Our Email to Diane

Diane, 

   First, we would like to thank you for your tireless work in the trauma room, ED, and beyond.  We are grateful for you beyond imagine.  We are also grateful for the collaboration with the trauma department.  We have worked hard to facilitate and assist in trauma resources, trauma downgrades, medical management of trauma patients and of course, the multiple simultaneous trauma situation.  As we had talked earlier this week, the NPs’ role in the trauma room has been a substantial dissatisfier to our staff.  I will speak only to the ER physician side.  We would like to keep our relationship strong and think a few boundaries are necessary.   The bottom line is that we want to be involved in trauma as much as possible.  We want to assist in managing these patients.  We want to be the resuscitationist helping you in the critical patients and the extra physician needed when multiple traumas come in.  We especially want to continue our practice of being actively involved in the procedures associated with these patients.  We feel the NPs should not be placing central lines, inserting chest tubes, or intubating patients in the ED.  These procedures in a trauma setting are critical to our skillset and are needed to maintain that skillset.  We hope that you can understand the significance of this issue with our doctors.  Again, you are the best.  We are very thankful for you.

The Emergency Physicians of Sharp Memorial

 

 

Diane’s Email Back

Surgeons met and agree to the following, so please let me know if we need to go back to the drawing board.  Of prime importance is our relationship w you, and we can be flexible w our team, so send back comments if there is still concern:

We prefer to train our NPs in a controlled setting where time is not a crucial issue.

We want NPs proficient in primary/secondary survey and will continue to have them respond to trauma to learn the pace of that workup and the intricacies of flow to CT etc.

We will not have them do any emergent procedures.  If an alpha trauma arrives unstable, all procedures will be done exclusively by ED and Trauma surgeons.

If there is a procedure that is being done in a delayed fashion where time is not a critical consideration AND where EDMD would not have been involved, trauma surgeons may use that as an opportunity to train NPs.   Nps may close lacs or do other pre-approved (Surgery Supervisory) procedures.

NPs who are proficient may provide benefit to trauma surgeons in simultaneous care in the trauma room, an alternative to bypass, extra hands during disaster, assistance in icu and other areas of need.

DEFUSE 3: 6-16 hours

Ischemic core volume of <70
-Age 18-85 years
-baseline NIHSS greater than or equal to 6
Endovascular femoral puncture between 6-16 hours
Pre-stroke mRS 0-2
Anticipated life expectancy of at least 6 months

Exclusion:
-other serious, advanced, or terminal illness
-pre-existing neurological or psychiatric disease that would confound the evaluations
-pregnancy
-contraindication to MRI/CRP contrast
-treated with tPA >4.5 hours after LKN
-known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency, oral anticoagulant with INR >3 (recent use of new oral anticoagulants ok if eGFR >30 ml/min)
-seizure at stroke onset if precludes obtaining accurate baseline NIHSS
-baseline glucose of <50 or >400
-baseline platelet count of <50, 000
-untreatable sustained hypertension SBP <185 or DBP >110
-presumed septic embolus, suspicion of bacterial endocarditis or cerebral vasculitis
-mechanical clot retrieval attempted prior to 6 hours from symptom onset

Imaging inclusion criteria:
-M1 MCA occlusion or ICA occlusion AND
-target mismatch profile on CT perfusion or MRI (RAPID)”
Ischemic core volume of <70 AND
Mismatch ration of >1.8 AND
Mismatch volume of > or equal to 15 ml
Or if only MRI, DWI lesion volume < 25 ml with M1 or CTA occlusion within 60 minutes
Neuroimaging exclusion criteria:
-ASPECTS <6 on noncontract HCT
-intracranial tumor (except for small meningioma)
-AVM
-acute intracranial hemorrhage
-neoplasm
-significant mass effect with midline shift
-evidence of ICA flow-limiting dissection or aortic dissection
-intracranial stent in the same territory that would preclude safe deployment/removal of device
-intracranial occlusions in multiple vascular territories

 

 

DAWN: 6-24 hours

Age 18 or greater
NIHSS 10 or greater
Prestroke modified rankin score <2
Anticipated life expectancy of at least 6 mo
<1/3 MCA territory involved via CT or MRI
Occlusion of either intracranial ICA and/or M1 via MRA or CTA

Clinical imaging mismatch via MRI-DWI or CTP-rCVF:
0–<21 cc core infarct; NIHSS ≥10 and age ≥80
0-<31 cc core infarct, NIHSS ≥10 and age < 80
31-<51 cc core infarct, NIHSS ≥20 and age< 80

General Exclusion criteria:
-severe head injury within 90 days
-rapid improvement to NIHSS <10 or vessel recanalization prior to randomization
-pre-existing neurological or psychiatric disease
-seizures at stroke onset
-blood glucose <50 or >400
-hemoglobin <7
-platelets <50,000
-sodium <130, potassium ❤ or >5
-renal failure
-hemorrhagic diathesis or INR >3 or PTT >3 times normal
-active or recent hemorrhage within 30 days
-severe allergy to contrast medium
-SBP >185 or diastolic BP >110
-pregnancy or lactation
-presumed septic embolus or suspicion of bacterial endocarditis
-prior treatment with thrombectomy intra-arterial therapies

Imaging exclusion criteria:
-intracranial hemorrhage
-flow limiting carotid dissection, high-grade stenosis, or complete cervical carotid occlusion
-excessive cervical vessel tortuosity
-suspected cerebral vasculitis
-suspected aortic dissection
-existing stent in the same vascular territory
-occlusions in different vascular territories
-significant mass effect/midline shift
-intracranial tumor

Trauma surgeons discussed this morning and agreed:

If at neuro baseline or GCS 15 (ie NO CHANGE or alteration of mental status)

AND

Family is reliable to monitor for neuro changes

AND

Initial head CT is negative

AND INR is within normal therapeutic range OR lower,

Then patients may be considered for discharge to home without follow-up CT.

“My low risk chest pain MDM”

This is a [36-year-old female] comes in for evaluation of [her] acute intermittent chest pain symptoms. Multiple emergent diagnoses were considered for this patient, however based on the current evaluation there is no evidence of acute coronary syndrome, and per the HEART score, their risk of a major cardiac event is less than 2% in the next 6 weeks. The patient agrees they can safely be discharged with further outpatient cardiac risk stratification if necessary through their primary care doctor. I also considered pulmonary embolism, however the patient has normal vital signs, and per the PERC criteria, I do not feel that any CTA chest or d-dimer is warranted at this time. Clinically, I doubt the patient has aortic dissection, there is no x-ray evidence of pneumonia, pneumothorax, or pneumomediastinum. The etiology of the pain at this time is unclear however the patient is agreeable to followup with a primary care doctor in the next 2-3 days for further evaluation. The patient understands and agrees with the plan, has no further questions, and was given strict return precautions. Extensive oral and written discharge instructions were provided.