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Whose nurse is she/he?
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at pdnews@frontlinemedcom.com.
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at pdnews@frontlinemedcom.com.
I suspect that there is at least one person in your office or on your team whose name is followed by the initials “RN.” How do you refer to that individual? Do you introduce her as “My nurse Louise”? Or do you say “I would like you to meet Lance, who is one of our nurses”? How often do you say “Rachel will be your nurse today”?
Is there really much difference between “my,” “our,” and “your” in this context? I suspect that most of us unconsciously avoid “my.” But, back in the era when solo practitioner owner/operators walked the earth, “my nurse” was a more frequent descriptor. The system was male dominated and hierarchical. And, of course, the doctor was paying the nurse’s salary.
However, a recent Ethics Rounds in the September 2017 Pediatrics titled “Physician-Nurse Interactions in Critical Care” has gotten me thinking more about what may seem to be semantic hairsplitting between “our nurse” and “your nurse” (doi: 10.1542/peds.2017-0352). The scenario revolves around a young neonatal ICU nurse in her first clinical position who is criticized by her supervisor for advocating for a young mother by questioning the doctor. A good part of the discussion focuses on the ethical dilemma faced by someone whose training has emphasized her obligation to advocate for her patients suddenly finding herself in a situation in which she sees the doctor’s care plan as flawed or at best inadequate. In this particular case, a more experienced nurse would probably already have acquired strategies and a vocabulary that could minimize or avert the conflict. However,
I hope that you have fostered a professional atmosphere that leaves room in which – as well as a process by which – a nurse can question your management of a patient without fear of retribution. Although it is never easy to have your actions questioned, it is certainly easier when the process takes place in a retrospective review rather than when the issue presents itself in the glare of real time and the nurse feels he must speak up now to advocate for the patient adequately.
When the call comes in from a panicked parent at 4 p.m., pleading to have her sick child seen, how does the nurse balance his commitment to the health of the patients against his concern for the doctor’s well being. Occasionally, I hear a nurse erring on the side of being zealous guardians of the doctor’s free time. However, I sense that, day in and day out, it is the nurse’s obligation to the patient that prevails most of the time. I hope I am correct.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Email him at pdnews@frontlinemedcom.com.
Death by meeting
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
I like to project an image of a renegade who at times ventures outside the norms of the profession, but when there are rules, I try to follow them. However, I will confess that for the last 10 or 12 years that I was in practice, I flagrantly disobeyed our hospital’s requirement for attendance at staff meetings. In fact, I didn’t attend a single one for more than a decade.
I can’t say that I have never attended what I would consider a good meeting. But
Often, the first problem is that the stated or implied goal of the meeting was poorly conceived. That is, if the person who called for the meeting had even considered setting a goal. If the purpose of the meeting was to convey information, there are so many more efficient ways to achieve that goal without pulling people away from their primary missions. In the case of a physician, this would translate to seeing patients.
In this electronic age, emails, videos, social media sites, hard-copy handouts, and memos reach the target audience more efficiently and with more clarity than a sit-down meeting does. If the purpose of the meeting also was to elicit feedback about the new information, that same suite of communication vehicles can be structured to function as effective sounding boards.
If the purpose of the meeting is to foster camaraderie and team spirit, then it clearly should be labeled as a team building exercise. However, the organizers should have done enough research into the proposed activity to be reasonably confident that it will achieve the goal of improved team spirit.
If the goal of the meeting is create something – for example – an office policy about stimulant medication, then that goal must be narrowly focused by an agenda published well ahead of the meeting. In this case, the agenda could include the questions: How often should the patient be seen? If the patient is not going to be seen, what questions should he or she be asked? Who will ask them? And where in the chart should this information be filed?
No meeting should last longer than an hour and a half, but an hour is optimal. If the goal has not been achieved, then a second meeting with a more realistic agenda should be scheduled. Attendees who have been assigned tasks for completion before the next meeting should be contacted several days before the rescheduled meeting. There are few things more frustrating than to sit down at a meeting and discover that homework critical to completing the goals has not been done.
Finally, I must caution to avoid meetings organized or chaired by people who have nothing better to do than go to meetings. Some of those folks may even enjoy the social atmosphere of a meeting, and many are likely being paid to attend. Meanwhile, they are squandering your productive face-to-face patient care time.
Fever and bilateral ankle pain
A 35-year-old man presents with bilateral ankle pain and swelling. He has had fevers over the past 5 days. Physical examination: temperature, 38° C; pulse, 90; blood pressure, 140/70 mm Hg. Ext: Edema bilateral ankles, ankle joints tender. No other joints are involved. Lab: WBC, 6,000; polys, 4.8; mono, 0.5; lymph, 0.7.
What is the most useful diagnostic test?
A. CRP.
B. ESR.
C. Uric acid.
D. Chest x-ray.
E. Rheumatoid factor.
This patient has acute onset of fevers and bilateral ankle pain and swelling. The acute onset and presence of a fever makes rheumatoid arthritis unlikely. Bilateral ankle arthritis is a very unusual presentation for gout, and would be very unlikely in such a young patient unless there were other risk factors for gout. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) will not help make a specific diagnosis.
This patient has Lofgren’s syndrome (acute presentation of sarcoidosis). A chest x-ray would be diagnostic, as the presence of bilateral hilar adenopathy along with the other symptoms would be diagnostic of Lofgren’s syndrome. The patient also has a low peripheral lymphocyte count, which is common with active sarcoidosis.
The combination of bilateral ankle swelling and inflammation is a clue to think about sarcoidosis. Juan Mañá, MD, and his colleagues reviewed the charts of 330 sarcoid patients who presented over a 20-year period.1 A total of 33 patients presented with periarticular ankle inflammation. Interestingly, the majority of these patients presented in the spring (54%). The average age of the patients was 33 years, and about 80% had stage 1 sarcoid on chest radiography (bilateral hilar adenopathy). All 24 patients who were followed up were in remission a year later.
In another study, the same investigators reported on the clinical features and course of Lofgren’s syndrome in 186 patients. Almost all the patients (93%) had erythema nodosum or periarticular ankle inflammation at presentation.2 Half of the patients presented in the spring, and the vast majority (87%) had no respiratory symptoms at the time of presentation. Most of the 133 patients (86%) who were available for follow-up (mean follow-up, 5 years) were in complete remission from sarcoid.
