EAST Day 3……and DODGEBALL

 

Today I received the award as the 2016 STN-EAST Foundation Nurse Fellow

Today I received the award as the 2016 STN-EAST Foundation Nurse Fellow

Dr. Glen Tinkoff- Official Referee

Dr. Glen Tinkoff- Official Referee

the STN Dodgeball Team- Blunt Force

the STN Dodgeball Team- Blunt Force

Today’s events started bright an early with a breakfast and learn session.  The topic discussed was Geriatric Trauma Service (GTS): Practices, Pitfalls, and Outcomes which was presented wonderfully by Dr. Douglas J.E. Schuerer.  Dr. Schuerer is the Trauma Medical Director from BJC Healthcare in St. Louis, MO.  Dr. Schuerer discussed in great length this morning the trials, tribulations, and successes that his facility encountered trying to develop a sustainable Geriatric Trauma Service.  As many of us know, mortality related to trauma increases dramatically once an individual reaches the age of 55.  The most common associated mechanism of injuries for the “Geriatric” population are falls, motor vehicle collisions, and penetrating wounds.  Along with managing the common injuries associated with these mechanisms of injuries, healthcare providers are often faced with trying to balance trauma and multiple co-morbidities such as hypertension, heart disease, diabetes, stroke, chronic obstructive pulmonary disease, dementia, arrhythmias, and endocrine dysfunction (just to name a few).  The problem with medical management of this sensitive older population often in most organizations, a struggle of power between multiple disciplines (trauma verses cardiology, ortho, neurology, pulmonary, medical, etc.).  What Dr. Schuerer and his colleagues determined was that they felt as if “they” (being the trauma surgeons) could best manage these patients independently and seek assistance of other disciplines when necessary and at their discretion.  This facility determined criteria of which any patient greater then age 55 with a significant injury related to trauma, would thus be admitted and primarily management by the dedicated Geriatric Trauma Service (same group of trauma surgeons, with dedicated APRN coverage for these patients).  Some of the other initiates that Dr. Schuerer determined his facility needed were consults to the hospitals geriatricians when applicable and provided guidelines as to when they should be involved in a particular patient case. They expanded PT/OT coverage to 10 hour shifts to allow more coverage of patient needs to evening time hours, weekends, holidays, and allowed this group of patients to receive PT/OT therapy twice a day to promote independence and encourage recovery.  Increased the size for the SICU from 24-36 beds to allow for more patients and prevent over flow of trauma patients to the MICU.  Social work and case managent teams were formed that care for patients throughout their hospital stay to assist with transitions and prepare for discharge. Dr. Schuerer and his team worked with the department of anesthesia to determine mutually agreed upon guidelines for patient testing/screening prior to OR time.  This helped to expedite and prevent unnecessary delays or testing when operative intervention should be timely in the geriatric population.  The GTS services performs medications reviews of all patients utilizing Beer’s Criteria and have discussions with patients PCP’s regarding medication adjustments or changes.  They developed numerous protocols and standard work ups for common injuries or diagnosis (including syncope, rib fracture, head bleeds, etc).

The paper lectures this morning were also extremely intriguing.  I found the lecture by Dr. Christine Leeper from University of Pittsburgh Medical Center quit fascinating.  Dr. Leeper and her colleagues performed a retrospective review of trauma induced coagulopathy in pediatric trauma patients.  Dr. Leeper’s study revealed that coagulopathy (defined as INR ≥1.3) is often common in severely injured pediatric patients and is the strongest independent factor of mortality.  INR on admission, at 24 hours post admission, and trending throughout hospital stay can be a valuable tool in determining patient’s outcomes. Her research proves that if a patients INR can be reversed (brought below 1.3) within first 24 hours after injury, outcomes and risk for survival will improve.  The research also noted that 1/3 of the patients that were adequately resuscitation and transfused correct their INR within 24 hours.  I personally believe that this research is extremely valuable in the efforts of caring for pediatric patients.  A test as simple as an INR can be a great predictor in survivability and mortality in pediatrics as well as adults. I often feel that this simple lab test can easily be forgotten.

The lecture given by Dr. Olubode Olufajo from Brigham and Women’s Hospital was also very interesting.  This lecture discussed how long a patients risk of venous thromboembolism persists after a patient has suffered a traumatic brain injury (TBI). The researchers looked at some retrospective data on patients who had suffered from a TBI and did some chart reviews to determine in the patient developed a VTE during their hospital stay, within 30, 60, 90, 120 and 365 days post discharge.  Their research suggests that the risk of VTE developed persists long after discharge in a significant proportion of patients with TBI injuries.  Contributing factors that can increase a patients risk for VTE developed after TBI include age and individuals who are discharge to an extended care facility.  The research teams recommendations are for careful consideration of long term management to prevent VTE in patients who have suffered a TBI.

