History and Physicals:
Journal Article Summary:
Green DM, Boston University School of Medicine & Boston Medical. Dept. of Neurology. Determination of Brain Death. NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMcp2025326. Accessed Feb 18, 2022.
One of the patients presented, DG, was a 58 y/o F who underwent a massive ICH w/ Subfalcine herniation. Brain death protocol was ordered based on clinical picture. I sought out to find an article that discussed, in detail, the determination of brain death which accounts for 2-5% of in-hospital deaths in the U.S. per year.
The determination is made clinically upon the demonstration of permanent profound loss of function in the brain and brain stem in the absence of any reversible factors confounding the assessment such as severe hypo/hypertension, electrolyte/acid-base disturbances, toxins, or medications. If confounding factors cannot be fully eliminated, cerebral blood-flow studies are typically performed to assess for cerebral circulation.
The first step is to identify the underlying neurologic diagnosis and confirm that it is irreversible and compatible with brain death which typically requires allowing at least 24 hours of observation. NYS and most others require 2 examinations for the determination, although a case series of 1400 patients showed no instances of the second exam being inconsistent with the first.
The clinical examination to determine brain death consists of LOC plus loss of all brainstem reflexes, and apnea. Coma/Absent brain stem reflexes is determined by absent responses in the following: consciousness, pupillary reflex, corneal reflex, oculocephalic reflex, oculovestibular reflex (cold caloric test), gag reflex, cough reflex, and motor response. If a large portion of the exam cannot be performed (ex: due to facial trauma) ancillary testing is required. The apnea test assesses the medulla by letting CO2 levels rise while pH falls to stimulate the medullary respiratory center and observe for absence of respiratory effort in response to this.
Although traditionally used, iso-electric activity on EEG is not used in recent guidelines due to risks of both false positives and negatives without additional benefit than what is derived from the aforementioned testing. Instead, cerebral perfusion testing is used when ancillary testing is needed. Evidence of blood flow would dispute the diagnosis of breath death while no blood flow would support it.
Documentation needs to include all findings of physical exam, apnea test, ancillary testing if applicable, examiners names, prior lab results including ABG, prior brain imaging, and time of death.
The aforementioned information summarizes the steps and documentation to properly perform brain death protocol consistent with New York State guidelines.
Site Visit Summary:
The first case I presented on was a 58 year old female presenting with a large intracranial hemorrhage with a subfalcine herniation. I followed this patient from the time of her arrival in the ED when the stroke unit was called, until her brain death protocol in the MICU and subsequent expiration. The history and physical was written from the perspective of my initial encounter in the ED with the patient along with the plan of care at that time. The feedback I received focused on adding in missing pertinent details into the HPI and removing certain details that were better placed in other areas of the note. The lab section had each lab written out as a list which created an overall cluttered appearance. My evaluator suggested that I adopt the shorthand “fishbone” laboratory diagram to improve the overall appearance and readability. My assessment had too much repeated detail that I was later shown how to scale down to the most relevant information. Under my plan section I had left out activity, goals of care discussion, and disposition which I subsequently discussed how to properly write with my evaluator.
The second and third H&Ps included all of the corrections and suggestions from the feedback I received from my first H&P. For these, I presented my second on a 60 y/o female with myxedema coma and a 68 y/o male with cellulitis. I received feedback for both articles that all of the details were appropriate but placement of my paragraphs needed adjustments. I had included the hospital course first followed by that day’s assessment when the order should have been reversed. The remainder of the formatting and information was appropriate, and the rest of the feedback focused on adding in additional details such as expanding upon the family history more comprehensively and including more details about prior immunizations and screenings. Overall, I need to focus on adding in more details to the family and social history sections in future H&Ps.
Being that this is my first time rotating in an inpatient hospital setting, I had a learning curve learning how to write a hospital course within an H&P and some aspects of standard hospital orders for the plan section. My evaluator provided meaningful feedback that helped me improve each H&P and there is significant improvement between my first and third H&P for this rotation.
Typhon Case Logs:
My Internal Medicine rotation was full of many “firsts”. I performed my first of several ABGs, nasogastric Intubations, & catheterization on patients, all of which were successful thanks to the guidance of my preceptors and the training provided during my didactic portion that prepared me for these procedures and interventions. I was also able to assist in my first lumbar puncture and perform my first CPR (I have now participated in several of each as well). Equally as important, I have become more comfortable managing the complications of some of these procedures. For instance, when a patient experienced epistaxis during one of my NG tube insertions, I immediately retracted the device and was able perform the proper steps to control and stop the anterior bleed.
Keeping in theme, this was also my first rotation for inpatient medicine and there was a learning curve I had to overcome being that I was accustomed to outpatient settings. Regarding documentation, I was unfamiliar with writing focused H&Ps, progress notes, admission notes, and discharge summaries. While I as a student do not directly enter information into patients’ charts, I was able to gain experience writing these different formats by creating pseudo-notes with orders for personal practice.
I had previously thought I wanted to work in an outpatient setting because I enjoy following patients over long periods of time and thought a hospital setting would not provide the patient timeline that I enjoy. I have come to find out that I really enjoy being able to see the patients for consecutive days in a row or even multiple times in a day to follow their progress. While I still highly value the prospect of working outpatient, I was happily surprised to find out that I also really enjoy working in the hospital setting.
The knowledge and clinical skills I have gained in internal medicine will undoubtedly help me in my next rotation for Emergency Medicine. The confidence I have gained in my technique performing the aforementioned procedures will allow me to build up and expand my procedural toolbox for my upcoming and future rotations. I also feel more prepared to handle the high patient volume typically found in the ED from getting better at problem focused exams and admissions in internal medicine.
Last, now that I have shared my accomplishments, I would like to share what I would like to improve upon for the next rotation. I want to continue getting better at speaking with patients. There were instances where I struggled to explain medical processes to patients in terms they would understand without them having a medical background. I am finding out that it is easy for me to give explanations in academic terms with medical terminology but difficult to relay this information to patients in a way they can grasp. My best remedy thus far has been picking a new topic each day and thinking of a way to explain it in non-medical terms.
Overall, I have learned a great deal during this rotation and also uncovered areas of improvement that I will focus on moving forward. I have thoroughly enjoyed my internal medicine rotation and am excited to see what I will do next in my Emergency Room for third rotation.