Johan Grunewald, MD, and Anders Eklund, MD, reported on 150 patients with Lofgren’s syndrome.3 In that study, 87 patients had erythema nodosum, and 63 had no erythema nodosum but did have symmetric ankle inflammation. There was an increase in patients presenting in the spring, about 80% had stage 1 sarcoid on chest x-ray, and the majority of the patients who presented with bilateral ankle inflammation and no erythema nodosum were men. They also found that there was a strong association with the presence of HLA-DRB1*0301/DQB1*0201 in patients who developed Lofgren’s syndrome. Resolution of disease was very common (85%) without recurrences.
There are several pearls to emphasize. Think of Lofgren’s syndrome in patients with symmetrical ankle inflammation or erythema nodosum. Order a chest x-ray to make the diagnosis; these patients usually will have no pulmonary symptoms to lead you in that direction. The prognosis is very good for these patients, with the great majority of them having full clinical resolution without recurrences.
Key pearl: Think of Lofgren’s syndrome in patients presenting with bilateral ankle inflammation.
References
1. J Rheumatol. 1996 May;23(5):874-7.
2. Am J Med. 1999 Sep;107(3):240-5.
3. Am J Respir Crit Care Med. 2007 Jan 1;175(1):40-4.
A 35-year-old man presents with bilateral ankle pain and swelling. He has had fevers over the past 5 days. Physical examination: temperature, 38° C; pulse, 90; blood pressure, 140/70 mm Hg. Ext: Edema bilateral ankles, ankle joints tender. No other joints are involved. Lab: WBC, 6,000; polys, 4.8; mono, 0.5; lymph, 0.7.
What is the most useful diagnostic test?
A. CRP.
B. ESR.
C. Uric acid.
D. Chest x-ray.
E. Rheumatoid factor.
This patient has acute onset of fevers and bilateral ankle pain and swelling. The acute onset and presence of a fever makes rheumatoid arthritis unlikely. Bilateral ankle arthritis is a very unusual presentation for gout, and would be very unlikely in such a young patient unless there were other risk factors for gout. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) will not help make a specific diagnosis.
This patient has Lofgren’s syndrome (acute presentation of sarcoidosis). A chest x-ray would be diagnostic, as the presence of bilateral hilar adenopathy along with the other symptoms would be diagnostic of Lofgren’s syndrome. The patient also has a low peripheral lymphocyte count, which is common with active sarcoidosis.
The combination of bilateral ankle swelling and inflammation is a clue to think about sarcoidosis. Juan Mañá, MD, and his colleagues reviewed the charts of 330 sarcoid patients who presented over a 20-year period.1 A total of 33 patients presented with periarticular ankle inflammation. Interestingly, the majority of these patients presented in the spring (54%). The average age of the patients was 33 years, and about 80% had stage 1 sarcoid on chest radiography (bilateral hilar adenopathy). All 24 patients who were followed up were in remission a year later.
In another study, the same investigators reported on the clinical features and course of Lofgren’s syndrome in 186 patients. Almost all the patients (93%) had erythema nodosum or periarticular ankle inflammation at presentation.2 Half of the patients presented in the spring, and the vast majority (87%) had no respiratory symptoms at the time of presentation. Most of the 133 patients (86%) who were available for follow-up (mean follow-up, 5 years) were in complete remission from sarcoid.
Johan Grunewald, MD, and Anders Eklund, MD, reported on 150 patients with Lofgren’s syndrome.3 In that study, 87 patients had erythema nodosum, and 63 had no erythema nodosum but did have symmetric ankle inflammation. There was an increase in patients presenting in the spring, about 80% had stage 1 sarcoid on chest x-ray, and the majority of the patients who presented with bilateral ankle inflammation and no erythema nodosum were men. They also found that there was a strong association with the presence of HLA-DRB1*0301/DQB1*0201 in patients who developed Lofgren’s syndrome. Resolution of disease was very common (85%) without recurrences.
There are several pearls to emphasize. Think of Lofgren’s syndrome in patients with symmetrical ankle inflammation or erythema nodosum. Order a chest x-ray to make the diagnosis; these patients usually will have no pulmonary symptoms to lead you in that direction. The prognosis is very good for these patients, with the great majority of them having full clinical resolution without recurrences.
Key pearl: Think of Lofgren’s syndrome in patients presenting with bilateral ankle inflammation.
References
1. J Rheumatol. 1996 May;23(5):874-7.
2. Am J Med. 1999 Sep;107(3):240-5.
3. Am J Respir Crit Care Med. 2007 Jan 1;175(1):40-4.
A 35-year-old man presents with bilateral ankle pain and swelling. He has had fevers over the past 5 days. Physical examination: temperature, 38° C; pulse, 90; blood pressure, 140/70 mm Hg. Ext: Edema bilateral ankles, ankle joints tender. No other joints are involved. Lab: WBC, 6,000; polys, 4.8; mono, 0.5; lymph, 0.7.
What is the most useful diagnostic test?
A. CRP.
B. ESR.
C. Uric acid.
D. Chest x-ray.
E. Rheumatoid factor.
This patient has acute onset of fevers and bilateral ankle pain and swelling. The acute onset and presence of a fever makes rheumatoid arthritis unlikely. Bilateral ankle arthritis is a very unusual presentation for gout, and would be very unlikely in such a young patient unless there were other risk factors for gout. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) will not help make a specific diagnosis.
This patient has Lofgren’s syndrome (acute presentation of sarcoidosis). A chest x-ray would be diagnostic, as the presence of bilateral hilar adenopathy along with the other symptoms would be diagnostic of Lofgren’s syndrome. The patient also has a low peripheral lymphocyte count, which is common with active sarcoidosis.
The combination of bilateral ankle swelling and inflammation is a clue to think about sarcoidosis. Juan Mañá, MD, and his colleagues reviewed the charts of 330 sarcoid patients who presented over a 20-year period.1 A total of 33 patients presented with periarticular ankle inflammation. Interestingly, the majority of these patients presented in the spring (54%). The average age of the patients was 33 years, and about 80% had stage 1 sarcoid on chest radiography (bilateral hilar adenopathy). All 24 patients who were followed up were in remission a year later.
In another study, the same investigators reported on the clinical features and course of Lofgren’s syndrome in 186 patients. Almost all the patients (93%) had erythema nodosum or periarticular ankle inflammation at presentation.2 Half of the patients presented in the spring, and the vast majority (87%) had no respiratory symptoms at the time of presentation. Most of the 133 patients (86%) who were available for follow-up (mean follow-up, 5 years) were in complete remission from sarcoid.
