POTD: Displaced Clavicles (LLFTP #6)

It's Friday yet again, and here's another pearl from The Pitt. 

Spoilers for the betting pool!

Several episodes ago, someone stole an ambulance that had been parked outside with the keys in the ignition (while there was good intent in "allowing someone to move it if needed", it was a violation of their EMS department policy). Since then, there's been a betting pool around who the perpetrator(s) are, how far the thieves would get before being stopped, and what condition the ambulance would be in. In episode 6, we get to see the results of the chase: two frat bros (sorry, one bro and one pledge) stole the ambo, decided they would take a joyride and have a merry police chase (the kind of classic mockery of Darwin that is so endemic to that demographic), and then crashed the ambulance into a tree. Tragically, that kind of impact vs a large stationary object means that this critical healthcare resource will be out of circulation. The frat bros are also injured, and are brought to the Pitt for care. 

Of the two rapscallions, the pledge is in far worse condition than his senior (whose product-laden frosted tips look totally unruffled). Miles Hernandez, 18 years old, unrestrained (because of course), arrives to the ED with signs of injury to the right chest and left leg, shortness of breath with an O2 sat of 91% on ?L supplemental O2 via nasal cannula, HR 120s, BP 100s/70s. Miles exhibits easily-audible wheezing when he tries to speak, with diffuse high-pitched breath sounds on lung auscultation. Dr. Robby quickly notices that the head of Miles's right clavicle is centrally depressed, raising concern for a posterior sternoclavicular dislocation, which could compress the trachea and explain his dyspnea. The dislocation is reduced with local anesthesia and a towel clamp, with immediate improvement in Miles's vocal quality and respiratory symptoms. 

A quick anatomy review — the clavicle (or "collarbone") is the bone that connects the scapula to the sternum to form the shoulder girdle. Its name comes from the Latin diminutive clavicula ("little key"), so called due to its shape and manner of articulation. The two joints of the clavicle are the sternoclavicular joint and the acromioclavicular joint, with dislocations of the latter being far more common than the former. AC dislocations classically occur in younger males playing contact sports, but can occur due to any trauma to the shoulder/extremity. Depending on the degree of injury, a high-riding/elevated clavicle might be visible/palpable on exam. The Rockwood classification of AC injuries is based primarily on the involvement of the acromioclavicular and coracoclavicular ligament complexes, with the combination of exam and radiographic findings being sufficient for determination. Type 1 and 2 injuries are usually managed nonoperatively w/ sling and orthopedics follow-up, Type 3 and up require a consult for OR reduction/stabilization (with some stable type 3 variants being eligible for nonoperative management). Complications of AC dislocation typically comprise pain and loss of function. 

Sternoclavicular (SC) dislocations also occur with trauma (or hypermobility disorders) and are considered high-energy injuries. The shape of the articular surface is inherently unstable, relying on ligamentous complexes to aid in stability. Anterior dislocation results from lateral compression on the shoulder girdle resulting in rupture of the anterior joint capsule; this causes pain and a visible/palpable bump over the SC joint. The posterior joint capsule is stronger and less prone to rupture, but a posterior dislocation still may result from direct force over the anteromedial clavicle or from indirect force to the posterolateral shoulder; symptoms of compression to the airway, nerves, vessels, or esophagus may occur, and may require urgent reduction. Anterior SC dislocation can be reduced at beside with direct pressure while the ipsilateral arm is abducted 90 degrees, but the rate of recurrence in absence of ligament reconstruction is high; and with the low mechanical impact of this type of dislocation, reduction may not be needed if pain is controlled. Posterior dislocations can be reduced with the towel clip method demonstrate in The Pitt, or with the application of extension force to the abducted tractioned shoulder. 

It is also possible to have a "bipolar clavicular dislocation" where both the SC and AC joints are disrupted. In the less than 50 known cases, all involved high-energy blunt trauma and all but 1 had anterior SC dislocation. 

Other little lessons from episode 6:

• Remember the ABCD's of ED efficiency — Always Be Constantly Dispo'ing! Getting patients out of the ED as soon as medically stable is the best tthat we can do as ED staff to address ED overcrowding. 

• Dr. Shamsi (surgery bigwig) demonstrates the psoas sign in appendicitis by having the patient flex his hip against resistance. The more orthodox method described by Sir Cope in 1921 involves passive extension of the patient's right hip with them lying on their left side. The test is fairly specific for appendicitis, but not sensitive (i.e. positive test rules in, but negative test does not rule out). See this article for more information.

• If holding sharps: keep a tight grip and move slowly and deliberately. 

• Sometimes, ignorance is bliss. When giving bad news (like dead tapeworm eggs in someone's brain), ease them into it with SPIKES.

