Calm in the Chaos: An Approach to Rapid Responses (Bamidele, 7/28/2021)

Kudos to Dr. Stephanie Bamidele, who delivered our very first R3 Grand Rounds of the Academic year. Her topic? Calm in the Chaos: An Approach to Rapid Responses.

A recording of her excellent presentation is available HERE for your viewing. 

And here are my notes:

Anyone who has worked in a hospital knows that rapid responses occur frequently in the hospital. But it hasn't always been that way! The concept of Rapid Response Teams emerged in the 1990s, modelled after Code Teams (which originated in the 1960s), as a standardized group of people expected to respond to a call for help before a patient requires a Code Team's assistance. The RRT goal is to intervene and respond to prevent major adverse events. And then make systems changes that allow for the next response to be even more effective. 

Anyone can activate an RRT.

RRT may be activated for a number of reasons: vital sign abnormalities, nurse or family detection of clinical deterioration, a change in mental status, and more.

Specific clinical criteria may be used to designate a RR present minutes to hours before a serious adverse event:

• HR <40 or >130
• SBP <90
• Respiratory Rate <8 or >28
• Oxygen saturation <90%
• Change in level of consciousness
• Change in urine output (<100ml/4 hours)

Like a Code, any Rapid Response starts with the basics: A (airway), B (breathing), C (circulation) and goes from there. See these images for a very clear description of events that should occur in the first five minutes of a RR: 

A	AIRWAY Assistance (call for help) Activate RRT Annunciate when providing key information Acquire Data Attend to patient until RRT arrives Access (IV) Assist as directed by team leader
B	BREATHING Bed (away from wall) Backboard if pulseless for CPR Blood glucose if altered mental status

 

C	CIRCULATION: check pulse and BP CPR Crash Cart Connect IVF Clear the Room Communicate to RRT
D	Defibrillate if Vfib or pVT Document vitals at time RRT was called
E	Explain (S-BAR) to team leader. Situation, Background, Assessment/Action, Recommendation/Report

As in all parts of life, communication is everything! 

Dr. Bamidele reminded us that a standard way of communicating (in this case, following the hospital ISBAR model) is the best way to go. Doing so, ensures that all people present at a RR, have a clear understanding of what is happening and what is being recommended.

 

Okay, doctors, so, you are the leaders of the RRT, right? What do you actually do then to be an effective leader? Here are key steps, as outlined by Dr. Bamidele:

1. Identify team members and roles: who is the leader? what are the roles? Does everyone need to be here. Start with a simple, "I am Dr. ____, and I am leading this RR"
2. Crowd control: limit to 8-9 people max, including the leader (doctor), ICU charge RN, bedside/flor RN, respiratory therapist, and any necessary techs (lab, xray, etc). Send everyone else back to work.
3. Set a calm and assertive and inclusive tone. Be respectful, willing to ask for help.
4. Promote a flattened hierarchy: think aloud, step back, voice specific findings (e.g. glucose, x ray findings, response to narcan_, ask for suggestions and/or feedback
5. Gather info via parallel processing (this is hard!): visual assessment, forming a plan, proposing an intervention
6. Have situational awareness: don't miss the forest through the trees, integrate evolving information in real time, reinforce plan, gather suggestions
7. Use closed loop communication: call out--> check back--> verification

Dr. Bamidele also gave us specific advice about the role of the Family Liaison during a rapid response or a Code event. There is mixed data on the harm/benefit of a family's presence at the bedside during these acute events, and so it is generally recommended that staff give the family the option of being present or leaving (without judgement). If the family is present, a designated staff person (RN, junior resident, etc) should be designated as the Family Liaison. That person should introduce themself, explain what is going on, stay by the family member's side (regardless of whether they stay or go), and provide that person an opportunity to ask questions. 

The aftermath

Once the Rapid response is done, it is super important to debrief, says Dr. Bamidele-- for two main reasons: first, because a Rapid Response often occurs in intense situations that may have a lasting impact on the team and that may require emotional processing and reflection. Second, reflecting on the process will hopefully allow you to do a better job next time. 

To address possible moral distress occurring in this context, consider the model of the 4As from the American Association of Critical Care Nurses (in graphic below)

Non-TB Mycobacterial Infections of the Lung (Miniae, 7/21/2021)

Thanks to our new(ish) SMGR Pulmonologist, Dr. Mike Minaie, we all know a LOT more about Non-TB Mycobacterial Infections of the lung (NTM) after the excellent Grand Rounds he gave this week on the topic. 