Johan Grunewald, MD, and Anders Eklund, MD, reported on 150 patients with Lofgren’s syndrome.3 In that study, 87 patients had erythema nodosum, and 63 had no erythema nodosum but did have symmetric ankle inflammation. There was an increase in patients presenting in the spring, about 80% had stage 1 sarcoid on chest x-ray, and the majority of the patients who presented with bilateral ankle inflammation and no erythema nodosum were men. They also found that there was a strong association with the presence of HLA-DRB1*0301/DQB1*0201 in patients who developed Lofgren’s syndrome. Resolution of disease was very common (85%) without recurrences.
There are several pearls to emphasize. Think of Lofgren’s syndrome in patients with symmetrical ankle inflammation or erythema nodosum. Order a chest x-ray to make the diagnosis; these patients usually will have no pulmonary symptoms to lead you in that direction. The prognosis is very good for these patients, with the great majority of them having full clinical resolution without recurrences.
Key pearl: Think of Lofgren’s syndrome in patients presenting with bilateral ankle inflammation.
References
1. J Rheumatol. 1996 May;23(5):874-7.
2. Am J Med. 1999 Sep;107(3):240-5.
3. Am J Respir Crit Care Med. 2007 Jan 1;175(1):40-4.
Rectal temps in the nursery
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
It seems to me that the closer one could get to the center of the child’s body, the more likely you would get a true reading – and the less likely you would fall victim to operator error. However, a study reported on the Pediatric News website suggests that our intuition is wrong again (“Axillary thermometry is the best choice for newborns,” by M. Alexander Otto, Aug. 24, 2017). In the study of 205 newborns at the University of North Carolina at Chapel Hill Medical Center, multiple temperatures were recorded using three methods over a 15-minute period. Rectal temperatures were accurate but less reliable than axillary readings, while temporal artery measurements tended to “overestimate temperatures by an average of about a quarter of a degree.”
However, before we jump on the no-rectal-temps in the nursery bandwagon, let’s look at the rectal probe not just as a way to assess a newborn’s temperature, but as a tool for examining the baby’s rectum. For a variety of reasons, the newborn perineum often seems to escape the careful examination it deserves, particularly if the initial exam is performed with the parents watching.
Of course, parents are interested in their baby’s hair and eye color, and whether it has the requisite number of fingers and toes. They will wait anxiously until you have lifted your stethoscope off the baby’s chest and given them a nod and smile. However, doing a thorough exam of the infant’s genitalia may appear a bit invasive and improper to some parents. Whether it is because we sense some unspoken parental discomfort or because we are trying to save time, the nether regions of little girls are inadequately examined.
But back to rectal temperatures. It seems to me that it would be prudent to adopt a guideline that says that a newborn’s first temperature be taken rectally. Not because it is any more accurate than an axillary temperature – which this study suggests that it is not. But because the process of taking the temperature would make it more likely (I hesitate to say guarantee) that someone will be taking a careful look at the newborn’s rectum. That initial rectal temperature is not going to detect every genital anomaly, but it may help find some in a more timely fashion. If nothing else, it will get that meconium moving.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Now missing in EHR charts: a good impression
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’ve previously written about “the monster note,” a creation of autofilled blanks with vital signs and test results that tells you very little about what’s really going on.
Recently, while on call, I discovered a new problem: the lack of a decent impression.
I was covering for another doctor, and a cardiologist rounding at a rehab center called to see if he could anticoagulate a recently discharged patient. It was certainly a reasonable question.
Unfortunately, not much was there. Most notes were the usual mishmash of test results, vital signs, and medication lists, with very little about the patient. So I scrolled down to the impressions to find out what the plan was.
Sadly, that area (which to me is the most critical part of a note) was also devoid of anything useful. Hoping for something like “embolic stroke, hoping to anticoagulate in future,” I instead found things like “To SNF or rehab soon” or “case discussed with family” as the entire impression and plan. That tells me nothing. The only note I found that had some sort of assessment and plan was the initial consult, which was done before any test results were in.
This seems to be the current state of things. Notes that actually give you some idea of the thinking and plan have become an endangered species. This helps no one, as most of us rely on other doctors’ notes to coordinate and plan care. While some of this is done through talking or texts, those things aren’t in the chart. So even though the doctors involved may have a good idea of what they’re doing (and I certainly hope they do), an outsider doesn’t.
In my opinion, that does nothing to improve patient care. I suppose it works if the same doctors are involved each day, but that’s not how American hospital medicine is any more. Hospitalists rotate in and out every few days and (as in my case) others cover call on nights, weekends, and holidays.
It’s also a gateway to legal challenges. A malpractice lawyer once told me that notes should be written so that if you have to read it 5 years later, you can get a pretty good idea of what your thinking was. If the details of the plan were carried in your head, or were in conversations with other doctors, those things aren’t going to help you. The written record is everything. If the issues these notes pose to patient care don’t worry you, maybe that thought should.
Back to my patient: It took me about 15-20 minutes of skimming through the note to find the answer I needed. And it wasn’t in any of the doctors’ notes at all.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Tips and Tricks: Using a ‘Roman sandal’ after compartment syndrome treatment
Compartment syndrome is a common complication after revascularization for acute lower extremity ischemia. Treatment with four compartment fasciotomy can result in significant morbidity, with wounds that are challenging to manage for both the patient and practitioner.
An alternative to wound VAC or simple wet-to-dry dressings, the “Roman sandal” technique makes bedside closure of these wounds possible, especially in patients with minimal postdecompression muscle edema.
Compartment syndrome is a common complication after revascularization for acute lower extremity ischemia. Treatment with four compartment fasciotomy can result in significant morbidity, with wounds that are challenging to manage for both the patient and practitioner.
An alternative to wound VAC or simple wet-to-dry dressings, the “Roman sandal” technique makes bedside closure of these wounds possible, especially in patients with minimal postdecompression muscle edema.
Compartment syndrome is a common complication after revascularization for acute lower extremity ischemia. Treatment with four compartment fasciotomy can result in significant morbidity, with wounds that are challenging to manage for both the patient and practitioner.
An alternative to wound VAC or simple wet-to-dry dressings, the “Roman sandal” technique makes bedside closure of these wounds possible, especially in patients with minimal postdecompression muscle edema.
