Annals for Educators - 16 May 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives16 May 2017Annals for Educators - 16 May 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201705160 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Taking Care of Ourselves and OthersOn Being a Doctor: This Is WhyForbidden TopicsAd Libitum: The ClearingWe start this issue of Annals for Educators with a difficult but critical topic that is as much about taking care of ourselves as it is taking care of our patients. This powerful On Being a Doctor essay compels each of us to look inside ourselves and ask if our actions have contributed to the suffering of our patients and colleagues struggling with mental illness. An anonymous fourth-year medical student discusses the struggles that health care professionals with mental illness face. The editorialist explores how to address this problem, focusing on teaching at the bedside. The poem might stop you in your tracks.Use these pieces to:Listen to an audio recording of the On Being a Doctor essay , read by the author of the editorial , Dr. Michael LaCombe.Ask your learners if they have ever heard fellow physicians make disparaging remarks about patients with mental illness. Think about whether you have ever made such remarks yourself. Why does it matter if we're just “joking” or “blowing off steam”?In what ways do we “label” patients who have mental illness? How do these labels affect the care of patients?Is our profession prejudiced against patients with mental illness? Do your learners think patients pick up on our prejudices?The author of the On Being a Doctor essay and the editorialist each comment that a professional culture that labels mental illness as a weakness, and even “dirty,” impedes us from seeking support when we need it for ourselves. How?Do your learners and your colleagues know where to turn for help if they need it themselves?Ask patients on rounds about their depression or other mental illnesses. Consider carefully how you will do so. How will your questions, responses, and manner be viewed by your learners?Suggest that these 2 pieces be discussed at your next faculty meeting.Clinical Practice PointsEffect of Using the HEART Score in Patients With Chest Pain in the Emergency Department. A Stepped-Wedge, Cluster Randomized TrialRapid Rule-out of Myocardial Infarction With a High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection. A Collaborative Meta-analysisThis trial assessed the effect on patient outcomes of using the HEART score, which includes a single troponin measurement and provides a formal recommendation for admission, observation, or discharge in individual patients. The systematic review of 11 cohort studies examines whether a single high-sensitivity assay for cardiac troponin T measurement below the limit of detection in combination with a nonischemic electrocardiogram can successfully rule out myocardial infarction in patients presenting to emergency departments with a possible acute coronary syndrome (ACS).Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners what variables assure them that a patient presenting with chest pain may be safely sent home.Does your hospital have a “chest pain pathway”? How closely is it followed? Review the results of this randomized trial. Why do your learners think some patients were admitted even when deemed appropriate for discharge by the HEART score? How does such nonadherence to the protocol affect the results?Review the results of the systematic review. How comfortable would your learners be discharging a patient presenting with chest pain, a normal high-sensitivity troponin T measurement, and an ECG without ischemic changes?Do all such patients with a high-sensitivity troponin T measurement above the level of detection require admission? What are the problems with such an approach? Use the accompanying editorial to help frame your discussion.Is the exclusion of an ACS your only concern in such patients? Is that all that is considered in the emergency room? What other entities need to be considered (e.g., stable or unstable angina)? What are the next steps to consider in these patients once an ACS has been safely excluded?Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position PaperSubstance use disorders pose a heavy societal burden, endangering individual and family health and well-being, tearing through communities, and sapping resources from the health care system. In this position paper, the American College of Physicians provides policy recommendations aimed at decreasing the burden of substance use disorders in the United States.Use this paper to:Ask your learners whether they feel qualified to treat a patient's substance use disorder. Which ones? Use the recent In the Clinic: Substance Use Disorders to help review key management issues.Where do your learners turn for help? Is it available? How do they arrange for a patient's acute safety and longitudinal care? What resources are available locally to patients at your center?Invite an expert in substance use disorders to discuss what your learners' roles should be in the identification and longitudinal management of these problems. How should the specialist and primary care physician share management?The position paper calls for increased access to methadone, buprenorphine, and naltrexone to treat opioid use disorder. Do your learners agree that access should be increased? Should your learners be prescribing these agents, or must they be managed by specialists?How might proposed changes to current health care laws and the definitions of “preexisting