Weekly Updates - August 20, 2012

By admin3

From the Director

Hi everyone!  Hope you had a great week. A lot of great Maestro tips have been passed around....show up to the extra personalization session to be held on Monday right after noon conference. Other cool opportunities coming up include a chance to teach CPR at the first Duke football game! Details are posted in the med res office - come out, see the game and do some community service. Thanks to JAR Matt Summers for an awesome chairs conference. Note to self....no humidifiers! And also to discussant Peter Kussin for great commentary. I've also heard some nice compliments about intern Ragnar Palsson and the excellent work he is doing on VA gen med as well as some (better late than never) gratitude to JAR Mike Shafique for helping the July interns on CAD! Thanks Mike. Got kudos for your colleagues? Shoot me an email! Really proud of our SARs who are cleaning up in the fellowship interview department! Thanks to you all and the chiefs for rearranging the schedules so that everyone can make it to where they need to go. I am very impressed and happy to see how much everyone is willing to help their colleagues. In Stead News, glad to hear that the Kempner Society hit Geer Street this weekend! Our QI is doing amazing as well. Check out the aggregate results from the sharepoint data...!
Diabetic Foot Exam - SharePoint Data Summary - July 1, 2012 - August 14, 2012
Training Modules:
# of residents assigned

35
# of residents completing all assignments

33
Patient Chart Review/Data Entry (time allocated to residents for project)
# of residents assigned

33
Diabetic Foot Exam - by Clinic

# Residents Reporting

Foot Exam

Monofilament

Vascular

Skin Integrity

All Exams
Duke Outpatient Clinic

14

83%

62%

70%

68%

39%
Picket Road Primary Care

2

89%

61%

64%

86%

43%
VA PRIME Clinic

17

88%

71%

78%

83%

63%
Data Sorted by Stead Society

# Residents Reporting

Foot Exam

Monofilament

Vascular

Skin Integrity

All Exams
A- Kirby

6

85%

61%

65%

55%

38%
B- Kempner

4

74%

60%

51%

67%

18%
C- Organ

4

90%

65%

93%

84%

60%
D - Smith

10

83%

62%

69%

77%

51%
E- Rankin

9

94%

80%

86%

91%

75%
Chart Reviews/Project Statements
# of Charts selected for review by residents

608
Avg # of charts reviewed per resident (target = 20)

19
Project statement - improvement plan

33
This weeks Pubmed from the program goes to 4th year med students and future IM applicants for their award winning work at AOA day! Best Basic Science Poster: David Rawsonfor "Role of the type III TGF-beta receptor in hepatocellular carcinoma" - mentor is Gerry Blobe Best Clinical Science Poster: Lindsey Wu for "Patterns of bone sarcomas as a second malignancy in relation to radiotherapy in adulthood and histologic type" - she was mentored at the NCI/NIH. Also congrats to intern Nick Rohrhoff for his comment published in the NY Times in response to an op Ed by Sanjay Gupta. http://www.nytimes.com/2012/08/04/opinion/taking-steps-to-prevent-medical-errors.html?smid=tw-share Re “More Treatment, More Mistakes,” by Sanjay Gupta (Op-Ed, Aug. 1): During postgraduate medical training, the haunting fear of making a mistake is inescapable. But it can be mitigated by the warm embrace of nurses, pharmacists, physical therapists and other providers. In concert with essential nonclinical personnel, our mission is clear: if it’s right for the patient, it’s the right thing to do. This is accomplished when each member of the team takes personal responsibility for his or her role. At Duke, “my patient” and “your patient” have largely been replaced by “our patient.” Among physicians, morbidity and mortality conferences have been successful because they are patient-centered and team-oriented. We should apply this concept to every conversation — with everyone involved — in caring for our fellow humans in need. NICHOLAS J. ROHRHOFF Durham, N.C., Aug. 2, 2012 The writer is a resident in internal medicine at Duke University Medical Center Have a great week, Aimee

What Did I Read This Week (Murat Arcasoy , MD)