Teratogenicity may not be a yes or no question
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Since thalidomide, the medical community has sought to ensure that we do not miss any safety signal that a drug could cause malformations or developmental delays after in utero exposure.
At the time of a drug’s debut, there are relatively small numbers of exposures in pregnancy, and it’s difficult to decipher teratogenicity. As the number of exposures increases, we are generally able to answer “yes” or “no” to the question of teratogenicity. But in the last decade or so, data on drug exposure in pregnancy has become robust enough – thanks in part to large registries – to provide potentially more useful answers on safety. Specifically, .
Animal studies show us that there is a dose dependent effect in pregnancy, and not every dose causes harm to the fetus. However, that information is not easily translated into clinical practice because of the vast differences between animal and human pharmacokinetics and sensitivity to toxicity.
The first drug that came into focus as having dose dependent teratogenicity in pregnancy is the epilepsy drug valproic acid. In the late 1980s, studies showed that the drug was associated with an increased risk for spina bifida. Later, more congenital malformations were linked to valproic acid, including oral cleft, cardiac and limb defects, developmental delays, lower IQ, and even autism. But in the last few years, an increasing number of studies point to a lower dose that may represent an acceptable risk for some pregnant women.
Looking at data from EURAP, an international registry of antiepileptic drugs and pregnancy, researchers showed that the dose of valproic acid with the greatest risk for harm was 1,500 mg per day or greater, with a 24% frequency of major congenital malformations. But at less than 700 mg per day, the frequency of major malformations dropped to 5.9% (Neurology. 2015 Sep 8;85[10]:866-72).
Another analysis of the EURAP data showed the same dose-dependent relationship with other drugs. The researchers calculated rates of major congenital malformations in 1,402 pregnancies exposed to carbamazepine, 1,280 on lamotrigine, 1,010 on valproic acid, and 217 on phenobarbital, and all showed that the frequency of birth defects increased along with the dose of the drug.
The study identified the dose for each drug with the lowest rates of malformation. For lamotrigine, it was a dose of less than 300 mg per day, with a 2% frequency of malformations. Similarly, the dose was less than 400 mg per day for carbamazepine (3.4% rate of malformations). Overall, risks of malformation were significantly higher in valproic acid and phenobarbital at all tested doses and carbamazepine at doses greater than 400 mg per day, compared with lamotrigine monotherapy at less than 300 mg per day (Lancet Neurol. 2011 Jul;10[7]:609-17).
The study is important because it gives us a benchmark for these drugs, allowing us to see the risks at lower doses.
But not all the data are in agreement. In 2016, a Cochrane review of different antiepileptic drugs in pregnancy found that only with valproic acid could the risk of a malformation be clearly linked to the size of the dose (Cochrane Database Syst Rev. 2016 Nov 7;11:CD010224).
Most recently, a large U.S. database of Medicaid patients, which included more than 1.3 million pregnancies, showed the dose-dependent risk of malformations associated with lithium, still widely used in treating bipolar disorder. The researchers examined the risk of cardiac malformations after first-trimester lithium exposure.
With the publication of each of these studies, we are moving toward an era where the question of teratogenicity is no longer just “yes” or “no,” but dose dependent. Soon, I hope we will be able to expand our knowledge by evaluating doses in milligrams per kilogram, rather than just a per day dose, thus addressing body size in evaluating the risk.
As more than half of pregnancies are unplanned, there are often times when women have been exposed to teratogens during early pregnancy and knowing the size of the risk is an invaluable decision-making tool. We don’t have the full risk picture yet, but it is growing clearer.
Dr. Koren is professor of pediatrics at Western University in Ontario and Tel Aviv University in Israel, and is the founder of the Motherisk Program. He reported having no relevant financial disclosures.
Upfront preparation key to QI projects
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.
Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.
In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.
Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.
A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.
Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.
In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.
Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.
A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.
Victor Ekuta is a third-year medical student at UC San Diego.
Editor’s note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform healthcare and revolutionize patient care. The program has been expanded for the 2017-2018 year, offering two options for students to receive funding and engage in scholarly work during their first, second, and third years of medical school. As a part of the longitudinal (18-month) program, recipients are required to write about their experience on a monthly basis.
I am currently working with my mentor, Ian Jenkins, MD, an attending in the Division of Hospital Medicine at the University of California, San Diego, to begin preliminary data collection for our project to cut catheter-associated urinary tract infections (CAUTI). The project time line is on track, and we hope to have things up and running in the next month.
Up to this point, we have been working to identify the most relevant data to collect to best explore our outcome variable. A key goal for our project is to show that increased education measures can ultimately lead to reductions in patient harm. Rather than directly measuring harm reduction, we have settled on tracking the closely identified process measure of the number of inappropriate Foley catheters removed. This measure is potentially more accessible for health care providers than measuring CAUTI rates would be because individual CAUTI events are rare.
In addition to starting data collection, I am quickly learning that conducting a quality improvement project requires a large amount of upfront preparation. Namely, it requires not only identifying the outcome measures you would like to track but also prospectively strategizing about how to track this measure to facilitate future data presentation and publication. Dr. Jenkins has been instrumental as a resource for bouncing off various ideas regarding how to streamline data collection and presentation. He has also been valuable in helping me to identify appropriate units for data collection and teaching me to be forward thinking regarding the best way to collect data for my project. This has truly saved me a significant amount of time and increased the project’s efficiency.
Outside of data collection, we have continued to engage as many stakeholders as we can to ensure the success of the project. Because our project was deemed high priority because of the high CAUTI rates at UCSD, we engaged higher-level hospital administrators who could be onboard with the project, as well as provide their own input to improve project’s effects. Separately, we have continued to collaborate directly with nursing and physician staff to not only share our ongoing project with them but also directly engage them in the project so we can better ensure that the project is not only theoretically palatable but will be realistically implemented as well.
A quality improvement project certainly presents its own unique set of challenges, but I am truly enjoying collaborating and troubleshooting in hopes of ultimately improving patient care.
Victor Ekuta is a third-year medical student at UC San Diego.
Personal models of illness
Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.
A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).
Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.
