Internal Medicine Residency News, September 21, 2015

September 21, 2015

From the Director

Hi everyone!

First, thank you all so much for your incredible support and many hugs this past week. Not that I had any doubt, but I can truly say that I have the best job in the world with the best people in the world!

Lots of kudos this week, and apologies in advance if I miss a few. First, thank you so much to all who participated in the wildly successful Stead Tread on Sept 12th. The new venue was a hit, and rumor has it that over $7000 was raised for the Lincoln Community Health Center. Special thanks to Matt Crowley and the Stead Tread Kempner Society Leadership team - Jon Buggey (in charge!), Caroline Sloan, Jess Morris, David Beavers, Melanie Goebel, Zach Wegermann, Megan Gillum and Christine Bates. Excellent work for an outstanding cause. Also kudos to Jason Zhu from his Gen Med interns Sarah Nouri and Megan DuPuis for generally just being an awesome Gen Med SAR, to Kahli Zeitlow for an outstanding chair’s conference (Stumped!), to Lindsay Boole for hosting pizza Wednesday in the Med Res library and to all who have given SAR talks in the past couple weeks.

We have a lot going on as we move into October. We have >3000 applications for residency already in ERAS, Turkey Bowl practice is in full swing, we have the Baldridge site visit (see attachment at end of posting), and also upcoming DOCTOBERFEST (stay tuned). This week, we are offering 2 opportunities for wellness and discussion – Dr. Galanos will be leading Noon Conference on the 24th and PAS will be hosting a group at 6p.m. on Wednesday, 9/23 in the MedRes library. The Medicine 3GT starts tonight – many of us have signed up. I think there is still time if you are interested in giving it a try.

Be on the lookout for our 2nd edition of the Duke IM Residency Annual Report. This document highlights many of your accomplishments from last year as well as sets our goals for this coming year. Thanks to Jen Averitt for putting together a beautiful document. Also please remember to update your profile on the website – Madi has the details if you have any questions. Finally, just a reminder to complete the survey requests you receive from the iCompare study team. Those completing the surveys will qualify to possibly win $100 or $25 eGift cards!

This week’s Pubmed from the Program goes to those who received Duke AHEAD grants - complete list available for download at the end of this post. We are really excited to be able to work on these projects.

Have a great week

Aimee

What did I read this week?

Submitted by Dr. Lynn Bowlby

In The Clinic: Carpal Tunnel Syndrome

Annals of Internal Medicine.

Kleopa, Kleopas A. MD. 1 September 2015. 163 (5).

One of the very practical series in the Annals is their “In The Clinic “ series. This one caught my eye thinking of all the CTS we see at DOC. This week Matt Atkins saw a patient where this was the main consideration in the diagnosis, and he had already pulled up this article.

CTS, or compression median neuropathy is the most common entrapment neuropathy, accounting for about 90% of these issues. It occurs in about 4% of the population, and work and personal factors predispose patients to CTS. It is disabling and costly , a major cause of lost workdays and workmans compensation cases. The presumed mechanism is increased pressure within the carpal tunnel, causing median nerve compression.

Screening and Prevention:

Causes related to work include repetitive, forceful hand work with wrist extension, vibration and cold. Vibration is a major cause. Obesity, especially in those younger than 63, genetic predisposition, and systemic disorders all are risk factors. A wider palm and more squared carpal tunnel, and higher wrist ratio may be genetic and lead to CTS. Systemic disorders include DM, ESRD, hypothyroidism, amyloidosis, collagen vascular disease, treatment with aromatase inhibitors and possibly lipid disorders.

There are no specific guidelines for the prevention of CTS. Ergonomic measures have been shown to prevent some epsiodes of CTS, especially related to the vibration. For those pts with ESRD, changing to a high flux membrane may reduce the risk of CTS.

Diagnosis:

A history of pain in the hand and arm, paraesthesias, weakness, dry skin, increased symptoms at night, age > 40, increased symptoms by repetition or sustained hand positions.

For physical examination, there are many tests that have been developed, all with a wide range of sensitivities in testing. These include 2 pt discrimination, atrophy, weak thumb abduction, tinel and phalen, and hypalgesia in the median nerve territory.

