From the Director
Hope you are all having a great weekend. Randy and Bill Hargett are in charge this week, so all compliments (and complaints!) should be sent their way. Block 2 starts for the JARs and SARs on Monday - great work everyone on the first block of the year.
Kudos this week to JAR
Armando Bedoya for his nomination for a Strength, Hope and Caring Award - for loyal Weekly Updates followers, you will remember that Armando helped a patient and his family during an emotional situation and was recognized by the 8th floor nursing staff. Also congrats to SAR
Bonike Oloruntoba for her selection as an Emerging Liver Scholar by the AASLD. From
Saumil Chudgar, thank you to the following residents who helped with the CSI:Durham clinical skills course -
Kim Bryan, Ryan Nipp, Ashley Lane and Lisa Vann.
Thanks Chiefs for the ITE and holiday schedule, with special thanks to Laura and Lauren for planning, cross-checking, fixing, entering and rechecking everything. It's a huge job, and often pretty thankless, so THANK YOU! With fellowship interviews beginning, please check your schedule to make sure you know where you are supposed to be!
Thank you also to
Shawna for helping us manage the QI data and modules. I'm so impressed with the data thus far.... Take a look in Sharepoint to see all that has been accomplished in just the first 4 weeks of the academic year.
PubMed: Pubmed from the program goes to...recent graduate
Gajarah Peterson and rheumatology attending
Lisa Criscione Schreiber for their case report in the American Journal of Medicine...
A Childlike Presentation? Peterson G and Criscione Schreiber L. American Journal of Medicine. June 2012
Have a great week! Aimee
What Did I Read This Week (Jon Bae, MD)
[box] Vancomycin-Induced Immune Thrombocytopenia, Von Drygalski, A, et al. NEJM, 2007; 356: 904-10 [/box]
Why did I read this?
I thought for a change of pace this week, I would not review an article about Quality Improvement and stick to some clinical medicine. Now I know you all can only think of me sitting in my Quality Improvement HQ, surrounded by Balanced Scorecards and PDSA cycles, reading nothing but the latest monthly issue of
Hospital Quality Improvement Made Ridiculously Simple, but I do on occasion take a break from constantly improving the quality of everything around me. On one of these breaks, I came across this article. Why did it catch my eye, you ask. For two reasons: 1) I am on Gen Med and recently had a patient with bleeding complications from thrombocytopenia (nadir of 9) who had a + IgG Vancomycin Dependent Platelet Antibodies test. Medication related thrombocytopenia is one of the more vexing of clinical dilemmas as a quick review of Clinical Pharmacology indicates essentially every medicine can cause it. We see thrombocytopenia often in our critically ill patients and not infrequently, due to concern for drug resistant infections, these same patients are getting vancomycin. I’ve held vancomycin accountable for thrombocytopenia on a number of occasions but it was news to me that there was actually a test for this – there is one for zosyn as well. Thus, when this test became positive, the practice-based learner in me came out and I decided to learn a little more about it. 2) The second reason I read this article was because the 2 weeks old hematology fellow Krish Patel sent it to me. So Krish, this one’s for you.
What I learned from reading this?
The first thing I learned was that this process occurs and is immune mediated. And there is a test for it! This article basically describes the authors experience in patients with this disease. The patients they describe developed thrombocytopenia after exposure to vancomycin for at least 6 days. I’m sure that brings a sigh of relief to those out there who like to start patients on vancomycin for what “ails them” until cultures are negative in 48 hours. There were several patients who had a precipitous decline in platelet counts on unintentional re-challenge. This actually describes my patient. The authors also comment that vancomycin induced thrombocytopenia seemed to be associated with a higher degree of bleeding complications (ecchymosis and hemorrhage) then thrombocytopenia due to other medications. Platelet counts had a average nadir of 13.6 and it took about 1 week for platelets to return to normal. Unfortunately, the authors could not comment on the overall incidence of this phenomenon because the size of the vancomycin treated population was unknown. Sending the antibody test is a little more academic and is helpful for future reference but its limited by the time it takes to return. We had stopped vancomycin in our patient long before the results of the test came back. My takeaway here is that in patients with thrombocytopenia for which alternative explanations cannot be found and medications are suspected, think vancomycin. Especially since the treatment is so simple – Stop the Vanc! For the curious, our patient’s platelet count continues to improve now that the vancomycin has been stopped. And for the record, my Gen Med team could have totally figured this out without Krish and his fancy test. But we thank him anyway.
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From the Chief Residents
Grand Rounds
| Date |
Division |
Speaker |
| 10-Aug-12 |
Pulmonology |
Dr. Wahidi/Crawford |
Noon Conference
| Date |
Topic |
Lecturer |
Time |
| 8/6 |
Common HIV/ID issues |
Charles Hicks |
12:00 |
| 8/7 |
Transfusion Medicine |
Nick Bandarenko |
12:00 |
| 8/8 |
Delirium |
Sarah Rivelli |
12:00 |
| 8/9 |
Acute Stroke |
Larry Goldstein |
12:00 |
| 8/10 |
Chair's Conference |
Chiefs |
12:00 |
SAR Talk Sign-up List
The SAR talk signup list was sent out by Nicole Greyshock last week. If you did not receive this, please email her.