First a random literary malady allusion: NTM is sometimes called "Lady Windemere Syndrome" in reference to a Victorian era character from an Oscar Wilde play (see above) who suffers a chronic cough and malady and is unable to cough and spit (because she has to be 'ladylike' in Victorian times). Historically it was believed that NTM (often presenting in thin post/perimenopausal women) was made pathogenic by the act of suppressing one's cough. Not sure the premise is quite correct. . . 

For those of you who would like to see the entire presentation, it can be found HERE.

For those of you who prefer my Cliff's notes, here goes:

• NTM is generally a subacute infection (symptoms occur over weeks, even months)
• NTM is NOT contagious
• NTM is often recurrent 
• Symptoms of NTM include non-specific complaints, e.g. night sweats, weight loss,  shortness of breath, low grade fever, hemoptysis as well as chronic cough (often with thick sputum) x months

Many NTM-- e.g. mycobacterium avium complex (MAC), are readily present in soil, air, and water. People with intact immune systems may be exposed to these mycobacterium (and even incidentally or transiently acquire them in their respiratory tract) but a the healthy immune system is generally able to clear the NTM without disease.

In contrast, patients who are immunocompromised (e.g. chronic steroid use, HIV) may be less successful in clearing the NTM from their airway, and then the mycobacterium can become pathogenic.

There are a variety of NTM, including those more commonly found (MAC/MAI, M Kansasli) and less common (M maxium, M. xenopi, M simiae). They are also often classified as slow growing (2-4 weeks) vs. rapid growing (4-8 weeks). Different varieties tend to be  regional (e.g. M Abscessus is more frequently encountered in these parts). 

CT findings in NTM are various:

• ground glass lesions
• evidence of bronchiectasis (straw-like lesions on CT)
• solid nodules
• cystic changes
• fibrosis

Diagnosis of NTM is accomplished via BOTH clinical and microbiological assessments:

1. clinical: pulmonary symptoms AND appropriate exclusion of other diseases (e.g. bacterial pneumonia, cancer, COPD)
2. microbiologic (+ culture from at least TWO expectorated sputum spaced out by ONE MONTH, or +culture from a single bronchoscopy sample, or transbronchial or other biopsy with mycobacterial features)

Does NTM always need to be treated?

The answer is NO, if the patient is asymptomatic and/or if symptoms resolve spontaneously (which is often seen in immunocompetent hosts). If you get a single +NTM in sputum but then does not recur, assume the immune system cleared the NTM itself. 

Indications for therapy:

• respiratory or constitutional symptoms with radiographic abnormalities
• recurrent/consistent isolation of NTM in  moderate to high numbers (i.e. not trace amounts on a single sample)
• histologic evidence of pulmonary parenchymal involvement

Treatment:

usually starts IV, then transitions to PO

often lasts >1 year (time starts at first CLEAR sputum)

3 drug abx regimen for MAC (e.g.) is typically: 

• Clarithromycin (1000mg three times per week) OR azithromycin (500mg three times/week) AND
• Rifampin (600mg thrice weekly) AND
• Ethambutol (25mg/kg thrice weekly)

Surgery can be considered in certain circumstances: if disease is isolated to a particular part of the lung, or there is a very large cavity (>8cm, risk of rupture and bleed is high: 50% in 2 years). Surgery may also be indicated if cultures don't clear after 6 months of active treatment. If patient cannot tolerate oral treatment. If they have macrolide resistance

Side effects of the 3 drug cocktail are many: GI intolerance, low WBC, impaired visual acuity and color vision, decreased auditory function, decreased renal function, peripheral neuropathy

NOTE: If patients are on the three drug regimen, be sure to monitor them for vision changes (risk of optic neuritis) is moderate, and meds may need to be stopped (particularly ethambutol, rifampin). Also tinnitus is a sign of macrolide toxicity, which must be stopped immediately in the setting of tinnitus

Also remember there is radiologic lag, so radiographic findings should not be used to guide treatment duration; but rather, clinical improvement and clearing of cultures.

And lastly, don't suppress that cough!

Eat Veg or Die: The Power of Plant Based Diets (Kohatsu, Naderi, Brown 7/7/2021)

Many thanks to our Integrative Medicine Fellow-- Dr. Tahereh Naderi-- and our Integrative Medicine Faculty-- Dr. Wendy Kohatsu and Dr. Ben Brown-- for their 3 Course presentation this week on the Power of the Plant-Based Diet. 

A video recording is available HERE. 

Did you know that 10.5% of the US population is diabetic? That $1 in every $7 of US healthcare dollars are spent on treating diabetes? That only 1 in 10 of American adults get enough fruits and veggies in their diet? 

As Dr. Naderi (and Hippocrates) started the presentation: "Let food be thy medicine and medicine by thy food".