A combination of typical symptoms with the exacerbating and relieving factors and the epidemiologic profile, and a hand symptom diagram, all lead to the diagnosis of CTS. Many symptoms are reported in both the median and ulnar digits. CTS may progress thru stages of severity. In severe CTS atrophy of the thenar eminence may occur. Progression is not inevitable.

The differential diagnosis includes cervical radiculopathy, polyneuropathy, brachial plexopathy, vascular disorders, cervical myopathy.

EMG and NCS are the gold standard for diagnosis particularly when the diagnosis is not certain , there is limited response to conservative therapy, or invasive treatment is planned. Imaging may be useful when structural disease is considered, Xray, or CT. MRI or US can be used to evaluate the actual nerve.

High frequency US is being used more often for nerve evaluation, especially when the EMG and NCS are negative, to directly evaluate the nerve.

Evaluation for systemic disorders with BS, TSH, Cr, ESR, prolactin, SPEP and others can be useful when secondary CTS is suspected.

Treatment:

Splinting at neutral, not extension, for 12-24 hours for at least 4 weeks, is generally first line, but there is little high quality evidence. (Cochrane Review 2012).

Exercise, mobilization and US treatment by PT are also options.

Little evidence for oral meds, but NSAIDS, corticosteroids for 2 weeks have some evidence. Lidocaine patch is an option.

Age > 50, symptoms for > 10 months and constant parasthesias are signs that conservative treatments are not likely to be effective.

Steroid injections generally indicated for mild to moderate symptoms, but may not be as effective in women, those with DM or NC abnormalities.

Inject proximal to the carpal tunnel thru the flexor carpi radialis tendon.

Refer to surgical specialist if not responding to conservative treatment for evaluation for surgical decompression, progressive deficits or EMG abnormalities.

An experienced hand surgeon is preferred. Open vs endoscopic surgical procedure is done.

QI CORNER

Hi everyone! Several announcements from me this week...

Get your flu shot! About one-fifth of you were able to get it done on the one-day blitz--congrats. If that didn't include you, do it now--like why not today? Do it to protect yourself, do it to protect your patients...and do it because it's required and so it's going to sit on your to-do list (and we're going to keep harassing you) until you do!

Hopefully you are forming your teams for the Making Wise Choices Easier HVCC proposal competition. Many members of the PSQC are forming teams, so if you're interested in participating but not sure how to get started, email me and I can plug you in with the PSQC folks. For proposal details, see the flier on the Med Res bulletin boards and linked at the bottom of Weekly Updates. Deadline is October 19th.

Mark your calendars for the next meeting of the PSQC on Thursday October 8th at 5:30pm in the Med Res Library.

Finally, we have two special events this week related to Resident Wellness:

There will be a special G-briefing noon conference on Thursday with Dr. G. G-briefings are sessions scheduled regularly throughout the year to promote our humanity and wellness by helping us process difficult cases. Thursday's will be a closed, housestaff-only (no students) session to discuss and process our program's recent tragedy, or anything else.
On Wednesday evening at 6pm in the Med Res, there will be a group session with PAS Counselors, dinner provided. RSVP is encouraged but not required for the Wednesday session--email Jake Feigal (jacob.feigal@dm.duke.edu), who has coordinated the session as part of our Resident Wellness program.

We will continue to provide Wellness sessions in various formats, and varying degrees of formality, as the weeks and months go on. Please contact me, Jake, or anyone in leadership if you have an idea for a format that speaks to you.

CLINIC CORNER

Hi everyone,

PRIME clinic is going through some changes.

Madge left last week and Beth’s last day was today. For all residents on PACT 3 team please forward any issues to your new interim nurse- Denna Kellum.

Please also introduce yourself to Christy Winn who is training for Carol’s position once Carol retires.

Looking forward to another great year. Please look after each other and let me know if you have any questions or concerns about PRIME, patients or life if general.