• When Mel was FaceTiming her sister in the ambulance access road, I was so worried that she would get hit by an ambulance. When walking to and from the hospital, please be mindful that the laws of physics trump any laws of man. The intersection of 48th St. × 10th Ave. is especially bad with drivers running the stop signs. 

Have an amazing weekend!

References:
https://www.tandfonline.com/doi/full/10.2147/ORR.S218991
https://pmc.ncbi.nlm.nih.gov/articles/PMC4832225/
https://pmc.ncbi.nlm.nih.gov/articles/PMC5174051/
https://pmc.ncbi.nlm.nih.gov/articles/PMC6435864

POTD: Medical Termination of Pregnancy (LLFTP #5)

Today we'll be looking at a case from episode 5 from "The Pitt", which was actually briefly mentioned in the signout from Dr. Abbott during episode 1. 

Spoilers!

Ms. Wheeler is 17 years old and pregnant and returns for elective pharmacological termination of pregnancy. She was evaluated by Dr. Abbott yesterday, with pelvic ultrasound showing a fetus with EGA 10 weeks and 5 days. EGA measurements in early pregnancy can be based on gestational sac size, crown-rump length, or biparietal diameter, with can be plugged into an exponential formula (use a calculator or a table for this). As per Dr. Abbott, she was supposed to come back in the morning for mifepristone — I'll discuss the reason for this delay later. Dr. Collins repeats the ultrasound and finds an EGA of 11 weeks and 2 days, which is problematic. Mifepristone (in combination with misoprostol chaser) is approved by the FDA for medical termination of pregnancy up to 10 weeks, with off-label use (and decreasing efficacy) through up to 12 weeks. Guidelines from both the Pennsylvania and NY Departments of Health allow the use of mifepristone + misoprostol at up to 11 weeks. Beyond that timeframe, the next step is a procedural/surgical abortion (subject to their own guidelines, which we won't cover today). 

Dr. Robby mentions that a +/- 5 day differential on EGA can be seen due to inter-operator variability (and other patient factors), but heavily implies that Dr. Abbott lowballed the measurement so that Ms. Wheeler could qualify for mifepristone — following that up by suggesting that Dr. Collins should either use Dr. Abbott's or obtain new measurements that show EGA < 11 weeks. As Dr. Collins points out, this is medical record fraud, and so Dr. Robby takes over the case and tells his resident to delete her documentation and images. I cannot emphasize enough that once something is saved to the electronic medical record, it can never be fully erased — we're past the days when you could theoretically shred/burn/"lose" a page on a chart and print a new one. 

After meeting Ms. Wheeler, Dr. Robby's "measurements" result in an EGA of 10 weeks and 6 days. Near the end of the episode, Dr. Collins returns to the room to give Ms. Wheeler and accompanying family member the medication and follow-up instructions. In the FDA-approved regimen, a single oral dose of 200mg mifepristone is given in the clinic, followed at 24-48 hours by 4x200μg misoprostol pouched within the cheeks for 30 minutes. In the off-label extended-EGA regimen that Dr. Collins explains, two doses of mifepristone are given — once in the clinic, then the 2nd dose at the 24-hour mark; followed another 24 hours later by two doses of misoprostol spaced 6 hours apart. Cramping and bleeding are expected, but patients should return for severe pain or heavy bleeding (as well as for symptoms of hypovolemia, infection, etc.). 

But before Ms. Wheeler can take the first dose of mifepristone, someone runs into the room screaming her name and beginning perhaps the second-most-dramatic conflict of the season thus far. Turns out the woman who was allegedly Ms. Wheeler's mother is actually her aunt, and the new woman is the real mom. Why does that matter? Because under Pennsylvania state law, except in the case of medical emergency (or other specific extenuating circumstances), a parent/guardian of an unemancipated minor must provide consent for a termination of pregnancy. 

On the other hand, in New York (and New Jersey) a minor may access termination of pregnancy services and other reproductive health services without consent from (or notification of) a parent/guardian. 

Stepping back and looking at another aspect of women's health, all 50 states (and DC) allow minors to consent to their own STI testing and treatment; however, further details vary (including confidentiality, vaccinations etc.). New York is very protective of minors' rights and privacy, and has measures in place to protect their confidentiality (including ways to avoid the situation of charges appearing on family insurance statements), with the exception of HPV vaccination needing to be reported to the Immunization Registry (which can be queried by a parent). 

Other little lessons from episode 5:

• If you don't have a tourniquet, you can substitute an inflated BP cuff as a workaround.

• I've never debrided a hematoma in the ED, but you could probably throw a Doppler or US probe on it to see if there's pulsatile flow before cutting into it. 

• When considering disposition for a patient with elevated care needs (e.g. just broke an arm), discuss with family what capabilities/services are available at home and if they would be amenable to evaluation for placement in a facility (e.g. nursing home vs acute rehab). 

