 Hi everyone. Welcome to our webinar series here at advanced clinical training. I am going to wait no longer than three minutes just to make sure we give all of our attendees an opportunity to join. Again, if you are joining thank you so much as I said right in the beginning I'm going to wait no longer than three minutes I just want to make sure that we give all of our particular all of our attendees an opportunity to join us. I just want to make sure I'm turning the chat features on I just want to make sure that everybody can hear me well, and that you are able to respond in the chat to me so if you can respond in the chat please let me know. Awesome thanks so much. Chat is disabled. Okay, let's see. All right, so I'm working on enabling the chat here so just bear with me here. Yes, I'm working on getting the chat turned on just bear with me. All right, so we're just going to go ahead and get started and we I will figure out the chat as we go. But again I want to welcome you all to the webinar series here at advanced clinical training. I want to thank you for spending your evening here with us. We're so excited that you were here. And so, if you don't already know me my name is Lea Medwig and I am the lead course instructor here at advanced e clinical training. I have been a nurse for over 12 years and I started my career in cardiothoracic surgery and then I went on to work in a level one trauma and burn emergency department, and a very large metropolitan city. I then went on to become a complex and catastrophic nurse case manager for a large national health insurance company. I completed my master's degree and since teaching was always in my heart I love teaching and students and precepting new hires. Education was kind of a very natural, a very natural progression for me so that is how I ended up here at advanced e clinical training. Let's see. Let's see here so if you're not familiar with advanced e clinical training we are a fully online south paced allied health care certification program so we offer programs, certification programs for certified medical assisting certified patient care tech certified pharmacy clinic and you can go ahead and check out our website is advanced clinical learning.org. We are asynchronous you can complete these programs and as little as eight weeks and we're here to you know pre health students but also towards students who want to go on to medical school to go on to nursing school, who also want to go on to PA school pharmacy school and that really need those direct. Direct patient care experience so that's what we're here for and for any student for any of our attendees who aren't current students, we are offering you a discount code today for $200 off any of our enrollment into any one of our certification programs and again that. That discount code is webinar 200. All right, and one last thing we will also of course be issuing all of our attendees a one hour clinical shadowing certificates, and we will be sending that to your email the email that you use to sign up for this webinar so. As far as the webinar goes, I want to try to make this an interactive experience I realized that the chat somehow is not working and I thought I have worked out but we have a couple of polls that I am going to have you guys participate in an answer. And then we can also of course just communicate with in the question and answer. form here so I think that will be fine again we can communicate in this question and answer feature if it may be but. is, but there's no pressure here this is a learning experience for everybody. i'm so we're going to keep it as light and as professional and fun as we possibly can so. This case is case 956 and you're going to see a video of a real patient who presented to the emergency department, he was videotaped with his permission of course for educational purposes. So we all can learn together so that being said, I am going to go ahead and share my screen and we will get started i'm going to start with the video of the patient. And if for some reason that you all can't hear me or hear the video please let me know and question and answer feature all right, so are you all seeing my video awesome okay perfect. Love it okay so if you can hear it good evening how you doing let's start it over. All right good evening how you doing tonight. Doing okay thanks for taking the time to do this video and Dr more here at Yale. So tell me what was the reason you came in here tonight. Yeah, so it was where was the where's the pain hurting where was it. My body, my chest, my legs. So the chest was hurting in your legs. Was this typical of your usual sickle cell pain. Yes. Is it any worse or different. About the same. Okay, but you did have some chest pain. Yes. Have you been coughing at all. All right, so we so he comes into the emergency department this patient does he has kind of diffuse body pain he has shortness of breath he has some chest pain and some cough. And then we, and then he lets us know that he has a history of sickle cell disease so let's take a look at that. Okay, so sickle cell disease. Sickle cell disease is a group of inherited red blood cell disorders so what you can see here is on the right side you see this healthy red blood cell and it's nice and round it's kind of concave in the middle. And with patients that have sickle cell disease, this is what their red blood cells look like. So, red blood cells contain hemoglobin and that's a protein that carries oxygen to the rest of our body. So, healthy red blood cells again around and they move through the small blood vessels to carry oxygen to all parts of the body, but somebody that has sickle cell disease the hemoglobin is abnormal as we can see. And it causes the red blood cells to become hard and sticky and look like this C shaped. They call it a farm tool called a sickle so that's how it gets the sickle cell disease so when the patient that has sickle cell disease when they're red blood cells that are sickle like this, travel through the small bed blood vessels they get stuck and they can clog blood flow. And this can cause severe pain. And it can cause other serious complications such as infection acute chest syndrome and stroke. So, also, what's important about this is that the sickle cells, they die