 Good morning everyone and welcome to Grand Rounds for those of you in the room. It's a special opportunity to welcome Dr. Caroline Craven or newest hire who is in the room for those of you virtual. She is excited to be here huge smile saying hi to Judith right now. Feel free to reach out via email or in person. When you do see her next. All right, Lydia, Lydia, sour will be moderating. All right, good morning everyone and I have the pleasure today to introduce Dr. Mubarak Mohammed, who is one of our wonderful PTO two colleagues. And I asked everyone about a fun fact for themselves yesterday, and he said that he is defending the fantasy basketball champion in his league. So, with that, he is going to talk about physician wellness, unlisted occupational hazards. Thank you, Lydia, and let me know if my voice is too loud or I'm not speaking up. But certainly appreciate everyone's attention I do regret not being present for for this Grand Rounds I'm actually in Ohio. With my family for the last week of Ramadan and they're just kind of scheduling I could not make it in person but certainly happy to be here and happy that you guys are all present and watch this presentation. And the title is that physician wellness, unlisted occupational hazards. We will keep going here. I have no financial disclosures. So in some ways, struggled with the phrasing of this title, you know, being a physician is incredibly rewarding. And one of the ability to positively impact the lives of, you know, others to profession where self actualization is possible. And while there's a spectrum of roles within medicine, you know, the job is not physically, you know, demanding as other professions I remember my dad telling me that, you know, work hard and education. You don't want to be like a construction worker or a forklift offer like I am and, you know, working with my back every day. So just, you know, telling me to use my brain and making sure that I didn't have any, you know, work related hazards. The job itself is, you know, well respected in the community. You know, a lot of people are esteemed and admired for being physicians. And you make money, you know, to live comfortably afford housing transportation food, you know, vacation and fund your child's aspirations as well. All in all, it's a pretty sweet job. And I think we're all lucky to get to experience this. However, like many other jobs, you know, it does have some occupational hazards and certainly not at once but little by little and through my experiences and early resident. You know, you could see like the impact of certain hazards, you know, amongst your co residents and colleagues as well as supervisors. And this is something that's over time, kind of overlooked and oftentimes, you know, not by society itself but you know ourselves and in the profession as well. And when many of these occupational hazards we are familiar with, you know, in the war in the clinic physicians are exposed to infections pathogens. Airborne continuous contacts. It's not an insignificant cause of physician morbidity in the workplace. We know that, you know, I looked at quality pottery and all of its kind of carcinogenic effect. And then as Jordan does it tell I presented early in the year and his grand rounds, kind of pretty accidentally as far as the musculoskeletal complications and ophthalmology, the force and skill required of manipulation and standing and sitting in the or lack of ergonomic insight that do lead to, you know, injuries among surgeons and physicians. So the occupational safety and health administration describes five categories of occupational hazards. I think we're all familiar with the physical safety hazards which include anything that could happen in the workplace as an injury. They are described as quote unquote health hazards where, unlike physical safety hazards they describe risks of injury after cumulative exposure to harmful condition or substance, rather than a similar accident. And then those are pretty self-explanatory as far as like chemical biological hazards physical hazards include like excessive noise or elevated or low temperatures or radiation. We can just kind of, you know, see over and over again that can impact your health and then ergonomic hazards we are well aware of as well. Notably one thing that is missing though are the psychosocial hazards aspect of work, which can, you know, have the potential to cause psychological or physical harm. Our government, the OHSA does not list it as one of the kind of five core occupational hazards, but this is just kind of the definition from the Australian government and their co-equivalent to OHSA, which lists again psychosocial hazards as being an aspect of the health and safety of their occupation. So this was a recent article that I saw back in September actually and I think we got an email from the GME as well. Just saying that, you know, that day I think it was September 17 that it was National Physician Suicide Awareness Day. I actually didn't even know there was a, you know, Awareness Day for Physician Suicide. Certainly I think, you know, as we go through training, we all have like many experiences with certain, you know, kind of the how hard work can be and certainly hear stories of, particularly with me as I started residency just in terms of the journey aspect of your mental health and burnout and things of that nature. And certainly we all kind of are, you know, have a cursory awareness that physician suicide is a thing and it's higher in the, you know, in our population than the general population, but certainly not to the extent that, you know, there's an actual day where you are kind of observing the amount of suicide that happens in the nutrition community. Certainly there's a lot of risk factors, you know, that sleep deprivation, long hours, excess workload, certain financial hardships in terms of loans and whatnot and then legal issues from a medical legal standpoint that exacerbate these issues. But it's oftentimes something that's not really looked at, you know, in our community and this is, you know, evident for me as well which, you know, as a physician I didn't even know, you know, a day kind of looking at this was something that was, you know, on the radar as far as on the national community. So I just wanted to kind of take this time as an opportunity for myself and just, you know, had the opportunity to present a grand rounds where I could kind of look at this a little bit more and then particularly talk about physician suicide to kind of not only educate myself but then, you know, other colleagues as well. So I'll start out with, you know, Burnout is something we're all familiar with it's a more related syndrome involving emotional exhaustion, depersonalization, in a sense of reduced accomplishment. These folks surgeon