Cognitive Biases (Dr. Acosta):
- Watch lecture here
- Cognitive errors plague our decision making and the astute clinician must be aware that they are being influenced by them
- Common cognitive biases that affect us clinicians
- Conjunction fallacy
- The probability of two events occurring together is always less than or equal two either one occurring alone
- Confirmation bias
- If a test supports a diagnosis on your differential, you may prematurely choose that diagnosis
- Leads to premature closure
- “Murder your darlings”
- Kill your diagnosis before you anchor
- Authority Bias
- We listen to “authorities” more whether we think they are correct or not
- Normalcy Bias
- Example given of Garner case
- EMT didn’t start compressions because police were acting normally
- We flight vs fight vs freeze (the last is normalcy bias in the trauma bay)
- Example given of Garner case
- Decision Fatigue
- It’s real
- Conjunction fallacy
- “The first principle is that you must not fool yourself, and you are the easiest person to fool.”
- Suggested reading
Neutropenic Fever (Dr. Somberg):
- Watch lecture here
- Oral temp over 101
- Rectal temp not recommended (no evidence to support this practice)
- Calculating ANC
- Band count replaced by immature granulocyte count at our sites
- Band counts were not clinically predictive
- Band count replaced by immature granulocyte count at our sites
- Determining who is high-risk vs low-risk
- Select group of low-risk patients may be treated as outpatient
- Treatment
- Empiric abx
- Single agent with pseudomonal coverage (e.g. cefepime, mero, zosyn)
- Add vanc for virtually everyone (exception ?normal vitals in a UTI)
- Antifungals if still febrile after 4-7 days despite abx or prior fungal infection
- PICC line
- Leave in unless grossly infected
- Empiric abx
Early Pregnancy Management (Dr. Nadas):
- Watch lecture here
- Viable intrauterine pregnancy options
- Referred for OB intake for prenatal care
- Women’s Options visit for termination
- Early Pregnancy failure options
- Patient’s want us to be candid with counseling and realistic with expectations
- Three options
- Expectant
- 25-80% expulsion rates
- Can return to Women’s Options clinic in 1 week
- Misoprostol
- Given within 10 weeks of gestation (by CRL)
- Cutoff because larger pregnancy = higher risk of bleeding
- 800 mcg x 1, may repeat x 1, buccal or PV
- Success rate = 84%
- Contraindications, suggested counseling discussed in talk
- Have follow up in Women’s Options Clinic in 1-2 days
- Given within 10 weeks of gestation (by CRL)
- D&C
- Have follow up in Women’s Options Clinic in 1-2 days
- Expectant
- Pregnancy of Unknown Location (PUL)
- If no pain or bleeding (i.e. not concerned about ectopic), they can follow up in 1 week in clinic
- bHCG
- Not used to distinguish between normal or failed IUP
- Used for
- Diagnosis of pregnancy
- PUL follow up
- Follow up on resolution of ectopic or molar pregnancy
- Referring a patient
- Call 718-918-7980 8a-4p Mon-Fri for an appointment
- After hours or on weekends, email jmcfamilyplanning@nychhc.org
- Distributed to MDs, RNs, and clerical staff
Giant Cell Arteritis (Dr. Haque):
-
- Watch lecture here
- Think about temporal arteritis in your elderly patients
- After 50 yo
- Highest incidence among Scandivanians!
- Features
- Fever (50% of pts), fatigue, weight loss
- Headache only in 2/3 of patients
- Jaw claudication in 50% of patients
- Nothing is pathognomonic
- Take any vision complaints seriously
- Mostly anterior ischemic optic neuropathy
- American College of Rheum Criteria for GCA not meant for use of undifferentiated population in ER; was developed from pts with known vasculitis
- It’s not a can’t miss diagnosis unless there are vision complaints or more severe vascular complications whose presentations won’t be subtle
Transfusion Reactions (Dr. Simich):
- Watch lecture here
- Urticarial Reaction
- Hives but no other allergic findings
- Not a contraindication for continuing transfusion
- Tx: Antihistamines
- Febrile Nonhemolytic Reaction
- Diagnosis of exclusion
- 2/2 release of cytokines from WBC in a product that has not been leukoreduced
- Tx: Tylenol, restart transfusion once you rule out a hemolytic reaction
- Acute Hemolytic Transfusion Reaction
- Most feared, often due to ABO incompatibility
- Mortality = 1 in 30
- Labs required for workup discussed in talk
- Treatment
- Stop products
- Replace tubing
- IV hydration with urinary output >1 mL/kg/hr
- Tranfusion-Associated Circulatory Overload (TACO)
- Form of pulmonary edema due to volume excess
- Risk
- 2-4 units = OR 2.0
- Age >85 = OR 2.1
- History of chronic pulmonary disease = OR 1.2
- Treatment
- BiPAP as needed
- Lasix as needed
- Transfusion-Related Acute Lung Injury (TRALI)
- 2/2 neutrophils in transfused product
- Treatments
- Stop transfusion
- Ventilatory support as needed
- Hemodynamic support
- Steroids – benefit not proven
Neutropenia – your abx choice, fever cutoff, and dispo (we’re still admitting most everyone) will be institution-dependent (and to a lesser extent, patient-dependent). The cocktail at Memorial will be very different from the cocktail at Jacobi. (Don’t get a nosocomial infection at Memorial, it’s probably resistant to everything).
As an aside, I used to admit all patients (all patients, not just cancer pts) with bandemia when I find nothing. I stopped doing that because all the patients had nada.
If you suspect temporal arteritis (TA) and the pt’s esr is 20, it’s not TA. Most TA patients can go home and follow up with neuro and ent (or whoever does the biopsy at your hospital). There’s a debate re starting steroids before a biopsy can be done (steroids can increase false-negative biopsies). Don’t forget that arteritis can affect other arteries.
Cord syndromes show up on the written boards all the time.
With very little exception, patients with transfusion reactions will be admitted because they are rare and we are conservative.