In one of my weekly phone conversations with my mother in Texas, she told me that Ricardo, the husband of close family friend, had sunk into a deep depression to the point where he could no longer leave the house for work. Ricardo is an unauthorized immigrant, having crossed the border from Mexico into Texas 17 years ago with his wife and 2-year-old son. He lives a story common to many families in Texas: two undocumented parents working in local businesses, one child with a DACA (Deferred Action for Childhood Arrivals) permit and their second child born in the United States, all assimilated into American culture. With Ricardo’s descent into personal darkness, their American dream was fraying. Family and neighbors were gossiping about what could have happened – had Ricardo gotten into trouble with drugs and alcohol? Perhaps his wife had bewitched him; perhaps this was a godly test that only prayer could overcome.
I called his wife to see if I could offer her help navigating the local mental health system. She recounted a story of severe depression, and, most worryingly, a recent self-aborted hanging. Because of cultural beliefs, stigma of mental illness, and his immigration status, Ricardo would not call the local mental health authority for assessment and treatment.
So I made a trip to Texas to see Ricardo as a friend and psychiatrist, despite not quite knowing how to navigate the moral and legal ambiguity of this situation. I could at least offer a comprehensive psychiatric assessment and provide him with some understanding of his illness to help guide his decisions. My conversation with Ricardo found a man helpless and confused as to how and why he lost all drive, energy, and desire to live. We spoke about his and my understanding of depression. I tried to help Ricardo by shifting his perception of his illness from fear of an unknown specter to the idea that his current state of mind could be attributed to a treatable brain disease.
The trip to Texas was also an opportunity to see my older brother’s newly purchased home. This was a serious achievement, following 2 years where he had lived with our parents to save money for a down payment. He had initially been forced to live at home because of legal consequences related to his struggles with addiction and depression, both backdrops to his life as a devoted math teacher. In the car ride to his new house, he told me about his twice weekly, state-mandated addiction counseling group sessions. He has benefited from the instruction to fill his sober time with positive forces, telling me that he could not have bought his house and started working a second, part-time job without his sobriety.
Yet, he disagrees when the counselor tells his class that addiction is a disease that compromises his free will, and compared to his peers, he has less control over his mind when exposed to alcohol. He says it’s a mixed message – be proactive and take control over a new sober life, but be careful, your brain is too weak and diseased to ever have a healthy relationship with alcohol.
I was affected when he told me that he was afraid to ever drink again; that he cannot trust himself. He is afraid to fail and lose the life he is building for himself. Now he lives in conflict between two models of his illness: the determinism of addiction versus free will to overcome his abusive relationship with alcohol. To overcome this conflict, he has surrendered himself to a self-designed treatment program, working two jobs to fill his days and nights, and guarantee fatigue and sleep by the end of the day. No time to think or drink; just time to work and sleep.
The night before I flew to Texas, I had an overnight call in the emergency department. I encountered a young woman whom I’ll call Laura. She was in her mid 30s with HIV/AIDS with a CD4 count of less than 30, and had not taken medication for her HIV in years. Mostly, she lived in and out of hospitals, both psychiatric and medical wards. I was called to assess her suicidal ideation with a stated plan to slip and fall in her shower in order to hit her head and die. She was cachectic, tired, withdrawn, disheveled, buried under a heap of blankets.
Our interview was an awkward dance around why she could not and would not take medications for either her HIV/AIDS or posttraumatic stress disorder and depression. No money, no transport, intermittently homeless, no desire to live nor a future to live for.
In our conversation, I searched for reasons for Laura to live, and she countered with reasons why it was easier to die. It was a level of apathy I have encountered with other severely ill AIDS patients – the brain is so immunocompromised and muddled, the body so tired, the spirit so damaged. Her three children living with a sister had lost their potency as motivation to desire recovery of her physical and mental health. I doubted the active nature of her suicidality, and her apathy and physical deterioration made me question her ability to act on a plan. Nonetheless, I admitted Laura to the psychiatric unit for safety. Two weeks later, I learned she had died in hospital of AIDS-related sepsis. She had 10 days of treatment on the psychiatric unit with no movement in her depressive symptoms and apathy. Eventually, she physically crashed and was sent to the ICU, where she died.
As psychiatrists, we create our own models of what mental illness and treatments are, and we apply some version of the model to each patient. With the concepts of cultural psychiatry and therapeutic alliance, we learn to work within our patients’ models of disease to enhance their response to treatment. My initial reaction to Laura’s death was surprise, fear, and guilt that maybe I had missed a pressing medical issue that contributed to her death. Then I just felt resigned to her death, probably as she did. She told me in the emergency department she was set on dying, and her actions, well before this last admission, had indirectly ensured an early death. We psychiatrists feel failure when we are unable to prevent a suicide. What was Laura’s death: Was it a suicide by apathy that a psychiatrist could have prevented? Or just an expected complication of an untreated chronic illness? Many residents had done their job by admitting her again and again for either psychiatric or medical illness. Yet none of us could understand why she refused to treat her HIV/AIDS, and none of us was able to address the model she had created of her illness. Her model, that her HIV was a death sentence, was anathema to our training.
Because of that dissonance, it was difficult to understand her narrative, let alone find a way to help her reframe it. Her model of illness was misunderstood by a wide swathe of medical professionals, and together we were unable to tailor a treatment to her needs. Since, I’ve worked to reframe her death in my own mind as a way to better understand models of illness, learning from her as well as from my brother and my friend Ricardo. Both the patient’s and physician’s conceptualization of illness affects prognosis of whether to surrender to a treatment or the illness. As psychiatrists, we must strive to understand all models of illness, so we can plan and implement our treatment intervention accordingly.
I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.
Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.
Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.
A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).
Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.
In one of my weekly phone conversations with my mother in Texas, she told me that Ricardo, the husband of close family friend, had sunk into a deep depression to the point where he could no longer leave the house for work. Ricardo is an unauthorized immigrant, having crossed the border from Mexico into Texas 17 years ago with his wife and 2-year-old son. He lives a story common to many families in Texas: two undocumented parents working in local businesses, one child with a DACA (Deferred Action for Childhood Arrivals) permit and their second child born in the United States, all assimilated into American culture. With Ricardo’s descent into personal darkness, their American dream was fraying. Family and neighbors were gossiping about what could have happened – had Ricardo gotten into trouble with drugs and alcohol? Perhaps his wife had bewitched him; perhaps this was a godly test that only prayer could overcome.
I called his wife to see if I could offer her help navigating the local mental health system. She recounted a story of severe depression, and, most worryingly, a recent self-aborted hanging. Because of cultural beliefs, stigma of mental illness, and his immigration status, Ricardo would not call the local mental health authority for assessment and treatment.