now we're kind of the first to assess burnout and resident in residence and faculty and the numbers are pretty high as we kind of all probably are aware of, you know, I'm 30% of residents in almost 30% of faculty as well scored in a high range of emotional exhaustion. More than 50% of residents and about a quarter of faculty scored in a high range of depersonalization, and then about a fifth of residents and 10% of faculty scored in a range of personal accomplishment, which, you know, is pretty eyebrows raising, you know, as far as, you know, we're all highly educated in a highly accomplished folks as well. And then in terms of, you know, suicide I think we all know that, you know, female physicians are about like twice as high to commit suicide as compared to the general population and then for males, the hazard ratio is about 1.4 In a recent study, serving almost 8000 surgeons in the UK, about 6% reported suicidal ideation within the past year. And then for the for that population itself among surgeons, it was three times more common. And the most probably, I guess, eyebrow raising, you know, fact is only a quarter of them sought psychiatric help and almost the majority, you know, 60% say they were reluctant to seek help, due to concern that could compromise their careers and I think we all know that's true as well. So I think I would argue, particularly with, you know, the hazard ratios that we see, and just for the fact that we have, you know, an awareness day for this in a profession that it is an occupational hazard of those physicians. It's the only cause of mortality that's higher in physicians than non physicians as well. And this was the study that I was citing earlier as far as the suicide rates among physicians by Sherman Homner as well. So, one study that I wanted to kind of look through was looking at suicide ideation in medical school and medical students. And this recent meta analysis, believe back about five years ago, or a little bit longer. Sure that the purpose was pretty high among medical students and it kind of started there. So the prevalence was about 11% in the medical student population and then when you kind of extrapolated out to the past year or so about a quarter of medical students indicated suicidal ideation within the past year based on that study. Notably this study also and other studies have shown that you know the burden and prevalence and incidence of mental health disorders is not higher among medical students compared to the general population. I know that suicidal physicians face unique barriers to care and I think we're all aware of just kind of the pressures and my professional standpoint. Encounter, you know, barriers that not only you facing like, you know, general population as far as stigma, lack of time and a lack of access to care. So physicians, especially have an added burden concerns in regards to concerns with regard to like confidentiality fear discrimination and licensing and applications for hospital privileges to actually do their job. And then this is a study by Shenifelt and co I believe out in Brasca and up to 35% of physicians did not have a regular source of health care, again, which is associated with less use of these preventative medical services. The use of mental health unsurprising was also low, but certainly in the research I was looking at there was a little bit of a lack of information in regards to these patterns. There is a little bit more known about medical students. But again, they have low rates of seeking help with only about. I think a fifth of those who had screen positive for for depression using mental health services so 80% of folks that are screening for depression or not. Talk to somebody utilizing psychiatric psychological services. And then for those depressed students that way that did have SI only 42% received treatment. And again, these are the physician late the students that will all, you know, become part of the workforce. And then most recently, or most frequently outside of barriers included lack of time, confidentiality stigma costs, and then fear of documentation on the academic record. So then, you know, why do these barriers, you know, exist. You know, practicing physicians with disorders often again occur encounter over or covert discrimination in regards to the licensing privileges insurance as well and then we know that malpractice insurance is a big deal as well particularly as you're transitioning to attending Most of the state licensing boards have removed questions about diagnosis or treatment toward questions about, you know, impaired professional performance at initial licensor and rules but there are some states again that still have kind of ambiguous questions in regards to kind of mental health. And notably the American with disabilities act has been deployed in legal challenges in regards to these medical licensing boards and then there are questions in regards to mental health questions. So it is reasonable to infirm or infer rather that the physicians concerned with disclosure of mental health records is widespread. These breaches of confidentiality between physicians and not only as you know colleagues but you know as a treating physician can resolve and kind of needless disclosures to core workers. These concerns coupled with professional attitudes that discourage admission of health vulnerability are probably the driving forces behind the the lack of you know seeking health and mental health care and in the medical setting for physicians. And I would like to maybe take about a 30 second break and you know just for everyone just to maybe think about, you know, a hard time and their training or maybe attending hood and then if you can think about maybe the most respected like colleague that you can think of someone that you really admire and if they came and disclosed, you know that they were having you know these impressive thoughts or suicidal ideation. How would you react and then kind of what your thoughts would be in regards to you know helping them out. Conversely, if you had you know a colleague that was struggling. Maybe you didn't get along with and again you found out by some way that they were also having these issues, what your thoughts would be as well as kind of a mental exercise for all of us. So in regards to the risk factors. Certainly, you have kind of the general risk factors among, you know, population itself so biological psychological and social components. Overall main risk factors for suicide include mental illness and substance use disorders about 90% of individuals who end up now passing away from suicide suffer at least one of these other notable risk factors including prior attempts homelessness access to legal means lack of an adequate support system and chronic medical conditions. And then, particularly