[box]     Red blood cell transfusion: a clinical practice guideline from the American Association of Blood Banks (AABB).  Annals of Int Med     [/box]

What is this article about? This article focuses on hemoglobin (Hb) concentration thresholds and other clinical variables that might trigger red blood cell (RBC) transfusion. Transfusion practices vary widely with most physicians using Hb concentrations to decide when to transfuse. What did the authors do? The 20 member expert panel (including Duke’s own Sunil Rao!) utilized a systematic review of randomized clinical trials evaluating transfusion thresholds, and performed a literature search from 1950 to February 2011. They examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, they examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay. Here are their recommendations verbatim: Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence). Recommendation 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence). Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence). Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence). This article is of interest to all practicing physicians regardless of their specialty and subspecialty. Previously published guidelines emphasized that transfusion be given for symptoms of anemia and not based on Hb level alone. The authors suggest that evidence-based recommendations on use of Hb levels will help standardize transfuse practice. This article also has an interesting Figure that depicts adverse effects of RBC transfusion contrasted with other risks (such as motor vehicle fatalities, death from medical errors, fall fatalities etc). My 2 cents This article will not change my current practice which I can describe as restrictive but a highly individualized approach to transfusion of RBCs in each of my patients, case by case. It is challenging (for me) to incorporate guidelines into “routine” practice to standardize the approach to the care of all patients, because the clinical judgment at the bedside is really key to the ultimate decision: in this case to transfuse or not (whether above or below a specific Hb threshold the use of which is suggested in these new guidelines). Hopefully, in our practice, we will not withhold transfusion from someone who really needs it or transfuse someone who does not need to be transfused. The clinical context is critical to make that determination. Recommendation 1 for the stable patient in hospital provides us with some degree of reassurance for implementing a restrictive transfusion strategy in general. [hr]

From the Chief Residents

Grand Rounds

Date Division Speaker
24-Aug-12 Oncology / Nephro Dr. Chertow, Stanford
31-Aug-12 Cellular Therapy Dr. Sandeep Dave

Noon Conference

Date Topic Lecturer Time Vendor Room
8/20 CXR interpretation Phil Goodman 12:00 Chic-fil-A 2002
8/21 Transplant ID Aimee Zaas 12:00 Domino's 2002
8/22 DVT/PE Vic Tapson 12:00 Jimmy John's 2002
8/23 Liver Transplantation Alastair Smith 12:00 Sushi 2002
8/24 Chair's Conference Chiefs 12:00 The Picnic Basket 2002

From the Residency Council

Congratulations to the newest Residency Council Representatives for 2012-2013: Intern Class:  Katie Broderick-Forsgren, Ryan Huey, Nick Rohrhoff, Michael Woodworth Med-Psych:  Amy Newhouse [divider]

From the Residency Office

Volunteer Opportunity - CPR @ Wallace Wade Stadium ( from Leatice Short)

On September the 1st, we will offer a CPR education tent at the football game at Wallace Wade Stadium.  We would welcome medical residents to assist as volunteers during shift 3.  Also, if others would like to volunteer during  shifts 1 and 2, that’s fine as well! Sign up sheets have been posted in the Residency Office.

In-training Exam Schedule

The updated schedule has been posted to MedHub.

Duty Hours - Three Weeks in a Row!!

Our hat is off to all of the residents who are logging in and keeping their duty hour logs up to date - and to Jen Averitt who is tracking these and following up.  I can assure you, Dr. Klotman and Dr. Zaas are not missing the emails filling their box on Monday morning directing that residents be pulled from duty for not logging in duty hours.   Well done!

Dates to Add to Your Calendars /Contact Information/Opportunities

Sept 19-20          Flu Shot BLITZ Oct 25                   Recruiting Kick Off Event Opportunities Internal Medicine Dutchess County (1) Westchester Internal Medicine FM IM - North Carolina Internal Medecine Physician - Atlanta FM & IM Flyer.TN   Useful links

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