early. So, this causes a constant shortage of red blood cells. So, I'm going to. As you can see here on the left, this is a normal patient or a healthy patient that is healthy red blood cells. And this is their blood vessel and you can see how the blood blood blood blood, blood, red blood cells just move very smoothly and nicely through their blood vessels. Here on the right you can see a patient that has sickle cell. This is their blood vessel. You can see these blood, red blood cells that are sickle shaped and they get sticky and they, they clog together they don't move easily through the, through the blood vessel, and then they also died early. So, there's always a constant shortage of red blood cells for these patients. So, let's go back to the video. All right. So, we're going to continue with the video. Please, again, let me know if you can't hear it or see it by utilizing the question and answer feature. Paul? A little but not so much. Yeah. How about your breathing? Are you short of breath or anything like that? Yes. You are short of breath? Yes. How long has that been going on? For like two to three days. Okay. And any fevers at all? Yes. You have that fever? Yes. At home, did you measure it? Do you know how high it was? No, 102. 102? Not 100.2 but 102? 100. No, 102. 102. Okay. All right. Well, we got you here on a little oxygen. Is that helping at all? Yes. Okay. All right. We're going to do some tests and probably give you some medicines, but thank you so much for taking the time to talk to us. Okay. All right. So I am going to take this out of full screen mode because there are some items I'd like you all to see here. So let's take a look at his vital signs. He comes into the ER, vital signs. He has a temperature of 101.1. So we know that he has a fever. His heart rate is 111. We know that a normal resting heart rate for a healthy adult is between 60 and 100. So he's a little tachycardic. His respiratory rate, I don't really believe that it's 18. If somebody has a pulse oximetry of 81% on room air, they're probably like deep breathing, taking more respirations a minute than 18, but we'll have to take it as 18. The important thing is 81% on room air. We know that he's hypoxic and that's not normal. A normal pulse oximetry for a healthy adult is 92% to 100%. So they have met oxygen. Of course, blood pressure 127 over 76. So that's normal. And as you can see here in this graph, some of his vital signs, so they did see here in the ER, his pulse oximetry was low. So they put him on a nasal cannula for some oxygen, and that certainly was the right thing to do. So I am going to stop sharing my screen because this brings us to my first poll for everybody. All right. So what do you think? Okay, so what do you think is happening with this fusion? Go ahead and choose your answer for me. And I will wait here to see what everybody thinks is going on. All right, we have a still getting some answers here. It looks like acute chest syndrome is winning the race at this point. A few more waiting for a few more people to answer. Just going to wait just a few more seconds so we can continue to move on. All right, so I think we have everybody answer that's going to answer at this point. So I'm going to go ahead and end the poll, but it looks like acute chest syndrome has kind of won the race here. And here are the results that you all can see. So that was kind of a trick question because this patient, he could have all of those answers. Those are all very valid and viable reasons why he is in the emergency room and he is as sick as he is. He could have had an asthma attack. He could have COVID-19. He could have pneumonia. He could have COVID-19 pneumonia. So it's a little bit of a trick question, but again, all of those answers are valid and viable. So let me see here. So based on that, so we know what his vital signs are. We know what his symptoms are. What kind of work up are we going to do for this person? So go ahead and put it in the question and answer feature for me. I apologize that our chat feature is not working, but if you utilize the question and answer feature, you can go ahead and let me just put it in there. So what kind of work up are we going to do? So go ahead and put your answers in the question and answer feature. I apologize that our chat is not working. So let me see what we have going. Well, X-ray, of course, we're definitely going to do chest X-ray. For sure, chest X-ray. Yes, tested for COVID-19. Yes, chest X-ray. Definitely EKG as well, right? He's pachycardic. So we want to see what his heart rhythm is. Definitely for sure. Yes, basic metabolic panel, blood work. Definitely CDC. Yes, complete blood counts. Yes. So you guys are all on the right track for sure. Okay. So let's see. I'm going to share my screen again. I'm going to go ahead and close down this question and answer. It looks like we're all on the right page and we're all moving in the right direction. So that's awesome. I like the way you all are thinking. Yes, clean medications. Yes. Yes. So all right. So let's take a look here. I'm going to share my screen again. We are going to go down to the actual outcomes. Okay, here we are. So we can see they did blood work. So we were again thinking you guys were all moving in the right direction. Your thinking was very valid and clear. And we see with this blood work his white blood cell count is 23.5. So that's elevated. An elevated white blood cell count is an indication for some type of infection. We see that his red blood cell count, his hemoglobin and his hematocrit are all very low. And I guess we would expect this in a patient with sickle cell. Of course, we know that they don't, you know, their red blood cells die more quickly. They don't carry the hemoglobin protein the way they need to. So we would expect all of this. But again, you know, it's 7.3 a hemoglobin. A normal for a man is 13.2 to 16.6. So definitely, he's definitely very low. Also, I want to show you guys the chest X right this is his actual chest X right here. So this is the darker spaces or the lungs. And so if you can see very, very small, there's these little small white patches and those are called patchy infiltrates. So he has some patchy infiltrates as in his lungs and that's usually indicative of a pneumonia, beginning