with physicians you know in addition to these general risk factors the the elevated risk among physicians is likely due to additional population specific factors among physicians so physicians are exposed to high levels of personal and professional stress. Oftentimes make life or death decisions, you know, particularly in our field you know life or I and then constantly at the risk of malpractice as well. They also have high stakes, you know conflicts, possibly with administration or colleagues and then certainly from, you know license or standpoint as well. That's something that's hanging over your folks heads as well. So, additionally, we know that medicine and kind of medical training encourages stoicism. So from, you know medical school on, we're almost taught that there's new room for error, expected, and our expectation is that we're, you know, able to perform that, you know, exacting standards, always putting the patient first and then trainees you know in this environment may believe that you know they might be faulted for vulnerability and thus avoid asking for help. It's ironic that you know even though physicians are typically better resourced in the general population. There still remains like a significant barrier seeking this help. This is a study out in Norway, just looking at the comparatives of risk and particular factors that are related to SI among residents and then attendings or specialists as they come, you know, they're in academic medicine. These are kind of the main risk factors. The perception of need to demonstrate competence was related to SI among the attendings. Subjects to harassment. Oddly enough was only found in the attendings but I'm sure, you know, if you're subject to harassment it's not getting free from mental health in the workplace and then. The sickness presentee, presenteeism was a new word I learned in this study and basically kind of shown up to work when you're not feeling well was also associated with a higher left a higher level of ideation for both groups. A lack of empowering leadership was also associated with a higher levels of SI for both groups and then lack of regular meetings to discuss just kind of the job itself and the demanding experiences at work were also associated with higher levels of SI among the attendings. This paper reported kind of similar but in terms of just kind of looking at more of the protective factors and this was by out in the UK and looking at junior doctors or residents. And the analysis that identified kind of three main themes and hope, you know, this is kind of the main sticking point of my talk but support from colleagues with regards to managing workloads and emotional support, support of leadership, including feeling valued and accepted trust, trusted and good communication, supportive learning environment. And then normalizing vulnerability and in those instances were helpful and found to be protective and then finally access to professional support, whether it be you know counseling CBT medication and having those avenues kind of highlighted were also protected as well. And then lastly this is a stadium, a high stadium horses we call it kind of a lot of my fond memories from college are here. And one of the finest memories is just hanging out with you know a lot of my friends and one of those friends was actually a medical student at a high state as well, or an undergraduate and then went out to a medical school elsewhere but he was a resident and just started his internship last year. And I think we all kind of know where the story is going but he passed away from suicide earlier in the year and anything, anytime something like that happens definitely makes you pause and reflect, not only in our daily interactions you know just with the system in general, you have kind of a multitude of feelings from kind of guilt and shame to like anger at the system as well. But certainly, just kind of remembering him and just kind of you know the wonderful life that he lived. I just wanted to just kind of give this presentation as well not only for myself and just to kind of educate myself a little bit more in regards to the rigors and pressures of medicine how that can affect us in terms of mental health. But just you know, mainly presented to you guys as well and particularly my co residents, just make sure that, you know, this is something we think about something that we turn to guard ourselves against. It's not easy, right. And we all kind of have battles that were kind of going through but I'm just remembering just to be kind to each other, patient to each other and then ultimately supportive of one another. And this kind of, you know, hard life that we kind of go through is going to be important so I just like to would like to end with this phrase here. By Ian McLaren he's a thing of the past out of Scotland but this is one of his most famous quotes from kindness. And just want to thank you guys for your attention and be happy to take any questions. Thank you for this wonderful and certainly very important presentation. I really have a question to start off with. Do you know if anybody has looked at the difference between surgical and non surgical residencies and how the numbers of suicide differ in those specialties. That's a good question Lydia I don't know. Some of the main quote the main paper I was citing. Looking at burnout was among orthopedic surgery residents and faculty. I want to say that paper showed that the rates of like burnout were higher among surgical subspecialties. I don't know if any papers directly comparing a sire suicide between surgical and non surgical specialties. Okay, great. I have another question for you. Thank you for this topic. Obviously sobering and thank you for sharing your personal experience. You know, it was really you and the other PG Y twos this year that gave me some some new insight after all these years of being an educator around the intense pressures that you feel to not look weak be weak not be relied upon by your colleagues and and we all feel it medicine but it really. It really made me re evaluate where we are in this space of wellness and. And I'll say this I'm really grateful to work at a place that kind of abides by the Maya Angelou quote which is, you know, do your best until you know better and when you know better than than, you know, act on that and. And, you know, whether it's the kind of meditation room we're creating for you guys upstairs griffin Jardine doing the best thing I think we've ever done in the program which was create some admin days for you all. We can't just be beholden to residency has to be hard and miserable because we were all hard and miserable we always have to do a little better. And so griffin just recently at a conversation we had last week he's, you know, independent