ischemic stroke: Netherlands phase 3 trial included mechanical or chemical thrombolysis/thrombectomy, within 6 hrs of CVA onset, outcomes based on Modified Rankin Scores & then NIHSS at 24 hrs & 57 days…
Typical care included IV tPA, but trial group had intra arterial interventions c preliminarily positive results.
230p ~ Faculty Grand Rounds (Brenner)
Decision Making Capacity & Surrogate Decision Making
What is Ethical vs. What is Legally Required?
*Respect for Autonomy, vs.
*Beneficence ~ doing what is in the pt’s best interests (sometimes pt may not know what they want or what would have most desirable outcome for them)
“CAPACITY” is a MEDICAL decision. “COMPETENCE” is a LEGAL decision.
Capacity: Dr. Bernie Lowe @ UCSF: Consider Mental Status, Reasoning, Psychiatry consult…
CURVES Mnemonic: Choose & Communicate, Understand, Reason, Value, Emergency, Surrogate)…
*Consider “.Capacity” or “.CURVES” smartphrase!
Family Health Care Decisions Act of 2010 (FHCDA) determines Hierarchy of next of Kin. In NYS: Spouse, Adult Children, Parent, Siblings, Close Friends, 2PC…
(initially based on inheritance law) <http://www.nysba.org/FHCDA/>