Sonal Patel, MD

PRIME Clinic Director

Durham VA Medical Center

Phone (919) 286-0411, x 6267

Pager (919) 970-5261

From the Chief Residents

Grand Rounds

Friday, September 25 - Oncology, Dr. Neal Ready

Noon Conference

Date	Topic	Lecturer	Time	Vendor
9/21/15	SAR Emergency Series:Neutropenic Fever	Rajiv Agarwal	12:00	Dominos
9/22/15	SAR Emergency Series: Peripheral Blood Smear Pearls	Myles Nickolich	12:00	Firehouse
9/23/15	SAR Emergency Series: Coagulation Disorders (PT, PTT, Platelets)	Amy Jones	12:00	Cosmic Cantina
9/24/15	Debrief	Dr. Galanos	12:00	Hungry Leaf
9/25/15	Research Conference	DN 2002	12:00	Panera

From the Residency Office

Get Your Flu Shot!!

Flu Vaccination Blitz This Week
We kicked off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill on Thursday, September 17, 2015. Mass vaccination clinics will be available at each of the hospitals and clinics throughout DUHS. Following the drill, we will continue our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics will be posted on the employee intranet in early September. This list will be updated throughout the vaccination season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

Applications for Medical or Religious Exemption should be submitted before Monday, October 12, 2015. This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy is no longer a valid reason for a medical exemption.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

Key points for trainees:

Get this done ASAP.
If you have medical exemption, be sure it shows up on your personal OESO Page—contact EOHW for any questions.
If the flu vaccine is received at any site (including the VA) besides DUH, DRH, or DUKE RALEIGH, you should take a picture of your documentation form (legible name, date, location and lot #) and email it to eohwflu@dm.duke.edu.

Please direct any questions to kathryn.andolsek@duke.edu

SCHWARTZ ROUNDS - 9/23/15

“Just let me die..no , wait, I'm okay now!”

Panelists:

Joshua C. Briscoe, MD

Resident in Internal Medicine & Psychiatry, PGY-4

Sarah K. Rivelli, MD, FACP

Program Director, Combined Internal Medicine-Psychiatry Residency

Department of Psychiatry and Behavioral Sciences

Department of Medicine

Debra Matthews, Clinical Dietician

Wednesday, September 23rd, 2015, Noon - 1 p.m., Duke North 2002.

About Schwartz Center Rounds:

All members of the Duke Medicine community are invited to attend an ongoing series of discussions called the Schwartz Center Rounds about the human side of patient care. Schwartz Center Rounds is a monthly interdisciplinary conference that offers all of us from no matter which discipline as well as non-clinicians who work closely with our patients a regularly scheduled time.... We are excited to have brought this program here to Duke and hope many of you will be able to join us on a regular basis.

Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), Nathan Gray, MD (nathan.gray@dm.duke.edu) or Bill Taub (arthur.taub@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!

BLS Blitz - November 2015

Just a reminder that the bi-annual BLS Blitz is coming up in November. The flier posted at the end of this blog has the dates. REMEMBER - Duke only holds BLS classes during the November and March blitz each yer, so if your BLS is expiring before March, PLEASE sign up for one of the dates in November!!

Global Health-Internal Medicine Residency Program Recruiting Eligible Candidates

Internal Medicine Residents who have successfully completed PGY1 are eligible to apply for the Duke Global Health Residency, an extended residency that leads to a Master of Science in Global Health and a total of nine months providing clinical care and conducting mentored research at a Duke University international partner site.

Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements as well as application instructions:www.dukeglobalhealth.org

Watch current global health resident John Stanifer, MD, discuss his decision to pursue global health training at Duke:

https://youtu.be/mE5wdtqP3_s

Send all application materials electronically to sarah.brittingham@duke.edu.

Applications accepted on a rolling basis until October 1, 2015. Offers will be made in November.

Now Accepting Applications for Global Health Elective Rotations
The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2016 and March 2017.
Application is open to Duke Cardiology Fellows (PGY 5 & 6) and Duke residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Neurology (PGY 2), Pediatrics (PGY 2).
The application is attached and available at http://dukeglobalhealth.org/education-and-training/global-health-electi…;
(For detailed site information, send request to tara.pemble@duke.edu).

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Application Deadline: October 5, 2015