of this conversation really kind of redoubling his efforts around wellness and the residency. No one's better than griffin at kind of bringing a little bit of joy into the room and. There's a reason why we have him in that place and anyway thank you I know we've got to get on to to Brandon who's going to brighten our morning with some humor here in a moment but sincerest thanks for this this topic and always a timely conversation to be had. So thank you all. Wonderful. Thank you, Mubarak and then we're going to move on to Brandon, and to have something a little bit lighter he actually didn't just gave me one fun fact but he gave me three fun facts. So I'm just going to read those are. The first is that Dr Chris bear has never bet him in ping pong. Bobby outside of medicine is sleeping. And then the last one that may even be in context with this talk is that apparently his first word as a baby was of terminology. So with that he is going to talk about communication breakdown. Thank you Dr so for the warm welcoming partially wasn't true. Thank you everyone for coming out and thank you to the Moran for allowing us to come up here and present unique cases and talk about topics that were passionate about some a third year ophthalmology resident here. I'll be presenting a case today title communication breakdown. So kind of talking about the background of this title my inspiration is really came from one of my favorite bands like definitely one of my favorite songs by them and for those of you don't recognize this band. Maybe you'll you'll recognize some other familiar faces and myself and some of my colleagues here who were involved in this case and they were really helpful so I just wanted to give them a quick shout out. So this case starts with a 77 year old female from a transfer center call and a busy Saturday shift that I took this year and there was concerned for acute angle closure of the left eye. In regards to the information that we gathered from the transfer center phone call. She had progressive left eyebrow pain blurred vision had a congenital vomiting that started about one day ago. She did say that she had a similar episode like this in the past after scopolamine patch use, but she didn't require any glaucoma drops, no laser procedures no cataract surgery in that left eye. Initial presentation at the outside urgent care, intracular pressures reported to be very high up to 58 net left eye, and despite three rounds of max topical drops, as well as dimox, which was instructed by the local ophthalmologist or the phone. The intracular pressure is still elevated. You can see here the patient was seeing overall okay 2060. And she did complain of eye pain and the eye was reported to be read with a mid dilated pupil local ophthalmologist was unable to come in, but he referred that the patient be transferred over to the Moran eyes center for laser procedure. So we accepted the patient. A little bit of background in regards to transfer center calls here at the Moran. If the patient is an established patient, we can typically just send them over to the Moran directly and we'll see them they'll come here. We'll get a page and we'll see them in our clinic. However, if they're not established yet will go to the ED, or if they're unstable, we need any imaging or anything more urgent. So we felt comfortable just bringing her directly over to the Moran eyes and she's already established. And typically we get a page saying that the patient is here and we'll come see them. However, in this case, I did not get a page. And I kind of went about my day was very busy call shift. And eventually I kind of went looking for the patient in the typical waiting room and also sometimes they'll be out in the main area. And when I walked out to the main lobby I saw an ambulance in front of the Moran eye center. And I'm sure most of you are well aware but we don't really accept ambulance transfers. If there's if they need an ambulance they should probably go into the ED. So I walked down and turns out this was our patient. They arrived in a stretcher. They were previously stable at the outside urgent care. However, they said that the EMS they've been waiting for over two hours, and the patient has mentally decompensated and they're concerned for hypoglycemia. And they're here because they were told that the patient needs to have laser surgery they've kept her MPO and also that she's due for eye drops soon. So after talking to the EMS I take the patient up to the Moran eye center the fourth floor from the stretcher up there in a wheelchair and get her some food, get her some water. I elicit a history patient overall is a sick patient multiple different cancers unfortunately, as well as a resected schwannoma of the right side, which resulted in some facial neuropathy. I think Dr. Patel did some plastic surgery with her to protect that cornea. Dr. Mifflin did two PKs on her and she also needed cataract surgery as well, but nothing in regards to the left eye. An examination here kind of some things highlight you can see overall she sees pretty well she's 2040 so not quite as bad as what we saw outside urgent care. The pressure for me was actually very low. So instead of 58 or 40 despite, you know, topical therapy, I got a pressure of six multiple different recordings and I was very soft. Then on my gonioscopic exam you can see here that the angle was essentially closed with near 360 degree peripheral anterior sneaky eye. The left pupil was mid dilated fixed. Not reactive power no APD by reverse. It's like an exam. The AC was shallow. Importantly, it was uniformly shadow shallow. Again, the pupil findings there and then this patient had a large cataract this lens, but the nerve did look okay. So here I put an hourglass up here because I want to kind of stop and talk about how long it took me to get the patient up from the ambulance to the Moran eye center fourth floor. I listed a history and do an exam this. This took almost two hours, which is a red flag. The patient was kind of falling asleep didn't have the energy to get herself into the chair she almost fell when I was transferring her into the chair. She didn't have the energy to keep her chin in the slit lamp. And I thought, you know, maybe she's just tired or dehydrated because she hasn't had anything to eat. Or, you know, I saw patients with angle closure in the past. They're not just throwing up. But it really was of concern and things were kind of progressively getting worse. In addition to this, you know, I was also somewhat confused. You know this patient is supposed to be a patient with, you know, a red painful I was throwing up who's nauseous pressures in the 50s pressures in the 40s despite max optical drops and my exam the I was white and quiet. And angry and the pressure is actually very soft. So, when