Annals for Educators - 20 June 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives20 June 2017Annals for Educators - 20 June 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201706200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Physicians' HealthOn Being a Doctor: Rock BottomDr. Muller describes how he descended to the lowest point in his training: exhausted, ashamed, and wanting everything—even his life—to just end.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners how often they have felt emotionally exhausted by their work as physicians.In his essay, Dr. Muller says he and his resident were reluctant to accept help with their overwhelming medical service when it was offered, “…out of a sense of duty to our patients, but we were probably also ashamed of looking like the weak link on our unit”. Do your learners believe they would ask for help if they needed it or accept it if it was offered? Why is refusing to do so dangerous for our patients and ourselves?How can we support each other? How can we prevent ourselves from hitting “rock bottom”? What should your learners do if they suspect a colleague is in trouble or if they are having trouble themselves?Clinical Practice PointsExtracranial Carotid Disease and Effect of Intra-arterial Treatment in Patients With Proximal Anterior Circulation Stroke in MR CLEANRandomized clinical trials for patients with acute ischemic stroke from an intracranial occlusion of the anterior circulation usually exclude those who also had extracranial disease in the carotid arteries. This trial included patients with extracranial occlusion of the internal carotid artery and reports whether therapy was as effective for patients with extracranial disease as it was for those who had only intracranial disease.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners what acute diagnostic tests and interventions they should initiate immediately upon recognition of possible stroke. How should blood pressure be managed? Should they give aspirin immediately or wait? Use the information in DynaMed Plus: Stroke (acute management) , a benefit of your ACP membership.Which patients with an acute stroke should receive intravenous thrombolytic therapy? How is it given? In whom is such treatment contraindicated?When should intra-arterial mechanical thrombectomy, such as that used in this trial, be considered? Invite a neurologist to join your discussion. What are the roles of the internist, ER physician, neurologist, and interventional radiologists at your medical center in the management of patients with acute stroke? How might your learners' roles in the management of patients with acute stroke change in other practice settings?Early Versus Delayed Feeding in Patients With Acute Pancreatitis. A Systematic ReviewHospitalizations for acute pancreatitis are common and costly. This systematic review of 11 randomized trials evaluates whether early feeding of adults hospitalized with acute pancreatitis affects length of hospital stay, mortality, and readmission rates.Use this study to:Have your learners generate a list of causes to consider for acute pancreatitis. What studies should be considered in the evaluation? When should a CT or MRI scan be obtained, and why? When should ERCP be considered? Use DynaMed Plus: Acute pancreatitis to help prepare a teaching session.What is the rationale for avoiding oral nutrition in patients with acute pancreatitis? What are the benefits to the gut of feeding patients with pancreatitis? The authors note these in the paper's introduction. How do your learners decide when to initiate nutritional support in patients with acute pancreatitis?How do your learners write dietary orders for patients with acute pancreatitis? Are patients fed by mouth or by nasogastric or nasojejunal tubes? Should parenteral nutrition be considered? How do they decide? Invite an expert in pancreatitis and/or a member of your institution's nutritional support team to join your discussion.What are the strengths and weaknesses of this systematic review? Use the accompanying editorial to help frame your discussion.Video LearningAnnals Consult Guys - Syncope: How Do I Figure This One Out?In this episode of the consultative medicine talk show, the Consult Guys take on a case of syncope. What would cause recurrent syncope?Use this feature to:Take a break with your learners and watch the short video together.Ask your learners what differential diagnoses must be considered in patients who have had a syncopal event.What testing should be ordered? Does everyone need an echocardiogram?Sign on to answer the multiple-choice questions and earn CME credit for yourself!Medicine and SocietyMarch for ScienceAlternative Facts Have No Place in ScienceThe first of these commentaries from a co-chair of the March for Science organizing committee discusses the crisis that the scientific community is facing today and why the defense of science is necessary. The second notes that progress toward improved health may be impaired when the politicization of science interferes with the pursuit of knowledge or the use of what has been learned. The authors decry such an approach and explain why it is imperative that we stand up for science.Use these papers to:Ask your learners why scientists might want to avoid engaging in political discussions. Are there discussions the scientific community should refrain from engaging in? How might a desire to “remain above the fray” create problems for science?Do your learners think physicians should be involved in the public debate over issues such as climate change?What is the “politicization of science”? The authors of the second paper offer a definition. Do your learners agree with the authors' opinions?If physicians are to speak up about issues such as climate change or health insurance, how should they do so? What are the risks of speaking up? What are the risks of not speaking up?Humanism and ProfessionalismOn Being a Doctor: Moral Dilemma in the ERDr. Al-Shamsi found himself distraught over a patient whose life he knew he could save if not for the refusal and personal threats of the patient's family and society.Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.Ask your learners what they think Dr. Al-Shamsi should have done. What would they have done if they were in that situation?Have your learners ever faced a situation where a patient's religious beliefs were in opposition to what your learners thought was the right thing to do? How did they handle it?How should we handle such situations when the patient cannot speak coherently for himself or herself? Is it the physician's job to determine whether a surrogate decision maker is expressing what the patient would say? What if the physician disagrees or thinks the surrogate is not saying what the patient would want for himself or herself? How do our own beliefs and values influence whether we believe the surrogate is expressing what the patient would say?How should a physician's concern for her or his own safety influence how a patient is treated?MKSAP 17 QuestionA 57-year-old man is evaluated in the emergency department for sudden-onset left-sided weakness and slurred speech. The patient also has atrial fibrillation, hypertension, and dyslipidemia. Medications are warfarin, metoprolol, chlorthalidone, and atorvastatin.On physical examination, temperature is 36.7 °C (98.1 °F), blood pressure is 140/70 mm Hg, pulse rate is 72/min and irregular, and respiration rate is 12/min; BMI is 31. Cardiac examination reveals an irregularly irregular rhythm; no carotid bruits are heard. Left facial weakness, moderate dysarthria, and a left visual field deficit with a right gaze preference are noted. The patient answers questions and responds to commands only if spoken on the right side of the bed. Speech content is normal. On muscle strength testing, he cannot move the left arm; he can lift the left leg briefly, but it falls back to the bed within seconds. Pinprick sensation is absent on the left. The patient's National Institutes of Health Stroke Scale score is 14.Results of laboratory studies show an INR of 1.3 and a serum creatinine level of 1.1 mg/dL (97.2 μmol/L); all other laboratory results are unremarkable.A CT scan of the head shows no hemorrhage or early sign of infarct.The patient is treated with alteplase, and blood pressure increases to 150/80 mm Hg.Which of the following is the most appropriate next step in management?A. Aspirin, rectallyB. CT angiographyC. Labetalol, intravenouslyD. MRI of the brainCorrect AnswerB. CT angiographyEducational ObjectiveEvaluate an acute ischemic stroke.CritiqueThe patient should next have CT angiography. He has an acute ischemic stroke and met all inclusion criteria for intravenous thrombolysis, which was appropriately administered. A National Institutes of Health Stroke Scale score of 14 is consistent with a large stroke of the nondominant hemisphere involving more than one cerebral lobe, which would be fed by the terminal internal carotid artery or middle cerebral artery stem. Intravenous alteplase improves outcomes in patients with this type of stroke, although the success rate of recanalization is low overall if the occlusion is located at the middle cerebral artery origin or internal carotid terminus. Several recently completed trials have shown a significant clinical benefit with endovascular treatment using state-of-the-art stent retrievers in a select group of patients. In all cases, visualization of the large vessel occlusion by neuroimaging was necessary before treatment initiation because, in rare instances, patients with this clinical presentation may not have such an occlusion, either because of recanalization with alteplase or because of a location in the thalamus. CT angiography can be rapidly performed in the emergency department and enables visualization of large vessel occlusions that are amenable to endovascular therapy.Although aspirin reduces the risk of recurrent stroke if administered within 48 hours of acute ischemic stroke, it should be held in patients given thrombolysis until neuroimaging is performed, typically 24 hours after treatment.Hypertension after intravenous thrombolysis is a consistent risk factor for symptomatic intracerebral hemorrhage, and patients require aggressive monitoring of blood pressure and early treatment if necessary. Current guidelines recommend treatment with intravenous labetalol or nicardipine after thrombolysis if the blood pressure exceeds 180/105 mm Hg. This patient's blood pressure is only 150/80 mm Hg.MRI with diffusion-weighted imaging is the gold standard for diagnosing an ischemic stroke. This test, however, can be time consuming and will not change immediate management, unlike CT angiography. After acute stroke therapy, MRI may indicate the final infarct size and the presence of hemorrhagic conversion or cerebral edema, which may dictate further treatment.Key PointIn a patient successfully treated with thrombolysis for an acute ischemic stroke caused by a probable large artery occlusion, recent guidelines recommend visualization of the occlusion by CT angiography to determine the appropriateness of endovascular therapy.BibliographyPowers WJ, Derdeyn CP, Biller J, et al; American Heart Association Stroke Council. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Oct;46(10):3020-35. Epub 2015 Jun 29.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 20 June 2017Volume 166, Issue 12Page: ED12KeywordsAcute pancreatitisAngiographyBlood pressureCarotid arteriesComputed axial tomographyHeartIschemic strokeNutritionStrokeTreatment guidelines ePublished: 20 June 2017 Issue Published: 20 June 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...