>DEM Rounds – June 10th 2014

Impressive attendance at today’s Rounds. This must be reflective of the quality of the presentations, which were both informative and entertaining.

Dr Todd Way kicked us off with a timely reminder on the importance of quality ED Charting. Remember, “if its not written in the chart – it didn’t happen” – Your best defence in any legal issue or complaint are high quality, contemporaneous and legible notes in the ED chart.

We were reminded of the importance of addressing inconsistencies between other related records (triage/EMS) and our own notes “historic alternans”

More and more physicians are now subject to the “Atlantic Colleges Medical Peer Review” process – which includes a thorough review of charting practice. So, now is a good time to reflect on your ED Charting by asking yourselves the following questions:

  • The best part of my chart is_________
  • The first thing I would change about the way I chart is _______.
  • The main reason I don’t do a better job of charting is ________.
  • My ED department could better support my charting by ________.
  • If I could choose 1 thing to change in my colleagues chart it would be _________.
  • The ideal type of charting for me is _______. (Ie. EMR, T-chart, form chart, dictation, scribed, etc.)

Full presentation here:  ER Charting-Way-June 2014

 

Dr Paul Page chose the beginning of summer to remind us that, with the close proximity of the Bay of Fundy, accidental hypothermia can occur at any time of the year here in Atlantic Canada!

Accidental hypothermia is defined as a drop in core body temperature to less than 35 degrees Celsius. Measurement of core temperature is dependent on properly calibrated low reading thermometers. In an intubated patient use a thermistor transducer inserted into lower 1/3 esophagus.

Rewarming with high volumes of warm (38-42 degrees Celsius) i.v fluids. Active external and minimally invasive internal rewarming.

Consider ECMO if not responding to medical therapy or when signs of life absent.

Up to 3 defibrillations but withhold epinephrine until temp > 30 degrees Celsius

Potassium  10-12 mmol per litre is the cut-off for futility.

Immersion has a better outcome than submersion.

 

Full presentation here : Accidental Hypothermia – Page – June 2014

 

Dr Paul Keyes gave us the benefit of his many years in practice with his talk “the orthopaedic things I wish I knew in 1998…”

 

Posterior dislocation of the gleno-humeral joint is commonly missed. Patients with poor ability to communicate suffer this injury disproportionately – Epilepsy, ETOH, Electrocution.

 

Knowledge of the shoulder radiographic views and ability to interpret the axillary Y view is imperative.

 

Whatever reduction technique is used the elbow must be able to cross the midline freely to confirm the shoulder is in joint.

If you cant prove its in joint then it’s out of joint…

 

Joint aspiration  delays arthroplasty by 3-6 months, due to perceived increased risk of infection by the orthopaedic surgeon. It may be appropriate if concerned about a possible diagnosis of septic arthritis, but do consider the implications and definitely don’t stick a needle through an infected bursitis in to a sterile joint.

 

Don’t aspirate a joint post-arthroplasty until you have discussed the case with the operative surgeon/surgeon on call.

 

Hip arthroplasty can be either Total or Hemi. Total hip arthroplasty (THA) includes an acetabular component which can result in an obstruction to straightforward reduction.  THAs are more likely to be damaged by vigorous reduction attempts. Therefore discuss with operative surgeon/surgeon on call prior to any heroics.

 

Flouroscopic guided reduction will save time and face. It should be considered for all major joint reductions but in particular the elbow joint.

 

Always document vascular/nerve integrity pre and post reduction.

 

Full presentation here: ED rounds Ortho – Keyes – June 2014

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