So I made a trip to Texas to see Ricardo as a friend and psychiatrist, despite not quite knowing how to navigate the moral and legal ambiguity of this situation. I could at least offer a comprehensive psychiatric assessment and provide him with some understanding of his illness to help guide his decisions. My conversation with Ricardo found a man helpless and confused as to how and why he lost all drive, energy, and desire to live. We spoke about his and my understanding of depression. I tried to help Ricardo by shifting his perception of his illness from fear of an unknown specter to the idea that his current state of mind could be attributed to a treatable brain disease.
The trip to Texas was also an opportunity to see my older brother’s newly purchased home. This was a serious achievement, following 2 years where he had lived with our parents to save money for a down payment. He had initially been forced to live at home because of legal consequences related to his struggles with addiction and depression, both backdrops to his life as a devoted math teacher. In the car ride to his new house, he told me about his twice weekly, state-mandated addiction counseling group sessions. He has benefited from the instruction to fill his sober time with positive forces, telling me that he could not have bought his house and started working a second, part-time job without his sobriety.
Yet, he disagrees when the counselor tells his class that addiction is a disease that compromises his free will, and compared to his peers, he has less control over his mind when exposed to alcohol. He says it’s a mixed message – be proactive and take control over a new sober life, but be careful, your brain is too weak and diseased to ever have a healthy relationship with alcohol.
I was affected when he told me that he was afraid to ever drink again; that he cannot trust himself. He is afraid to fail and lose the life he is building for himself. Now he lives in conflict between two models of his illness: the determinism of addiction versus free will to overcome his abusive relationship with alcohol. To overcome this conflict, he has surrendered himself to a self-designed treatment program, working two jobs to fill his days and nights, and guarantee fatigue and sleep by the end of the day. No time to think or drink; just time to work and sleep.
The night before I flew to Texas, I had an overnight call in the emergency department. I encountered a young woman whom I’ll call Laura. She was in her mid 30s with HIV/AIDS with a CD4 count of less than 30, and had not taken medication for her HIV in years. Mostly, she lived in and out of hospitals, both psychiatric and medical wards. I was called to assess her suicidal ideation with a stated plan to slip and fall in her shower in order to hit her head and die. She was cachectic, tired, withdrawn, disheveled, buried under a heap of blankets.
Our interview was an awkward dance around why she could not and would not take medications for either her HIV/AIDS or posttraumatic stress disorder and depression. No money, no transport, intermittently homeless, no desire to live nor a future to live for.
In our conversation, I searched for reasons for Laura to live, and she countered with reasons why it was easier to die. It was a level of apathy I have encountered with other severely ill AIDS patients – the brain is so immunocompromised and muddled, the body so tired, the spirit so damaged. Her three children living with a sister had lost their potency as motivation to desire recovery of her physical and mental health. I doubted the active nature of her suicidality, and her apathy and physical deterioration made me question her ability to act on a plan. Nonetheless, I admitted Laura to the psychiatric unit for safety. Two weeks later, I learned she had died in hospital of AIDS-related sepsis. She had 10 days of treatment on the psychiatric unit with no movement in her depressive symptoms and apathy. Eventually, she physically crashed and was sent to the ICU, where she died.
As psychiatrists, we create our own models of what mental illness and treatments are, and we apply some version of the model to each patient. With the concepts of cultural psychiatry and therapeutic alliance, we learn to work within our patients’ models of disease to enhance their response to treatment. My initial reaction to Laura’s death was surprise, fear, and guilt that maybe I had missed a pressing medical issue that contributed to her death. Then I just felt resigned to her death, probably as she did. She told me in the emergency department she was set on dying, and her actions, well before this last admission, had indirectly ensured an early death. We psychiatrists feel failure when we are unable to prevent a suicide. What was Laura’s death: Was it a suicide by apathy that a psychiatrist could have prevented? Or just an expected complication of an untreated chronic illness? Many residents had done their job by admitting her again and again for either psychiatric or medical illness. Yet none of us could understand why she refused to treat her HIV/AIDS, and none of us was able to address the model she had created of her illness. Her model, that her HIV was a death sentence, was anathema to our training.
Because of that dissonance, it was difficult to understand her narrative, let alone find a way to help her reframe it. Her model of illness was misunderstood by a wide swathe of medical professionals, and together we were unable to tailor a treatment to her needs. Since, I’ve worked to reframe her death in my own mind as a way to better understand models of illness, learning from her as well as from my brother and my friend Ricardo. Both the patient’s and physician’s conceptualization of illness affects prognosis of whether to surrender to a treatment or the illness. As psychiatrists, we must strive to understand all models of illness, so we can plan and implement our treatment intervention accordingly.
I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.
Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.
Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.
A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).
Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.
In one of my weekly phone conversations with my mother in Texas, she told me that Ricardo, the husband of close family friend, had sunk into a deep depression to the point where he could no longer leave the house for work. Ricardo is an unauthorized immigrant, having crossed the border from Mexico into Texas 17 years ago with his wife and 2-year-old son. He lives a story common to many families in Texas: two undocumented parents working in local businesses, one child with a DACA (Deferred Action for Childhood Arrivals) permit and their second child born in the United States, all assimilated into American culture. With Ricardo’s descent into personal darkness, their American dream was fraying. Family and neighbors were gossiping about what could have happened – had Ricardo gotten into trouble with drugs and alcohol? Perhaps his wife had bewitched him; perhaps this was a godly test that only prayer could overcome.
I called his wife to see if I could offer her help navigating the local mental health system. She recounted a story of severe depression, and, most worryingly, a recent self-aborted hanging. Because of cultural beliefs, stigma of mental illness, and his immigration status, Ricardo would not call the local mental health authority for assessment and treatment.
So I made a trip to Texas to see Ricardo as a friend and psychiatrist, despite not quite knowing how to navigate the moral and legal ambiguity of this situation. I could at least offer a comprehensive psychiatric assessment and provide him with some understanding of his illness to help guide his decisions. My conversation with Ricardo found a man helpless and confused as to how and why he lost all drive, energy, and desire to live. We spoke about his and my understanding of depression. I tried to help Ricardo by shifting his perception of his illness from fear of an unknown specter to the idea that his current state of mind could be attributed to a treatable brain disease.