when you encounter this situation as a resident, you should, you know, do it all good residents do and that's, that's call your your chief, your chief resident for help and that's exactly what I didn't do I went straight to the glaucoma fellow. And that's Dr Chamberlain and he told me what he should have told me and that's to call my chief fellow or chief resident so that's what I did I called Dr Colin and and at this point, Dr Colin agreed. I thought it didn't really make sense there was concern for, you know, cute compensation from a mental standpoint and also if this patient didn't need a laser. At this time I think I already got six new pages by the time I finished with the history so it's also very overwhelmed so Dr Colin ended up coming in. He walked in the room took one look at the patient said she looks horrible this is one of the sick patients I've seen. So we decided to do an actual physical exam check her pulses, and we were concerned so we sent her down to the ED directly. And once the patient got to the ED, these were her initial vitals and take note that in the urgent care, she drove herself in she was human dynamically stable there's absolutely no concern. And she was supposed to self driver, self over to the Moran so you can see she's very hypotensive she's great a card to Kip Nick, who's setting in the 70s on a full air mask and she was also hypothermic. They also did EKG and showed that she was in second degree heart block baseline labs as well. You can see many electrolyte abnormalities or hemoglobin slow. She's also hyperglycemic. And then her the ED notes. She essentially said one thing to that the initial provider and that is she felt like her head and her neck were melting into the chair. And surely after saying that she passed out and fell off the exam chair became unresponsive they had to do rapid on her. They also gave her two liters of IV fluid rapid warming protocol, multiple different basal pressures as well as atropine. So very serious situation escalated very quickly. Kind of taking a step back and thinking here about this entire case and where we started and where we've we've come. We have 77 year old female overall unhealthy but presented to the urgent care with stable vitals complex past medical history issues, essentially transferred for further evaluation and possible lpi for you angle closure glaucoma of the left eye. Initially her pressures were read to be in the 50s at the outside hospital. They were instructed to do max topical drops which they did three rounds of and also one one oral diamox pill and now the pressure was six when I saw her. On my exam the I was white and quiet as the AC was uniformly shallow. I was near closed off on my gonioscopic exam I was mid mid dilated pupil with possible fake amorphous component. Then lastly she she had that subacute kind of alter mental status where she was kind of slowly decompensating we sent her to the EB. You prove the hemodynamically unstable required transfer to the McHugh and resuscitation. So kind of thinking back and what was going through my mind at this point you know I had to take a step back to my intern year and think about actually you know medicine and this patient had a stroke. Maybe probably not with her with her presentation but possibly you know this life threatening need to consider that she had a PE. She's definitely a hyper coagulable patient with multiple cancers in her history about a heart attack about some type of arrhythmia. It should be septic and we miss this HP hypovolemic shock or dehydrated or internally bleeding. These are all things that went through my mind as she kind of mentally decompensated over the hour or two I spent with her. Essentially in the ED and in the micu they did of course you know work up for all of these things including imaging of the brain chest X right EKG labs and essentially ruled all of these things out. So at this point we still you know did not know what was going on and fortunately you know I had to continue with my call shift. So fast forwarding a little bit Dr. Polsky was our consult resident she was able to see the patient the next day in the micu and patients transfers the micu for further support you know continued fluid resuscitation. Basal presses report eventually the patients electrolytes didn't normalize the mental status didn't prove that next day the ophthalmology exam was overall unchanged pressure was still low. Despite being off all drops and importantly once the patient's mental status has improved we're able to elicit more of a history from her. And we found out this is a direct quote from the patient that the EMS gave her three different drops these were the max topical drops every five minutes while in the ambulance for about three hours. So for all this residents who just took O caps, thinking about you know, not only the ocular but the systemic side effects of topical glaucoma drops. There should be no surprise that this is a case of systemic toxicity from glaucoma drops. You know patients receiving for monodine Timelaw dorsolomide and tannopros every five minutes for three hours. It was no surprise you know the things that we learn about for monodine and how it penetrates a blood brain barrier and causes respiratory depression and stuff like these things were all occurring right in front of my eyes. And you know in addition to Timelaw beta block toxicities you know some basic things we learn in medical school and how that can affect the cardiovascular system lungs metabolic system electrolytes and so forth. So going back to differential. This patient ended up being diagnosed with systemic for monodine and Timelaw toxicity diagnosis of exclusion a quick follow up here so while the patient was still inpatient we brought her over to our glaucoma clinic when she was stabilized. See Dr. Zabriski he did an LPI that left eye but the AC was still shallow. And at that point he agree thought this was likely fake amorphid. So when she was sent home and stabilized we brought her back for more definitive treatment. I think this was a combined case with either Chai on Mifflin or someone else here where they did you know cataract surgery removed the cataract polyurethane, adroplasty, gonioviscid dissection and also repeated the LPI. And most recent follow up she was seeing well 2015 pressures are normal AC was nice and shallow or nice and deep not shallow and she was dropped free at that point. And I kind of just wanted to go back you know this was a very humbling case. I could have kind of dove deeper and this could have also been presented as an M&M but when we're you know introduced into medicine, you know we go into medicine wanting to help people and one of the first things we do, you know, at a white coat ceremony is repeat the hypocritic oath and first you know harm I remember