illnesses” affect your patients?Video LearningConsult Guys: The Adult Survivor of Hodgkin Disease: Falling Through the CracksHoward and Geno (the Consult Guys) answer the complicated question of what follow-up is required for the survivor of a malignancy.Use this feature to:Take a break, and watch the short video with your learners.Ask them whether they have patients who are considered “cured” of a malignancy. Is there anything your learners do differently in these patients?Ask what malignancies are particularly concerning after successful treatment for Hodgkin lymphoma.What cardiac abnormalities might result from mantle radiation?Use the provided multiple-choice question to teach, and be sure to enter your answer online to earn CME credit for yourself.MKSAP 17 QuestionA 62-year-old man is evaluated in the emergency department (ED) for a 3-hour history of dull, substernal chest discomfort. He has type 2 diabetes mellitus, hypertension, and dyslipidemia. He does not smoke cigarettes. Medications are low-dose aspirin, lisinopril, and pravastatin. His younger sister was diagnosed with coronary artery disease at the age of 50 years.Electrocardiogram obtained upon his arrival to the ED is shown. He is administered aspirin and sublingual nitroglycerin. His chest discomfort is relieved within 15 minutes of arrival.On physical examination, blood pressure is 148/86 mm Hg, pulse rate is 62/min and regular, and oxygen saturation is 94% on ambient air. BMI is 28. Cardiac examination is significant only for the presence of a grade 1/6 holosystolic murmur at the left lower sternal border. The murmur does not radiate. Lungs are clear. The remainder of the examination is normal.Initial serum troponin I concentration is 0.94 ng/mL (0.94 µg/L).Portable chest radiograph demonstrates a normal cardiac silhouette and no evidence of pulmonary edema.Which of the following is the most appropriate initial management?A. Administer clopidogrel and enoxaparinB. Emergent coronary angiographyC. Exercise stress testingD. Monitor in the emergency department until a second set of cardiac enzyme markers is availableCorrect AnswerA. Administer clopidogrel and enoxaparinEducational ObjectiveManage a patient with a non–ST-elevation myocardial infarction with antiplatelet and anticoagulant medications.CritiqueThis patient should be given a P2Y12 inhibitor, such as clopidogrel, and an anticoagulant, such as the low-molecular-weight heparin enoxaparin, and be admitted to the hospital. Once the diagnosis of a non–ST-elevation myocardial infarction (NSTEMI) has been confirmed by the presence of ischemic chest pain, ST-segment depression on the electrocardiogram (ECG), and/or abnormal cardiac biomarkers, the use of antiplatelet and anticoagulant medications, antianginal medications, and cardioprotective medications is imperative. This patient was given aspirin and nitroglycerin prior to the diagnosis of NSTEMI, and he takes daily ACE inhibitor and statin medications. The additional therapies that are warranted in this situation include a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor), an anticoagulant (unfractionated heparin or low-molecular-weight heparin), and a β-blocker. The use of clopidogrel, in addition to aspirin, is the best-studied combination of antiplatelet medications.In patients with an ST-elevation myocardial infarction (STEMI), reperfusion, preferably via percutaneous coronary intervention, should be performed as quickly as possible from symptom onset. This patient does not have evidence of ST-segment elevation or left bundle branch block on the initial ECG. Although an early invasive strategy (defined as within 24 hours of hospital admission) has been proved to be effective in treatment of NSTEMI, there is no evidence that earlier angiography (<6 hours or at hospital admission) offers incremental benefit to these patients.In patients with a low TIMI risk score (0-2), indicating a low in-hospital risk of death or recurrent ischemia/infarction, predischarge stress testing may be warranted to further define a large ischemic burden and guide revascularization decisions. This patient has a TIMI risk score of 4 (≥3 traditional cardiovascular risk factors, ST-segment deviation, daily aspirin use, elevated cardiac biomarkers), placing him at intermediate risk. These patients have improved clinical outcomes with an early invasive strategy. Exercise stress testing is not appropriate and may be dangerous.Clinical decision-making should not be affected by the results of the second set of cardiac biomarkers. The presence of an elevated troponin level drawn in the emergency department is prognostically significant and warrants hospital admission, treatment of NSTEMI, and risk stratification.Key PointInitial therapy of non–ST-elevation myocardial infarction is medical, with antiplatelet and anticoagulant medications, antianginal medications, and cardioprotective medications; early angiography (<6 hours or at hospital admission) does not provide incremental benefit but an early invasive strategy (defined as within 24 hours of hospital admission) may improve outcomes.BibliographyAmsterdam EA, Wenger NK, Brindis RG, et al; ACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 3;130(25):2354-94.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 16 May 2017Volume 166, Issue 10Page: ED10KeywordsAcute coronary syndromeAnticoagulantsAspirinEmergency departmentIschemiaMyocardial infarctionNon st segment elevation myocardial infarctionThoraxTroponinTroponin T ePublished: 16 May 2017 Issue Published: 16 May 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.Loading ...