Weekly Roundup 9-13-2013

Did you know that fear of Friday the 13th has been called friggatriskaidekaphobia? Try that one on your therapist at your next session (if you suffer from this debilitating condition, find help at http://www.friggatriskaidekaphobia.com/).

This week we had fun with JT, documentation and signout tips with special guests, a thought provoking ethics conference, and more.



Intern Intake Wrap-Up: Documentation Tips and Signout Template

Brian and Dr. Simon presented very useful tips on accuracy and integrity in documentation, along with a bit of musings on the relative qualities of ducks, mallards, and platypuses. Click below for links:

Documentation tips presentation 

Platypus

Documentation diagnosis staging reference - (very useful for your notes!)
Documentation quicktexts tip sheet

Daniel Ling gave an overview on how to safely and efficiently provide written and paper signout:

Signout overview and mnemonic
Signout template


From David Cho (Chief Rounds): Elderly male with history of heart failure presented with shortness of breath initially presumed to be heart failure, however all cardiopulmonary workup was negative and patient was finally diagnosed with neuromuscular disease due to likely ALS.

• Not all shortness of breath in a patient with known systolic chronic heart failure is related to the heart! Keep an open differential that includes pulmonary etiologies, musculoskeletal weakness, anemia, or even severe metabolic acidosis. 
• Consider EMG in patients with suspected neuromuscular causes of dyspnea.
• Patients with ALS do not typically have a co-existing cardiomyopathy (per brief literature search), though there has been an association with Takotsubo's cardiomyopathy in case-reports, which is thought to be driven by sympathetic hyperactivity

Ethics Rewind: We had a thought provoking ethics discussion with our expert guests, ethicist Dr. James Hynds, and ethics fellow, Tyler Gibbs. Thank you to everyone who participated, especially to Shone for providing us with the case.

Teaching points:

• UCLA policy on withdrawing or withholding medically inappropriate life sustaining treatment is policy HS 1319 (link here http://mednet.ucla.edu/Policies/pdf/enterprise/HS1319.pdf) . In summary, physicians are not required to provide medically inappropriate treatment, examples:

1. Treatment that only prolongs survival in an ICU without reasonable possibility of prolonging life in non-comatose state.
2. Treatment without reasonable possibility of clinical improvement to live outside of an ICU.
3. Burdens of treatment outweighs benefits – causing undue suffering, loss of dignity, or unnecessary pain.

• If treatment is determined to be medically inappropriate, providers are not obligated to provide this treatment even if patient or surrogate has previously specified a wish to receive a particular treatment. Call ethics consult if this occurs to help with how to resolve any conflicts! See here http://mednet.ucla.edu/Policies/pdf/enterprise/HS1319.1.pdf for specific policy on UCLA No CPR order including when CPR is medically inappropriate.

From Noon Conference with Dr. Eric Yang: Sharpen you ECG skills with the online version of the software he used at http://www.blaufuss.org. Scroll down to ECGviewer (Adobe Shockwave required). Answer key here.