Today’s Presidential Address was given by outgoing EAST President Dr. Stanley Kurek.  His presidential address was discussing resilience.  He defined resilience simply as how people respond to change and their ability to “bounce back” after change or adversity.  He stated that “success in the world is based largely on ability to cope with adversity.”  He described three characteristics of resilient people: those who accept reality, those who believe like is meaningful, and those who have the ability to improvise.  He also described eight steps to success:

1. Accept Change

2. Perceive and Believe (“excuses are the poetry of failure)

3. Manage Your Emotions (use the 24 hour rule before addressing high emotions)

4. Self-Empowerment (take charge of YOUR OWN LIFE)

5. Prepare (also be prepared and on time)

6. Stay Busy, Busy, Busy (if your busy your mind doesn’t have time to wander)

7. Professional Networks (know who you can call for help)

8. Give Help

These simple eight rules of life can help anyone be successful.  I felt that this wonderful speech was easily relatable to anyone could in professional and personal aspects of their life.

 

Lastly, to finish off this amazing trip I spent the afternoon playing dodgeball (YES DODGEBALL!!!!) with hundreds of amazing surgeon, emergency medicine physicians, and nursing professionals.  For those of you who do not know, EAST has an annual Dodgeball Tournament to support the EAST Foundation.  This is a VERY serious event that is hosted by the one and only Dr. Glen Tinkoff (picture below) who comes prepared with his very thorough list of official rules (which you may not in his picture, he proudly wears around his neck while refereeing).  This year’s dodgeball tournament hosted 16 different teams; I participated as a member of the STN team (GO BLUNT FORCE!!!!). I am sad to say that even with great effort we did not win, but that’s ok neither did the three teams from Shock Trauma!!! This was a wonderful event that allowed EAST members and family to participate! 

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EAST Day 2

 

Katie Arnold (Right) and myself (Heather Panichelli) during the STN Reception this evening! Katie is the 2016 STN-EAST Fellow Runner Up! I am so glad she could be here with me this week!!

Katie Arnold (Right) and myself (Heather Panichelli) during the STN Reception this evening! Katie is the 2016 STN-EAST Fellow Runner Up! I am so glad she could be here with me this week!!

So I began today with a little bit of reflection from yesterday’s events at EAST.  Mostly I would like to point out that EAST is not only a conference for trauma surgeons, but residents (surgery, trauma, and yes emergency medicine), advanced practice providers (PA’s and APRN’s), but also NURSING.  Yup, I said it NURSING!!!!  I think one thing that has really surprised me the most was the amount of respect and admiration I received from the many wonderful surgeons I have met thus far.  The congratulations, the praise, and appreciation that I have received is substantial….plus all the multiple praise I have received about the healthcare facility of which I work, as well as the acclaim I have been given for dealing with one of most respected (and sometimes trying) trauma surgeons of which I work with on a daily basis, Dr. Glen Tinkoff.  On a side note: I respect Dr. Tinkoff to the highest degree and praise his efforts for handling his patients, his residents and many students while balancing the interesting array of trauma population we see in little Delaware.  He may have a hard exterior, but underneath he is an outstanding surgeon, that takes great pride in his specialty and I would trust my life in his hands (and that says a lot).  This experience thus far has been more than I could have imagined, not only am I gaining tons of knowledge about new and up and coming trauma related patient bedside care, I have been listening to some young surgeons and residents present their research that reflect current trends/changes in care delivery or are challenging common practice. 

Now back to today’s sessions…

This morning’s scientific sessions were presented by a fast array of individuals from medical students (YUP! I said medical students- and Ms. Morgan Oskutis did a phenomenal job presenting), to surgeons, and even one emergency medicine physician (E. Reed Smith MD).  I found three of these lectures particularly interesting and bear with me as I recap them for you!

                The first lecture that I found fascinating was presented by a well-known physician from University of Tennessee Dr. Stephanie Savage.  She discussed the research that was performed regarding suction evacuation of hemothorax and the outcomes regarding incidence of retained hemothoraces and other potential late complications (such as empyemas).  The first part of this research that took me a bit by surprised was the method of which they used to evacuation the hemothorax prior to chest tube insertion.  The physician placing the chest tube would make a normal incision, dissect into the pleural cavity, utilize a Yankauer to suction as must blood as possible prior to placing the chest tube. The findings of this study were inconclusive as draining the blood collection or lack thereof (this was identified as a weakness to the study- there was no definitive imaging studies to confirm that a hemothorax existed on any of the study patients- all patient requiring a chest tube received this procedure) did not protect against, or contribute to, a late empyema or retained hemothorax.  The results did not reveal a change in the patients overall ICU or hospital length of stay, did not provide an increased risk of infection on the sample group. However, the procedure did provide a low risk to the patients and had no additional cost to the patient.  Just putting my nursing cap for a few minutes, this study made me think…there was no discussion as to what mmHg were utilized for the evacuation?  Was this consistent throughout the study with the patient sample?  My concern more is for the safety and lining of the pleural cavity.  What mmHg is safe to use for this procedure, 20mmHg, 40mmHg?  Can one cause harm the patient or the pleural space? Could you cause more trauma or bleeding inside the cavity?  I understand fully the importance of preventing further patient complications from large hemothoraces such as retained hemothorax, recurrent pneumothorax, and empyema development which could potentially result in further procedures for the patient, increased morbidity/mortality, and prolonged hospital length of stay.  There is just something that makes a nurse nervous about sticking a Yankauer into a patient’s chest that puts me on edge!