saying these words and it was really a gut punch the next day sleep deprived after taking a hard call shift I read the ED note and this was the first line of the assessment from the ED attending. It was a real gut punch it says the failure to initiate interventions such as adequate history taking discussion poising control and admission on an urgent basis likely resulted in sudden clinical and significant life threatening deterioration in this case. So this was a huge huge near miss this could have been much worse. And I you know it made me really take a step back and think about all the things that you know I potentially did wrong at the communication errors all the steps along the line of this entire case and in what things could have been prevented. That's why I want to talk real quickly about our favorite kind of diagram here the Swiss cheese model. And essentially this is you know a model where it demonstrates that although we have multiple layers of defense. Each of those layers still have flaws and when the flaws in those multiple layers of defense or checkpoints don't prevent misses or near misses. When those flaws line up near misses can become misses and serious medical errors can happen. We see this all the time and we've learned about this multiple times so I thought about what were the steps in this case that you know potentially went wrong where kind of I you know improved help prevent this what kind of learn from this case. So the things that were you know, on my mind you know the transfer center call there's a lot of assumptions made there's poor communication. We did not tell them to you know continue drops until they're seen for three hours but someone did but we also didn't tell them not to. We didn't know they're gonna be coming over an ambulance there's no communication there so there's just a lot of communication errors in regards to the transfer center call the paging system. And that I think was kind of highlighted here as well. You know the patient was out front in an ambulance from multiple hours before I knew they were even here. The handoff from the EMS in myself. You know, I was not told that the patient was receiving drops for three hours but I also didn't ask. And I think I was just a little bit overwhelmed so and kind of shocked at the current situation so this communication could have been better as well. And again patient history yes the patient at all through mental sadness was hard to elicit a history but I think I had a lot of cognitive biases. You know in my mind this patient was a patient with acute angle closure they need a laser at six their patients to see. Let's you know let's let's go. So the first fourth four topics here out of the five really highlight communication and that's really the highlight of this topic and we hear about this a lot in regards physician handoff and transfer of care between between attendings and there should be no surprise that almost 80% of serious medical errors do involve miscommunication between caregivers and patients. When being transferred or handed off and there's lots of discussion on the literature about things that we can do to help prevent this and we see it in our everyday lives. You're with checklists with the EMR surgical timeouts. There's also some mnemonics that we learned in medical school nursing school, all kind of encompassing areas to talk about everything that's important in regards to handoffs. In person communication has also shown the decrease this miscommunication between caregivers and handoffs. Lastly just close the communication kind of restating what you were told and what needs to happen. And one more quick topic I wanted to touch on and that's that's kind of cognitive biases. You'll hear Dr. Marks talk about this all the time you know every bump isn't actually in Dr. Zaw give a really good grand rounds and this a while back and it's one of kind of quote here cognitive biases are systematic unconscious automatic patterns of thought that made us start thinking and potentially the errors and another words how I think about this is essentially cognitive biases are our mental shortcuts. Our brain shuts off takes the path of least resistance doesn't do you know critical thinking things that were taught to do this in turn these shortcuts can increase the risk for errors. So it's kind of real quickly going through a couple biases that we're familiar about but I think it's going to be reminded about. That's confirmation biases you'll see this a lot of history taking if a patient's coming in with you know, painful eye with a bump that's kind of an oozing and read they've had this before. You're already thinking to lazy and so you kind of only ask history and gather history about what you possibly think could be going on and neglect evidence that contradicts that anchoring bias similar to confirmation bias which is kind of how we prioritize or interpret that information that affects our initial impressions and even when data or impressions are wrong, we kind of still anchor on those history points that may support our initial diagnosis effect her a stick bias. This is where we rely on our emotions or past experiences with patients or certain types of patients that may alter our judgment decision making instead of objective data. And lastly overconfidence bias and I think all of these kind of played a role in this case but this is something you know even I felt transitioning from a page by two to a page by three is I've seen this before similar presentation. I'm confident about this and when that happens that really limits our ability to dive deep into history taking consider other forms of treatment and even diagnostic work up. So overall, take away points is you know really this miscommunication highlighting this case here and most near misses and medical errors do result from miscommunication force be aware of the cognitive biases I only touched on four but those are the main ones. And lastly, I can't talk about a glaucoma case without, you know, bringing up you know the side effects contraindications drug drug interactions definitely remember these things slow down remember to be a doctor. And lastly, I know Dr Rasko is listening somewhere so it's one of touch base in the light trial and then the new data that we have out there to kind of show that SLT is just as you know effective as drops in certain cases and it doesn't have the side effects that jobs do. Thank you everyone who was involved in this case, all the attendees took care of the space as well. Here are my references any questions. Hey, can you guys hear me I'm trying driving to redwood sorry. Okay, so, yeah, thank you so much Brandon for presenting this case, I think that, you know, when we're, you know, when you're a medicine intern and they're telling you that you are responding to a