The trip to Texas was also an opportunity to see my older brother’s newly purchased home. This was a serious achievement, following 2 years where he had lived with our parents to save money for a down payment. He had initially been forced to live at home because of legal consequences related to his struggles with addiction and depression, both backdrops to his life as a devoted math teacher. In the car ride to his new house, he told me about his twice weekly, state-mandated addiction counseling group sessions. He has benefited from the instruction to fill his sober time with positive forces, telling me that he could not have bought his house and started working a second, part-time job without his sobriety.
Yet, he disagrees when the counselor tells his class that addiction is a disease that compromises his free will, and compared to his peers, he has less control over his mind when exposed to alcohol. He says it’s a mixed message – be proactive and take control over a new sober life, but be careful, your brain is too weak and diseased to ever have a healthy relationship with alcohol.
I was affected when he told me that he was afraid to ever drink again; that he cannot trust himself. He is afraid to fail and lose the life he is building for himself. Now he lives in conflict between two models of his illness: the determinism of addiction versus free will to overcome his abusive relationship with alcohol. To overcome this conflict, he has surrendered himself to a self-designed treatment program, working two jobs to fill his days and nights, and guarantee fatigue and sleep by the end of the day. No time to think or drink; just time to work and sleep.
The night before I flew to Texas, I had an overnight call in the emergency department. I encountered a young woman whom I’ll call Laura. She was in her mid 30s with HIV/AIDS with a CD4 count of less than 30, and had not taken medication for her HIV in years. Mostly, she lived in and out of hospitals, both psychiatric and medical wards. I was called to assess her suicidal ideation with a stated plan to slip and fall in her shower in order to hit her head and die. She was cachectic, tired, withdrawn, disheveled, buried under a heap of blankets.
Our interview was an awkward dance around why she could not and would not take medications for either her HIV/AIDS or posttraumatic stress disorder and depression. No money, no transport, intermittently homeless, no desire to live nor a future to live for.
In our conversation, I searched for reasons for Laura to live, and she countered with reasons why it was easier to die. It was a level of apathy I have encountered with other severely ill AIDS patients – the brain is so immunocompromised and muddled, the body so tired, the spirit so damaged. Her three children living with a sister had lost their potency as motivation to desire recovery of her physical and mental health. I doubted the active nature of her suicidality, and her apathy and physical deterioration made me question her ability to act on a plan. Nonetheless, I admitted Laura to the psychiatric unit for safety. Two weeks later, I learned she had died in hospital of AIDS-related sepsis. She had 10 days of treatment on the psychiatric unit with no movement in her depressive symptoms and apathy. Eventually, she physically crashed and was sent to the ICU, where she died.
As psychiatrists, we create our own models of what mental illness and treatments are, and we apply some version of the model to each patient. With the concepts of cultural psychiatry and therapeutic alliance, we learn to work within our patients’ models of disease to enhance their response to treatment. My initial reaction to Laura’s death was surprise, fear, and guilt that maybe I had missed a pressing medical issue that contributed to her death. Then I just felt resigned to her death, probably as she did. She told me in the emergency department she was set on dying, and her actions, well before this last admission, had indirectly ensured an early death. We psychiatrists feel failure when we are unable to prevent a suicide. What was Laura’s death: Was it a suicide by apathy that a psychiatrist could have prevented? Or just an expected complication of an untreated chronic illness? Many residents had done their job by admitting her again and again for either psychiatric or medical illness. Yet none of us could understand why she refused to treat her HIV/AIDS, and none of us was able to address the model she had created of her illness. Her model, that her HIV was a death sentence, was anathema to our training.
Because of that dissonance, it was difficult to understand her narrative, let alone find a way to help her reframe it. Her model of illness was misunderstood by a wide swathe of medical professionals, and together we were unable to tailor a treatment to her needs. Since, I’ve worked to reframe her death in my own mind as a way to better understand models of illness, learning from her as well as from my brother and my friend Ricardo. Both the patient’s and physician’s conceptualization of illness affects prognosis of whether to surrender to a treatment or the illness. As psychiatrists, we must strive to understand all models of illness, so we can plan and implement our treatment intervention accordingly.
I asked my friend from home and my brother for their permission and sent them this piece to make sure they approved. I changed certain details about Ricardo’s story to protect his identity. With my brother, there was no way to change his identity, but he was touched and happy to be included. I also changed key facts about the patient I called Laura.
Dr. Posada is a third-year resident in the psychiatry and behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, and health disparities, and she plans to pursue a fellowship in consult liaison psychiatry.
Approaching intraoperative bowel injury
Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.
In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.1 Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.2
Some basic principles are critical when surgeons face a bowel injury:
1. Recognize the extent of the injury, including the size of the breach, the depth (full or partial thickness), and the nature of the injury (thermal or cold).
2. Assess the integrity of the bowel, including adequacy of blood supply, prior bowel damage from radiation, and absence of downstream obstruction.
3. Ensure no other occult injuries exist in other segments.
4. Obtain adequate exposure and mobilization of the bowel beyond the site of injury, including the adjacent bowel. This involves releasing other adhesions so that adequate bowel length is available for a tension-free repair.
Methods of repair
The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.
Simple small bowel closures
Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.
Small bowel resection
Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.
Large bowel repair
Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.
Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.6
Postoperative management
The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.
The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.7 In general, for small and large intestinal injuries, early feeding is considered acceptable.8
Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.6
Avoiding injury
Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.9 However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.10 Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.
Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.
References
1. Int Surg. 2006 Nov-Dec;91(6):336-40.
2. J Am Coll Surg. 2001 Jun;192(6):677-83.
3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.
4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.
5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.
6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.
7. Br J Surg. 2005 Jun;92(6):673-80.
8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.
9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.
10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.
Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.
In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.1 Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.2
Some basic principles are critical when surgeons face a bowel injury:
1. Recognize the extent of the injury, including the size of the breach, the depth (full or partial thickness), and the nature of the injury (thermal or cold).
2. Assess the integrity of the bowel, including adequacy of blood supply, prior bowel damage from radiation, and absence of downstream obstruction.
3. Ensure no other occult injuries exist in other segments.
4. Obtain adequate exposure and mobilization of the bowel beyond the site of injury, including the adjacent bowel. This involves releasing other adhesions so that adequate bowel length is available for a tension-free repair.
Methods of repair
The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.
Simple small bowel closures
Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.
Small bowel resection
Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.
Large bowel repair
Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.
Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.6
Postoperative management
The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.