                The second lecture I would like to discuss is the wonderful presentation given by the third year medical student from University of Maryland School of Medicine, Morgan Oskutis.  Maybe I have a soft spot for medical students as my sister (Ashley Panichelli) is a first year family medicine resident, so I know second hand how difficult medical school is and I commend Morgan for submitting the abstract of her research endeavor and applaud her for standing in front of hundreds of the WORLDS leaders in trauma and surgery to present her findings so eloquently. Morgan presented her work on how CT scan findings that determine presence of osteopenia and sarcopenia can provide a better assessment of patient susceptibility to injury and trauma, from motor vehicle collisions, rather than the individual’s chronological age alone. Some of the findings from the study include, osteopenia was the only factor that was significantly associated with sever spine injuries, patients who had presence of osteopenia are 4x more likely to sustain a severe spine injury over those non-osteopenic patients, sarcopenia was associated with severe thoracic injuries, and an individual’s chronological age was not significantly associated with developing severe spine or thoracic injuries.

                The third lecture that I also found extremely interesting for many points was the one given by E. Reed Smith MD from George Washington University.  First off I would like to say that this emergency medicine physician did a wonderful job presenting his research to a room full of trauma surgeons.  His research discussed the difference in wounding patterns comparing the victims of civilian active shooters events verses those wounds sustained in combat situations.  His was main discussion detailed the injury patterns often seen for both the civilian active shooter population as well as those patients from combat zones. This was intriguing to me, personally because I have never thought about the differences.  Most combat type injuries are from blast injuries which typically result in multiple injuries covering the thorax and extremities or ballistic injuries that are typically from further distances then those received from a mass shooting incident.  The mass shooting incidents are typically at a closer range with emphasis on brain and torso injuries. The main purpose of Dr. Smith’s lecture was that no matter how well lay individuals are trained with the use of tourniquet type devices, this may not necessarily be beneficial in mass shooter incidents.  I will directly quote the conclusion from his abstract as I feel I cannot provide justice to the way Dr. Smith and his colleagues stated this… “Although tourniquets and external hemorrhage control techniques hold value, their role in active shooter events may be over-emphasized as a means to decrease fatality.  Instead, rapid access to the wounded, initiation of damage control resuscitation, and rapid extrication of definitive care may offer a more effective means to minimize mortality.”  Thank you Dr. Smith and colleagues for such thought provoking initiatives, we as a world need to be more prepared for these instances as, unfortunately, they are occurring more and more often throughout the world.

I did also get the pleasure of attending the Today’s Topic presentation on Initial Pharmacotherapy in the Trauma Bay that was presented by Dr. Daniel Holena.  I will not go into super long detail, but this lecture was great for both nursing and physicians.  Dr. Holena did an awesome job with a fun interactive case based lecture that discussed many potential issues that may present in a trauma resuscitation bay and his recommendations for medication management.  Some of the topics were handling agitation patients (we know that this never happens in a trauma bay, all patients are calm and cooperative when they roll into the bay), the prophylactic use or non-use of antibiotic coverage with chest tube insertion, the controversial topic of which medications to use for rapid sequence intubation (RSI) (to sum up his suggestions Succinylcholine and Etomidate are best when no contraindications arise), and ICP management- the ongoing debate of Mannitol verses Hypertonic Saline, and antibiotic coverage for open fractures- just to name a few!

I know this is getting lengthy today, and I apologize however, I would like to point out the Keynote Address given by Dr. Donald Jenkins and the wonderful Oriens Essay Presentations given by both winners Dr. Dylan Nieman and Dr. Samuel Ross.  All three of these speeches were extremely motivational and moving.  Dr. Donald Jenkins gave a powerful speech regarding leaders, leadership, communication, and teamwork.  Here is one of the many quotes that Dr. Jenkins utilized in his lecture that I found empowering, “Good leaders are made, not born. If you have the desire and willpower, you can become an effective leader.  Good leaders develop through a never ending process of self-study, education, training, and experience” AG Jago.  The speeches given by Dr. Nieman and Dr. Ross discuss the personal reasons of which both gentlemen chose to become trauma surgeons and pursue their career goals. Both of these heart wrenching speeches depicted those memorable patients (we all have one) that have led them down the career path they are on today.  I thank both of these men for sharing their stories that I know are often hard to relive, but a word of advice for an experienced nurse who has that one memorable patient, DO NOT EVER FORGET THESE PATIENTS!!!! Remember their story. Remember how they make you feel today.  Remember their face, and know that their lives have touched you for a reason.  There will be hundreds of other patients that you will touch and affect their course of life, but remember the one or two patients that got you to where you are today, and remember that these memorable patients will help guide your motivate to be the best you can be in the future.

 

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