1.17.19 Conference Summary

CLE Rising - Dr. Daniel Axelson

Social Determinants of Health



  • Social determinants of health:

    • Conditions in which people are born, live, work, etc

    • Social factors that have heavily influence the health and well-being of an individual (physical, social, financial, political, environmental, etc)

    • Social struggles are associated with medical struggles, and small changes can have a big impact

  • A few major social determinants of health

    • Homelessness

      • Homeless people significantly more likely to visit the ED

      • Housing associated with reduced use of emergency medical services

    • Transportation

      • Limited transportation associated with limited access to health care (missed/delayed follow up, poorer health overall, etc.)

      • Approximately 70 million patients covered by Medicaid in the U.S., the majority of which do not have reliable transportation; Medicaid covers transportation (including on non-emergent basis) for medical needs

    • Health Literacy

      • Degree to which people can access and attain information regarding their health

      • Patients and parents with low health literacy more likely to visit the ED or bring their child to the ED compared to those with higher health literacy

      • General recommendation to provide health information at or below a 6th grade reading level


  • Sodium is not a problem with sodium, it’s a problem with water

  • Get fluid/urine studies to better assess volume status… you aren’t as good at assessing volume status as you think (especially in euvolemic-hypovolemic pts)

  • Ways you can cause more harm in managing hyponatremia

    • Too rapid correction

      • Can cause osmotic demyelinating syndrome

      • Goal 6-8meq/L in 24 hrs

      • 1-2L bolus is enough to overcorrect

      • If unwilling to calculate a fluid correction rate: NOT GIVING FLUID IS OK

    • Giving 0.9% NS to patient with SIADH

      • Results in further drop in Na level by desalination

      • SIADH = too much ADH = free water absorption in the kidneys

      • If urine osmolarity is more concentrated than the fluid you’re administering (i.e. 0.9% NS), the body sees it as free water so the kidney will dump salt to try to get rid of it; in SIADH, the kidneys will continue to retain water from ADH

  • Hyponatremia algorithm

    • If seizing (or severely neurologically altered): give 2cc/kg 3% saline x2 and recheck Na

    • If hemodynamically unstable: resuscitate (give 1L NS bolus)

    • Check glucose

      • Hyperglycemia: add 2.4 to Na for every 100 of glucose over 100

      • If normal, stop fluids, order serum & urine osm, urine Na & K +/- urine urea & Cr

    • Check serum osmolarity

      • High (>300) — hyperglycemia, mannitol/IVIG, contrast

      • Normal (280-300) = ‘pseudohyponatremia’ (excess proteins/lipids, lab artifact due to large molecules; true Na level is normal)

      • Low (<275) — too much water in vasculature

        • Check urine osmolarity (to understand water)

          • Dilute (<100 mOsm/L) —> FLUID RESTRICT

            • Psychogenic polydispsia, beer potomania, low solute intake

          • Concentrated (>100 mOsm/L)

            • Low urine sodium (<25 mmol/L)

              • Total body fluid overload: CHF, cirrhosis, nephrotic syndrome —> DIURESE

              • Total body fluid low: volume depletion —> FLUID CORRECTION RATE

            • High urine sodium (>25 mmol/L)

              • Kidney not working: acute renal failure —> address kidney problem

              • Body causing kidney to not work: SIADH —> FLUID RESTRICT

                • SIADH = dx of exclusion (normal renal/heart/liver/thyroid/adrenals, no diuretics)

EM/Trauma: Massive Hemorrhage - Dr. Chris Miller

  • For patients with massive hemorrhage, resuscitate with blood rather than fluids

  • Permissive hypotension = ‘just sufficient normotension’

  • Balanced resuscitation with plasma, platelets, RBCs in 1:1:1 ratio is the generally accepted practice (based on PROPPR Trial)

  • PROPPR Trial

    • RCT comparing ratios of plasma, platelets, RBCs severely injured/bleeding patients requiring massive transfusion and comparing plasma, platelets, RBCs in 1:1:1 vs 1:1:2 ratio

    • Patients receiving 1:1:1 ratio had: 1) significant decrease in death from exsanguination (most common cause of death) in the first 24 hours, and 2) increased hemostasis (compared to the 1:1:2 group)

    • Critical administration threshold: 3 hours

    • INR is most predictive of mortality (over base deficit, lactate, hemoglobin, etc)

  • Despite current standard of care with blood product components (civilian), a fair amount of military data supports use of warm fresh whole blood as they have found potential survival benefit compared to component blood (currently used in a few civilian settings)

    • Whole blood contains 29% HCT, 65% plasma, 88k platelets

  • Triad of Death = coagulopathy, acidemia, hypothermia (extreme temps and acid denature proteins, which are responsible for clotting cascade)

  • Thromboelastography (TEG): measures dynamics of clot development, stabilization and strength, and fibrinolysis

    • Provides real-time data of patient’s hemostatic state — allows for goal-directed transfusion and avoids having to wait for routine hemostatic lab studies



Leadership Curriculum: Communication - Dr. Riley Grosso, Dr. Samia Farooqi


Styles of Communication

  • Action-oriented:

    • Focus on results, objectives, doing, achieving; may be direct, decisive, impatient

    • Communication with action-oriented person: state results/conclusion first, be as concise as possible, state best recommendation (few alternatives), emphasize practicality, use visual aids

  • Process-oriented:

    • Focus on facts, organization, strategies, details; may be systematic, verbose, unemotional

    • Communication with a process-oriented person: be precise, state facts, organize presentation in logical order, break down recommendations, include options/alternatives, do not rush

  • People-oriented:

    • Focus on people, communication, relations, teamwork, motivation; may be empathetic and conscientious

    • Communication with a people-oriented person: allow for small talk, stress relationships of people involved, indicate support from well-respected people and show how idea has worked well in the past, use informal writing style

  • Idea-oriented:

    • Focus on concepts, theories, innovation, creativity, opportunities; may be unrealistic, full of ideas, charismatic

    • Communication with an idea-oriented person: allow time for discussion, be patient when they go off on tangents, emphasize uniqueness and future value, start with overall statement/key concepts then go into more detail after