• EMTALA obligates the hospital to evaluate and stabilize; consultants cannot refuse to evaluate a potential surgical emergency on the basis of "we weren't the ones who did the patient's procedure". 

• The DuCanto catheter is a large-bore (28 Fr) suction catheter that, if available, could have been used as part of SALAD technique (2016) to intubate the post-tonsillectomy hemorrhage patient. It is larger than the Yankauer tip (18 Fr, "large" bore), and can accommodate a bougie for said technique. 

• Retrograde intubation is an older method for addressing difficult airways, and involves passing a wire superiorly through a cricothyroidotomy. 

References:
https://portal.311.nyc.gov/article/?kanumber=KA-02538
https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm
txtType=HTM&ttl=18&div=0&chpt=32&sctn=6&subsctn=0
https://www.plannedparenthood.org/learn/abortion/the-abortion-pill
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information|
about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation
https://ag.ny.gov/sites/default/files/abortion-laws-english.pdf
https://www.cdc.gov/std/treatment-guidelines/adolescents.htm
https://www.hivguidelines.org/guideline/adolescent-consent/

POTD: PPE + Precautions (LLFTP #4.5)

Today's POTD is going to be short but sweet. 

It's not based on a particular case from The Pitt, but rather emerged from seeing the physical comedy of poor MS4 Whitaker being soaked in various patient fluids at multiple points in the season. As we all know, patient fluids — along with their droplets, aerosolized particles, etc. — can be vectors for the transmission of disease. Recognizing that, today we'll be talking about the primary ways to protect yourself from communicable diseases in the healthcare setting: PPE and isolation precautions!

We're all trained in "standard precautions", a minimal level of common-sense practices that should be used during all patient encounters to reduce risk of infection and transmission. 

• Hand hygiene

• PPE used as needed

• Cough etiquette

• Clean and disinfect equipment

• Clean/replace textiles/laundry

• Safe sharps practices

When a patient is suspected to carry certain infectious diseases, "transmission-based precautions" should be added to reduce risk. These include specific recommendations as to what type of PPE one should wear. 

Contact precautions are added for pathogens tthat spread through direct contact with the patient or with contaminated materials (blankets, clothing, etc.). This includes suspected C. diff or enterococcus infection, norovirus, uncontrolled diarrhea due to other gastrointestinal infection, MRSA, Candida species, MRSA, lice and scabies, and herpesviruses. 

• Minimize contact with other patients

• Wear gown + gloves for all patient/environmental contact

• Cover patient during transport, disinfect rooms/equipment during/after transport

• Use dedicated or disposable equipment

Droplet precautions are added for pathogens that spread through respiratory droplets generated by talking, coughing, or sneezing. This includes influenza, Neisseria and HIb meningitis, other meningococcal disease, mumps, pertussis, plague, rhinovirus, rubella, group A streptococcal disease, and COVID in general. For many of these conditions, droplet precautions can be deescalated after 24 hours of appropriately antimicrobial therapy.

• Single patient room vs dedicated isolation unit

• Source control w/ patient masking, especially during transport

• PPE should cover eyes, nose, and mouth, and should be discarded (or sanitized) immediately before room exit

• Extra emphasis on "covering the eyes" — see the face shield vs goggles in the CDC graphic below. Regular eyeglasses are inadequate (I am often guilty of this, even though we have masks with integrated face shields readily available in the ED's yellow carts).

Airborne precautions are added for pathogens that can be aerosolized, i.e. carried through the air in small particles that remain airborne for an extended time and are small enough to penetrate many barriers. This includes herpes zoster that is disseminated or in immunocompromised patients, measles, SARS, smallpox, pulmonary or extrapulmonary draining tuberculosis, and COVID with aerosol-generating procedures.

• Airborne infection isolation room (if unavailable, patient masking + private room w/ closed room) 

• Source control w/ patient masking, especially during transport

• Use a fit-tested N95+ respirator, which should only be removed after leaving room

• Limited contact with susceptible healthcare workers

• Often combined with contact precautions (add gown + glove)

Lastly, and most relevantly for Whitaker, procedures should prompt the use of appropriate barrier PPE. 

• Gloves, always

• Mask + eye protection for any procedure that may generate respiratory droplets or fluid splashes

• Semipermeable (yellow woven/spun) isolation gown for procedures on patients with contact precautions, light splash risk

• Nonpermeable (blue plastic-y) isolation gown for procedures with risk of high volume fluid exposure (bloody traumas, disimpactions) 

• Sterile gloves, sterile gown, mask, and bouffant cap for all sterile procedures

References:
https://www.cdc.gov/infection-control/hcp/basics/standard-precautions.html
https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html
https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html
https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control