The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.7 In general, for small and large intestinal injuries, early feeding is considered acceptable.8
Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.6
Avoiding injury
Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.9 However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.10 Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.
Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.
References
1. Int Surg. 2006 Nov-Dec;91(6):336-40.
2. J Am Coll Surg. 2001 Jun;192(6):677-83.
3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.
4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.
5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.
6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.
7. Br J Surg. 2005 Jun;92(6):673-80.
8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.
9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.
10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.
Enterotomy can be a serious complication in abdominopelvic surgery, particularly if it is not immediately recognized and treated. Risk of visceral injury increases when complex dissection is required for treatment of cancer, resection of endometriosis, and extensive lysis of adhesions.
In a retrospective review from 1984 to 2003, investigators assessed intestinal injuries at the time of gynecologic operations. Of the 110 cases reported, about 37% occurred during the opening of the peritoneal cavity, 38% during adhesiolysis and pelvic dissection, 9% during laparoscopy, 9% during vaginal surgery, and 8% during dilation and curettage. Of the bowel injuries, more than 75% were minor.1 Mortality from unrecognized bowel injury is significant, and as such, appropriate recognition and management of these injuries is critical.2
Some basic principles are critical when surgeons face a bowel injury:
1. Recognize the extent of the injury, including the size of the breach, the depth (full or partial thickness), and the nature of the injury (thermal or cold).
2. Assess the integrity of the bowel, including adequacy of blood supply, prior bowel damage from radiation, and absence of downstream obstruction.
3. Ensure no other occult injuries exist in other segments.
4. Obtain adequate exposure and mobilization of the bowel beyond the site of injury, including the adjacent bowel. This involves releasing other adhesions so that adequate bowel length is available for a tension-free repair.
Methods of repair
The decision to employ each is influenced by multiple factors. Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. Additionally, resection and re-anastamosis should also be considered if the damaged segment of bowel has poor blood supply, integrity, or the repair would result in tension along the suture/staple line or luminal narrowing.
Simple small bowel closures
Serosal abrasions need not be repaired; however, small tears of the serosa and muscularis can be managed with a single layer of interrupted 3-0 absorbable or permanent silk suture on a tapered needle. The suture line should be perpendicular to the longitudinal axis of the bowel at 2-mm to 3-mm intervals in order to prevent narrowing of the lumen. The suture should pass through serosal and muscular layers in an imbricating (Lembert) stitch. For smaller defects of less than 6 mm, a single layer closure is typically adequate.
Small bowel resection
Some larger defects, thermal injuries, and segments with multiple enterotomies may be best repaired with resection and re-anastamosis technique. A segment of resectable bowel is chosen such that the afferent and efferent limbs to be re-anastamosed can be reapproximated in a tension-free fashion. A mesenterotomy is made at the proximal and distal portions of the involved bowel. A gastrointestinal anastomotic stapler is then inserted perpendicularly across the bowel. The remaining wedge of connected mesentery can then be efficiently excised with an electrothermal bipolar coagulator device ensuring that maximal mesentery and blood supply are preserved to the remaining limbs of intestine. The proximal and distal segments are then aligned at the antimesenteric sides.
Large bowel repair
Defects in the serosa and small lacerations can be managed with a primary closure, similar to the small intestine. For more extensive injuries that may require resection, diversion, or complicated repair, consultation with a gynecologic oncologist or general or colorectal surgeon may be indicated as colotomy repairs are associated with higher rates of breakdown and fistula. If fecal contamination is present, copious irrigation should be performed and placement of a peritoneal drain to reduce the likelihood of abscess formation should be considered. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.
Standard prophylaxis for hysterectomy (such as a first-generation cephalosporin like cefazolin) is not adequate for large bowel surgery, and either metronidazole should be added or a second-generation cephalosporin such as cefoxitin should be given. For patients with penicillin allergy, clindamycin or vancomycin with either gentamicin or a fluoroquinolone should be administered.6
Postoperative management
The potential for postoperative morbidity must be understood for appropriate management following bowel surgery. Ileus is common and the clinician should understand how to diagnose and manage it. Additionally, intra-abdominal abscess, anastomotic leak, fistula formation, and mechanical obstruction are complications that may require surgical intervention and must be vigilantly managed.
The routine use of postoperative nasogastric tube (NGT) does not hasten return of bowel function or prevent leak from sites of gastrointestinal repair. In fact, early feeding has been associated with reduced perioperative complications and earlier return of bowel function has been observed without the use of NGT.7 In general, for small and large intestinal injuries, early feeding is considered acceptable.8
Prolonged antibiotic prophylaxis, beyond 24 hours, is not recommended.6
Avoiding injury
Gynecologic surgeons should adhere to surgical principles with sharp dissection for adhesions, gentle tissue handling, adequate exposure, and light retraction to prevent bowel injury or minimize their extent. Laparoscopic entry sites should be chosen based on the likelihood of abdominal adhesions. When the patient’s history predicts a high likelihood of intraperitoneal adhesions, the left upper quadrant site should be strongly considered as the entry site. The likelihood of gastrointestinal injury is not influenced by open versus closed laparoscopic entry and surgeons should use the technique with which they have the greatest experience and skill.9 However, in patients who have had prior laparotomies, there is an increased risk of periumbilical adhesions, and consideration should be made for a nonumbilical entry site.10 Methodical sharp dissection and sparing use of thermal energy should be used with adhesiolysis. When injury occurs, prompt recognition, preparation, and methodical management can mitigate the impact.
Dr. Staley is a gynecologic oncology fellow at the University of North Carolina, Chapel Hill. Dr. Rossi is an assistant professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.
References
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2. J Am Coll Surg. 2001 Jun;192(6):677-83.
3. Doherty, G. Current Diagnosis and Treatment: Surgery. Thirteenth Edition. New York: McGraw Hill, 2010.
4. Hoffman B. Williams Gynecology. Third Edition. New York: McGraw Hill, 2016.
5. Berek J, Hacker N. Berek & Hacker’s Gynecologic Oncology. Sixth Edition. Philadelphia: Wolters Kluwer, 2015.
6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156.
7. Br J Surg. 2005 Jun;92(6):673-80.
8. Am J Obstet Gynecol. 2001 Jul;185(1):1-4.
9. Cochrane Database Syst Rev. 2015 Aug 31;8:CD006583.
10. Br J Obstet Gynaecol. 1997 May;104(5):595-600.