Academic Half Day
There has been some confusion about how the Friday morning ambulatory schedule appears on medhub. Due to how medhub is set up, we have to list the academic half day conference speakers for everyone on ambulatory. You should only go to academic half day if your schedule says academic half day for Friday morning. If your schedule lists another clinic, you should ignore the conference speakers & go to your assigned clinic.
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From the Residency Office
In-training Exams
Please note that although assignments for the exams are posted in MedHub and Amion, they are subject to change. Why? We are continuing to work though schedule adjustments to accommodate fellowship interviews.
Holiday Schedule
The holiday schedule will be entered into Amion and MedHub on Monday. Please note that the actual rotation for the holiday time that you are
assigned to be on service are
subject to change as we "scramble" to accommodate as many requests as possible.
MKSAP
This year we would like to help make MKSAP more readily available – starting as early as your 1
st year of training (open to Intern, JAR, and SAR classes). You can submit your request as shown below:
- First, you need to become a member of the ACP
Associate membership costs $109/yr
https://www.acponline.org/membership/dues/new_us.htm
Please make note to record your ACP # - you will need it to complete our online request form
- Which MKSAP format to you want?
The cost for Digital MKSAP 16 is covered by the program – simply complete the order blank using the following link. The updated digital version will be released in January, 2013.
https://www.surveymonkey.com/s/MKSAP_16_Request_Form
If however you request MKSAP 16 Print (hard copy), or the complete set, you will need to cover the additional cost. The printed copies are released in two phases. Part A is available now – Part B will be released at the end of the yr.
Cost:
MKSAP 16 Digital - $339 for members (paid for by the program)
MKSAP 16 Print - $389 for members (
your cost $50)
MKSAP 16 Complete - $629 for members (
your cost $290) includes Digital and Print copies
Summary:
- This offer is open to all Categorical, Med Peds, and Med Psych trainees who have NOT previously received a copy of MKSAP
- We cover the cost of the MKSAP 16 Digital release
- You are required to be a current ACP member to participate
- You have the option to request the printed version or complete set – but you will need to cover the additional cost
- We do not place orders randomly at different times in the year.
Notice About the Schedules in the Block Folders:
Schedules posted in the Block Folders on MedHub are often placed there several weeks before the start of the rotation. Major schedule changes will be updated and posted as a revised schedule. Minor changes are not made to the schedules in the folders. To insure you are seeing your most current schedule, it is important that you check Amion and MedHub each week.
If changes are made to your schedule within two weeks of the event and it is not a change that you arranged with a Chief, it is my practice to page or email you to let you know about the change.
Please let me know if you have any questions. Laura Kujawski
Respiratory Fit Testing Schedule for August 2012
Fit Testing/ T-Dap Vaccination/ TB Skin Testing will be available at
Duke North Room 4000C. (Forth Floor beside service elevator)
Resp Fit Testing-T-Dap-TB Skin Testing Flyer August 2012
From the Robert Wood Johnson Foundation
Dr. Loren Robinson, a
Med/Peds medical school alumna of Duke University, has been selected as a 2013
Robert Wood Johnson Foundation Clinical Scholar. Through the program, Dr. Robinson will learn to conduct innovative research and work with communities, organizations, practitioners and policy-makers in order to take a leadership role in improving health and health care in the U.S
. She will join more than 1,100 distinguished Alumni including RWJF President, Dr. Risa Lavizzo-Mourey. Dr. Robinson will begin her fellowship at the University of Pennsylvania in the Fall of 2013.
Maestro Tips (submitted by Ryan Nipp, MD)
1. Refill all medications: go to the medications tab and click each medicine while holding 'control' then click reorder.
This will refill the patients' medicines all at once. Don't worry if they already have refills there, go ahead and "top them off" because they are not charged until they go to the pharmacy to pick them up.
2. Make sure that the patient's pharmacy is entered before you 'sign' an order for a prescription, or else the Rx will just print to the nearest printer, instead of going to the pharmacy.
3. As long as you have entered 'visit diagnoses' and associated specific orders with these diagnoses, when you get to the assessment and plan of your note, type .assessplan (dot assessplan for those with 'super user' lingo).
4. Any text that shows up highlighted in blue, you can right-click and click 'make selected text editable' so you can type within this text.
5. To get your medicines autopopulated, simply type .cmed (dot cmed) for 'current meds'
6. Don't forget the "Best Practice" tab, as it has evidenced based guidelines for specific actions you should be taking for your specific patient at that visit date.
7. When ordering a Toradol injection to be given in clinic, don't forget you want the order with the BED next to it (meaning it is given in clinic by the nurse) and then the toradol order is set to be given as IV, so you need to click the IM button in order for the nurse to give the med IM.
I hope this helps some people. - Ryan
Annual Duke Medicine Patient Safety & Quality Conference
Attached is the “Final Early Call for Abstracts" for the 8
th Annual Duke Medicine Patient Safety & Quality Conference scheduled for March 14, 2013.
Final Early Call for Abstracts_March 14_2013
Cindy Gordon, RN; Administrative Director; Patient Safety Office, Duke University Health System
Dates to Add to Your Calendars /Contact Information
Useful links