code your first they say first check your pulse. I think in our setting in our on call in clinic setting my personal motto is now check your denial. Yeah, I had a similar kind of presentation of a case. This patient came to me in my chief clinic I had never seen her before but she seemed very, very out of breath, speaking in short sentences and just kind of pale. But her family was with her and said she had been like this for a couple weeks so it wasn't really sure she was there for you know VZB keratitis I kind of continued with my exam but she progressively got more drowsy. So I also just wanted to remind everyone the rapid response line for teams to come over from the university to our clinic is 1222. And not everybody is familiar with that and it didn't also didn't always use used to be the case that a rapid response team would come, but she actually did collapse in my chair. We called rapid response and she went to the emergency department and she actually ended up having a saddle embolus pulmonary embolus without any known vascular risk factors. I think the first sign in this case is taking two hours to try to get a drowsy patient up to the clinic or just having them arrive in an ambulance. I think that you know we are seeing a lot of patients by ourselves as residents and that's definitely a safety issue but a lot of these patients even with acute angle closure as you know I send to the ED or even anybody who has any sort of medical illness. I'm sending them directly to the ED just because they can't have other needs, but again thanks for highlighting, you know, all the things that fell through and you did an amazing job kind of identifying your own and a lot of other people's, you know, reactions and biases. Thanks, Dr. I'll just chime in too so I am listening Brandon. This is a really, really nice presentation and I know we discussed this a little bit at the Journal Club with Theresa and the team and Cole and Sean. Actually, yeah, and you and Sean did a great job with this and it is something we talk about as the VA, because we do see sick patients but I just want to remind everyone to I've had very healthy individuals. One drop, you know, start on Timalol and end up going into bradycardia and we were talking about this on Monday. So even when you take histories from patients, you may not have all the information and some of these drops do uncover other systemic comorbidities that even the patients don't know. And it is gut-wrenching and I think one thing you can all do better is telling our patients to bring their drops with them when they go to see their medical doctors, you know, so often we we tend to work in a vacuum. So thank you. Thank you for sharing this case and really doing a deep dive into our. Thank you, Dr. Roscoe. Paul has a question. We can hear you Paul if you want to just. Yeah, I was going to say I remember this kid. I don't know. Was this the one where my son started a fire? I was going to mention that but I didn't know. Yeah, I think right when you called my son has started a kitchen fire so that's why I was kind of can you can you call you anyway I don't think I had the full history so I apologize for not like coming in right away. But I did want to and I think we talked about this afterward but just for the residents, you know, if someone shows up shows up in an ambulance do not take the patient into the room that is you feel bad because you feel like oh my punting this to something else or someone else or, you know, should I be able to handle this. But, again, going back to what Dr. petty was saying during Varix talk about, you know, you feel like you don't want to put anything on anyone else, especially early on in your training like you, you should not know attending should be taking a patient from an ambulance at the Moran, especially on the weekend when you buy yourself. I mean, if they if they drove themselves like that's one thing. You know, they got discharged from the urgent care and you set up a follow up that's fine. But even if, even if they were healthy if someone shows up in an ambulance. They need to go to the ER. We shouldn't be taking that and just for if this ever happens to residents even if they've been sitting there for two hours tell them, you know, go around the corner. I'll see the patient, but they need to go to the we just, we can't take that risk for the patients. Totally agree. Thanks. Great talk. Any other questions. And then we have one more speaker today. The last speaker is forced hammering. He is a P2I one medical, P2I one resident in the neurological service. And his fun fact is that he lived for one year in Mozambique. And he's going to talk about ocular manifestations of intracranial cavernous malformations. Okay, I appreciate the chance to be able to speak today. We always try to tie this into something neurosurgical and today I'll be speaking about ocular presentations of cavernous malformations. And it starts with a case of a 26 year old female who had no past medical history other than a recent viral illness for which she was febrile three weeks previous to her encounter with neuro ophthalmology. And she had 10 days of intermittent vertical dyplopia for which she was seeing neuro ophthalmology and it was interfering with her work. She was a data processor. Her vital signs were within normal limits and you can see her visual acuity there and her best corrected visual acuity right to the 2020 both eyes with pinhole. She had no recent travel, no smoking alcohol or other drug use. But on her exam, her extra extra ocular eye movements revealed a vertical gaze palsy, which actually improved with testing the vestibular ocular reflex. And she did have some subtle convergence movements when performing up gaze, but her lamp and fundus exams were within normal limits. And the differential diagnosis for someone with isolated vertical gaze palsy obviously brings up super nuclear etiologies such as a mass or demyelination. And we also considered less likely on the differential was mycena gravus or thyroid eye disease. And again, convergence spasm was thought to be less likely. It was not classic for this, but that was considered. So an MRI was performed, revealing this lesion here on axial T one on the left and a coronal T one imaging on the right. This is post contrast and this lesion was correlated with a finding on SWI sequencing. You can see at the very the midbrain there this lesion on SWI, which is classic for a cavernous malformation. And just to show some still images, these are two different slices on SWI imaging and revealing this cavernous malformation. And just to review some of the anatomy associated with this vertical gaze palsy and this finding on MRI, the some of the control centers for vertical gaze are located in the rostral interstitial nucleus of the medial