Wednesday Lectures, 3/25/2015 (Sim, Tox, & Grand Rounds Day)

10a ~ Tox ASA & APAP (Marraffa)
APAP: NAC (IV v po) now 24 hours after ingestion(s).
We overtreat many ppl c NAC, probably ok.
Activated Charcoal can interfere c oral NAC? so IV NAC more often given now.
starting NAC “within 8 hours of OD & no one gets sick”. Wait for the 4 hr level.
NAC doesn’t taste bad, just smells terrible. IV NAC comes in D5W so beware Sodium balance for cerebral edema, Sz risk, etc… IV NAC could also have anaphylactoid rxn if given too fast!
Oral NAC delivers to liver, so maybe more direct first~pass…
Fulminant Hepatic Failure goes to Rochester… Kings College Criteria…
Lactate >3.5 c APAP tox, or Lactate>3.0 after Resuscitation is 90% predictive (sensitive) for mortality.
Continue NAC until AST <1000, or until AST/ALT 150mg/kg, Life Threatening >500mg/kg? No HalfLife in OD bc it becomes saturable, Zero order kinetics (Michaelis Menten model)
ASA uncouples ATP synthase pathway & causes Resp Alk, Met Acidosis, tinnitus (Lv >30), neuroglycopenia, keep so keep >euglycemic! pH 100mg/kg.
ASA (“Done”) Nomogram exists but not very reliable…

11a ~ Faculty GR Pt Experience (Frechette, Hospitalist)
Learning to Convey Empathy! (a.k.a. being a good actor)
Press Ganey, Innovation… Storytelling in the patient experience…
consider humor in medicine in relating to patients, although be careful.
HCAHPS Medicare survey tool being used to create hospital accountability & create incentives.
Press Ganey different, independent company. Best doctor scores always the best hospitals. Doctors are symbolic of a hospital’s worth?
“Did the doctor treat you with courtesy & respect?”
“Did the doctor listen carefully? …explain things?”
*Pts want CONFIDENCE in their doctors. (Maybe gray hair helps)
*Pts want sense that their care is well COORDINATED. Organize the messages & people.
*Pts want to perceive our EMPATHY.
Be adaptable, “chameleon”…
Tell stories to relate personal experiences. Being a patient creates sympathy, which can support empathy.

12p ~ TQM (Goldberger)
Safety in the ED now that Security carries Vocera…
ED is a potentially dangerous job, assault stats…

1230p ~ SIM EXTRAVAGANZA (Rodriguez) ~ Log Procs!
Rodriguez Sarsfield CVC IJ SC Femoral
EShaw LP, LP
Prince ChTube DPL/Paracentesis


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