Comments for Receiving.

Comment on Senior Report 5.21 by Shawn Horrall

Shawn Horrall — Fri, 11 May 2012 22:58:05 +0000

http://www.childrensnational.org/files/PDF/EMSC/PubRes/EMTALAIssueBriefLegalIssues.pdf

Comment on Senior Report 5.21 by Shawn Horrall

Shawn Horrall — Fri, 11 May 2012 22:31:28 +0000

Question 1 has incorrect answer. As a receiving physician, you are not liable for a patient with which you have never had contact. Please give references if you are under a different understanding.

Comment on Senior Report 5.19 by Katie Ohlendorf

Katie Ohlendorf — Thu, 29 Mar 2012 11:08:20 +0000

1. D. Tracheo-innominate artery fistula.
2. C. Obtain surgical consultation in the emergency department.
3. D. Overinflate tracheostomy cuff. This is successful in controlling 80% of hemorrhages. If this is unsuccessful, you can reintubate orally and apply manual compression of the innominate artery against the sternum while working on getting the patient to the OR.

This is a good, concise resource:
http://www.surgicalcriticalcare.net/Guidelines/post%20tracheostomy%20hemorrhage%202009.pdf

Comment on Senior Report 5.15 by A. Groves

A. Groves — Fri, 16 Mar 2012 13:41:19 +0000

Shereaf- Outstanding discussion. One area of disagreement. You state that there are patients that are high pre-test probability and should not have a d-dimer, but should get automatic CT. This is true for the older d-dimer tests, but with the high-sensitivity d-dimer that we, and many EDs, are now using we can use d-dimer on high pre-test prob patients and if negative you are done with your work-up. You may not save a huge number of CTs in this population, but will definitely spare some unecessary radiation. This is supported by Jeff Kline, etc. AG

Comment on Practical Pearls by Michael Fernandes

Michael Fernandes — Wed, 07 Mar 2012 04:46:43 +0000

Very true Dr. Wahl!

Comment on Senior Report 5.15 by Justin

Justin — Fri, 02 Mar 2012 03:55:34 +0000

There, I did it this week.

Comment on Senior Report 5.12 by kjones100

kjones100 — Sat, 11 Feb 2012 04:14:47 +0000

From Dr. Leo Bunting

Thanks Dr. Dang for an excellent case. I just want to clarify one thing:

If the quant is 1200 and the ultrasound is non-diagnostic, you should not as a rule discharge patients for followup quants in 48hours. There have been ruptured ectopics described with quants less than 10 (for example http://www.ncbi.nlm.nih.gov/m/pubmed/17694977/). I’ve seen them personally with quants in the 300-500 range. It is often common to not see the ectopic on even TVUS and possible to miss small ruptures. Therefore we have to maintain a high index of suspicion even if the quant is below the discriminatory zone.

So if the quant is below 1500, nothing concerning on TVUS (no large free fluid, no “complex mass not fully characterized”) and a benign exam = call an OB to establish followup and continuity of care for repeat beta.

If there is something concerning about the patient, I consult OB.

Also, forget the discriminatory zone for trans abdominal scanning – it varies dramatically from hospital to hospital.

Thanks, Leo

Comment on Senior Report 5.12 by John Wilburn

John Wilburn — Tue, 07 Feb 2012 13:29:54 +0000

1.
2.
3.

I’m coming for the # 1 Spot

John

Comment on Intern Report 5.11 by Adam R

Adam R — Thu, 02 Feb 2012 02:50:33 +0000

(secret answers)

Comment on Intern Report 5.10 by matt

matt — Mon, 30 Jan 2012 23:46:31 +0000

CDC recc for inhalational bioweapon exposures are for a poly drug regime:
ciprofloxicin or doxycycline, plus 1 or 2 other drugs(rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenim, clindamycin, clarithromycin) with caution that naturally occuring beta-lactamase in native B. anthracis is relativly high, so the ‘cillins are not good initial choices.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5042a1.htm#tab1

I’m not sure if the previous terroism events around 2001 were single strain or not. With a natural infection a single strain is thought to predominate. Sverdlovsk PCR has revealed at least 4 separate strains from autopsy samples. I have been unable to chase down the complete epidemiology but with a bioweappn unusual things can crop up like the published autopsy data, 42 cases, 9 female and no kids, out of 70 fatalities, interesting for a weapon. The other articles frequently list the fatalities as “70 people” without demografic identifiers.

Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979.
Abramova FA, Grinberg LM, Yampolskaya OV, Walker DH.
Proc Natl Acad Sci U S A. 1993 Mar 15;90(6):2291-4.

Proc. Natl. Acad. Sci. USA
Vol. 95, pp. 1224–1229, February 1998
Microbiology

As a bioweapon you will like see multiple strains with likely variations in antibiotic resistence across the various strains choosen for dispersal. Generally what is published seems to support the “Go Big or Go Home” or “Kill it all and let the ID Docs sort it out” philosophy