longitudinal fasciculus and interstitial nucleus of Kahal and the posterior commissure. And looking at another section here showing the interaction between the between these centers and posterior commissure controlling the superior oblique in the in the motions of the superior and inferior rectus. Just to briefly briefly review the epidemiology of cavernous malformations, the prevalence in the overall population is 0.5%. And if a patient presents to the neurosurgery clinic with an intracranial vascular abnormality, they'll represent 5 to 15% of all vascular abnormalities that present to us. And the majority are supertentorial and they'll often present with seizures if they're in this location. But they're around 10 to 23% present in the posterior fossa. And the most common risk factors are a family history because they they run an autozoma dominant incomplete penetrance pattern with a variable expression. And 30 to 50% of these cavernous malformations are familial. The majority have CCM1 on chromosome 7Q. And they're also more common in the Hispanic population, especially the familial. And so the natural history of cavernous malformations, there's a 1 to 2% bleeding risk per year. And so patients who are very young have an overall higher cumulative risk of having a bleed. And that's when they most often present is having a sentinel event where they have a bleed and it becomes symptomatic. And the risk of rebleeding is much higher than that 1 to 2%. Some have quoted 8%. Some have quoted up to 30% higher risk of bleeding after there's one event. And the risk of bleeding may be higher in brain stem relations. However, this could be simply due to the fact that they are more likely to be symptomatic if they do bleed. And they may be trauma induced. Obviously patients with these lesions should be counseled to avoid head trauma. And they may develop in the brain or spine after radiation. 40% are associated with venous abnormalities, which when they're surgically resected should be left alone. And they most often present in the third to fifth decades. And then common presentations, they're most often asymptomatic until a bleeding event and they will cause seizures most often. But obviously in the brain stem, they often present with Diplopia, for which neuro-ophthalmology is often consulted in their senior clinic by the neuro-ophthalmology team. And so just a quick literature review. This is a neuro-ophthalmology paper, which went over nine patients who had posterior phosin, brain stem, cavernous malformations, most often presenting with double vision, secondary to INO, third, sixth, and fourth cranial nerve policies. And some of them underwent surgery. And overall, most of the Diplopia resolved in its own. And when they did not resolve at 12 months follow-up, they were offered lenses or surgery, we're pretty mentioned. And the natural history of brain stem and cavernous malformations again shows that there's around a 1 to 2% per year risk of bleeding. And having a mass that's greater in size is obviously associated with greater risk of bleeding. And again, another paper looking at 690 patients found that the prospective risk of hemorrhage was at 7%. This is patients who often presented to this group having blood. And so the risk of hemorrhage was higher and it decreased after the first year. And obviously, if they present with worse findings, a greater size on presentation or across the midline, those were associated with higher risk of bleeding. So I just want to briefly cover the important part is how can we counsel these patients when we find them to have brain stem cavernous malformation. The risk of bleeding is again 1 to 2% each year. And the bleeds are often symptomatic, but they may resolve on their own without intervention. They don't always need an intervention. But once they've had a bleeding event, the risk of reblead is higher. And so they should be followed more closely. And they likely need a neurosurgical consult because management can often go in two different directions depending on how often or how many lesions there are where the lesion is located and if they've bled. And monitoring will likely consist of MRIs either guided by the neurosurgical or the neurology team every three to six or 12 months. And several studies have shown that anti-platelet or anti-coagulation therapy has been shown to diminish bleeding risk. And this is mostly in prospective and retrospective studies that have looked at patients who were already on anti-platelets or needed anti-platelet or anti-coagulation therapies. And they had a lower risk of bleeding. And this is thought to be due to clotting in the center of the cavernous malformation causing venous stasis and the clots that form causing venous stasis and ultimately hemorrhage. And then patients should be counseled to get genetic testing in case this is one of those autosomal dominant patterns of inheritance. And then intervention for high risk lesions. They can undergo surgery, radio surgery, or just anti-seizure medication. And obviously there's a high rate of post-operative deficits if it's resected in the brainstem up to 50%. But this is center dependent. If you have a very confident surgeon who's done procedures like this before, the rate of post-operative deficits is actually much lower and can be in a safe range. And then SRS can reduce their bleeding risk. But this is after a two year latency period where the risk remains the same. And then for ophthalmology, once the lesion is treated or decided to be managed conservatively, rective lenses, conservative therapy, or extra business surgery is often offered. And here's just a recent case that we did where the patient had a brainstem cavernous malformation bleed. And we opened up the cerebellum and resect, or I guess retracted the lobes of the cerebellum and found this lesion there. This raspberry-looking lesion is the cavernous malformation. And one of the reasons why we went after this is because it was so close to the surface of the brainstem through the fourth ventricle that we could safely remove it. And it had bled at least. And this is after the resection. So this patient, the 26-year-old that presented to us with a vertical gaze palsy, represented after two months and her symptoms had resolved without intervention. And she's planning to follow with imaging and with neurosurgery in both neuroanthermology and neurosurgery clinics. And in conclusion, these lesions are rare, but they potentially have a high risk of bleeding, especially in the brainstem. And they typically are symptomatic if they do bleed. And neurosurgery consultation is obviously recommended. And then 12-month neuroanthermology follow-up is important to decide what symptoms, if any, are persistent. If there's any persistent ophthalmoplesia, what intervention should be offered.