What is a plant-based diet (PBD)? 

PBD are eating habits that avoid consumption of most or all of animal products, support high consumption of fruits, vegetables, legumes, seeds, whole grains, and nuts. This may include:

• vegan
• lacto-ovo vegetarians
• pesceterian
• flexitarian
• Mediterranean diet
• whole foods, plant-based, low fat

What are the benefits of a plant-based diet?

• reduced body weight
• lower blood pressure, cholesterol and blood sugar
• lower risk of heart disease, diabetes, and cancer
• linked to longer lifespan
• improved joint pain/inflammation in certain autoimmune conditions
• better for the environment

PBD are effective for weight loss. On average, a vegetarian diet reduces weight by 7.6 kg for men, 3.3 kg for women, and a 2 point lower BMI.Vegetarians tend to eat more nutrients and less total fat, and sadly, there is a positive association between meat consumption and obesity.

PBD are effective for both prevention and treatment of diabetes. Vegetarians have 1/2 risk of developing diabetes over their lifetime. In a RCT of low fat vegan diet based on a diet based on ADA guidelines, there was a reduction of a1c by 1.23% vs. 0.38% and reduction in medication need by 43% compared to 26% in ADA group. 

PBD are associated with improvement in psychological outcomes including improvements in depression and quality of life with patients with diabetes, as well as improvement in neuropathic pain.

PBDs appear to have anti-inflammatory properties, improving our gut microbiome, decreasing inflammation and joint pain, and improving symptoms by decreasing triggering foods (meats, egg, dairy)

If you are curious about the data on the above statements, check out the book The China Study (by T. Colon Campbell) or the documentary "Forks over Knives". Here is a quote from the authors of the China Study:  "People who eat the most animal based foods get the most chronic disease. People who ate the most plant-based foods were the healthiest"

Finally, PBD are better for the environment (see graphics from the Plantrician Project):

Of note, says Dr. Brown says there are many reasons why eating a PBD makes sense. In fact, diets high in animal proteins are associated with a

•  75% increase in mortality
• 400% increase in cancer risk
• 500% increase in diabetes
• significantly higher IGF-1 levels.

Red meats have been associated with chronic inflammation, and how you cook it might increase that risk (e.g. grilled meat containing heterocyclic amines) may be worse. However, if you combine grilled meat with anti-inflammatory foods (garlic, broccoli, lemon, cumin, hibiscus), it may mitigate some of those potential harms.

Whereas eating lots of fruits and veggies can be life-prolonging, it is important to consider how these foods are produced. Specific fruits and veggies are more likely to contain life-altering pesticides and should be eaten organically whenever possible (i.e. Dirty Dozen); others are less risky if eaten from conventional farms (i.e. Clean 15). See image below and consider putting it up on your fridge to help guide your purchasing habits.

Dr. Brown also shared with us the concept of the ORAC value. The ORAC unit (Oxygen Radical Absorbance Capacity), ORAC value, or ORAC score is a method developed by scientists at the National Institute of Health and Aging (NIH) to measures the antioxidant capacity of different foods. He encouraged us to take a look at this list and eat preferentially foods with high ORAC values, including dark chocolate!

Don't forget choosing the right oil! It should be plant based and care with deep frying. FOr a simple resources, check out this article from the Cleveland Clinic.  And don't forget lots and lots of fiber!!

Dr. Kohatsu finished up the Grand Rounds with a slew of "Pro Tips" as our in house expert-physician-Chef. Here are 10 of Dr. Kohatsu's pro-tips: 

1. Check out Good and Cheap by Leanne Brown, how to eat on <$4 a day, PDF with recipes available free via download.
2. If you are worried about getting enough protein in your plant-based diet, change to plant-based proteins, including nuts, seeds and beans
3. Easy beans/legumes to consider: brown beans, lentils, soy beans, chickpeas, black beans and pinto
4. If you are worried about getting gas from beans, soak them overnight, choose newer beans, skim the foam off the top, add gas dissolving herbs and spices (cumin, epazote, fennel), chew well, and use digestive enzymes (e.g. Bean-O)
5. Consider trying "Meatless Mondays" just one days per week. Recipes and ideas available here:
6. To increase your nuts and seeds intake, put 1/4 cup of nuts in a bag to snack on during the day, add nuts to salads, use nut butters, and use tahini based dressing/sauces
7. Keep your oil in small containers, dark bottles, in a cool area, avoid deep fat fryers and don't store right above your stove (it's too hot!)
8. Try roasting your cruciferous veggies (kids love them)
9. Cook at home (it's cheaper and almost always healthier!)
10. Eat dark chocolate