of pneumonia, which is an infection in the lungs. So you guys were all thinking in the right direction. So yes, pneumonia definitely has pneumonia. No, he has some definite anemia. His hemoglobin is low. All right, so let's take a look at what the different differential diagnosis is for this patient. So of course, sickle cell crisis, sickle cell pain, we know that, and then acute chest syndrome. So this is kind of a new one acute chest syndrome. It's not very common. But they did again in the emergency room, the lab evaluation blood work and the chest X, right, which we've already talked about. So this brings me to our second poll that so I'm going to stop sharing my screen. Let's see. So what do you think causes acute chest syndrome. What is causing his acute chest syndrome in this patient. Go ahead and answer here in this cool as my attack yet pneumonia. Plural pleural fusion pulmonary embolism asthma is all thinking appropriately. So we have almost everybody is answered 80% participants have answered I'm just going to wait a few more minutes guys go ahead and answer the second full question for me what causes acute chest syndrome. All right, so it looks like everybody is going to answer has so I'm going to end our poll here. And I'm going to share the results with you. Also pneumonia went out pulmonary embolism was very close plural fusion asthma attack. So let me. And that was a little bit of a trick question because several of those things could cause acute chest syndrome but acute chest syndrome is not a normal thing it's not something that we see in the emergency room all the time so I'm going to go back to the PowerPoint because I want to show share some information with you. So here, what is acute chest syndrome and sickle cell disease so acute chest syndrome is a complication of sickle cell disease. And it involves chest pain, cough fever, low oxygen levels, and abnormal substances accumulating in the left so these lung infiltrates and we did see that on the chest x ray that this patient did have this patchy white infiltrates in his lungs indicative of a beginning of pneumonia. And he definitely has the chest pain he has the coffee has the fever and he has the low oxygen levels so what's what's problematic about this is that this condition can progress quickly and it is also one of the most common causes of hospitalization and death and people with sickle cell disease. All right, so I'm going to stop sharing my screen I want to go back to our video to share some information there with you. All right, so let's take a look at the diagnosis. So, yes, so we, so we were right so we were all thinking in the right direction this is like a journey we're all taking the journey together and we're getting there so he was actually diagnosed with acute chest syndrome and at sickle cell crisis. I don't think that that is too far off from probably what we were all what we were what we were all thinking here so based on that I'm going to stop sharing my screen. Because I am going to put a question here for you all on the question and answer feature. So, how are. So how are we going to treat this patient huh. Knowing his vital signs knowing his lab work knowing his chest x ray and what his diagnosis is so what how are we going to treat him are we going to get him better. So go ahead and pop your answers and not a shouldn't answer feature. So, I think we need to get the fluids antibiotics of course antibiotics we definitely need that for the pneumonia that's for short ID fluids definitely. You know he's probably dehydrated that could be why he's tachycardic again. You know if you have a patient that is tachycardic they could be. They could be dehydrated so ID fluids, definitely antibiotics definitely. Now, so iron medication so I wouldn't say so much iron medication he's going to need something much more strong than that he's going to need a blood transfusion or probably a couple of blood transfusions to get that hemoglobin in his red blood cells up, but definitely supplemental oxygen for sure so we are all I like the way you think you're all. Moving in the right direction so. I'll be in a role, you know anything to help support his respiratory system, definitely. Right I like the way you guys think blood transfusion. Awesome, because I should do that out of the way of my face. All right. So I'm going to stop sharing. I'm going to share my PowerPoint with you because I wanted to I want to I want you all to see this image that I have, but you all are thinking awesome like you're all on the right track. Okay, so let's see here. So what is causing the chest and so we want to know what causes acute chest syndrome so bone marrow necrosis fat embolism infection. So these are the things that people that have sickle cell disease, this is some of the things that can cause their acute chest syndrome in our patient here. And most likely that this infection and so it seems like he probably had some type of viral respiratory infection that then developed into a pneumonia that then caused, you know, his acute chest syndrome. It could have been a bacterial pneumonia as well that we don't really know for sure most nine times out of 10 it's viral. But it's the one ammonia he's still going to be treated with IV antibiotics so that's what happened to our patient but here is a very interesting image so this is the death spiral of acute chest syndrome and sickle cell disease so you can see why this condition is so dangerous and for our patients that have sickle cell disease. So, you know, it could start our patient could start here, it could start here he could start here here. It looks like our patient probably started right here so he had a viral pneumonia or bacterial pneumonia. It started to cause some hypoxia. So hypoxia is low oxygen saturation in the blood. So you can see hypoxia further promotes red with the red blood cells to sickle. So, because he had the low oxygen levels, it's making his already condition worse by settling those red blood cells so he starts here then he goes up here. And so the sickling occurs in the lungs it's it's because that's what he has his sickle cell disease so that's already going to happen and it's a parent it's impairing his pulmonary micro micro vasculature. So then he moves over here. So now he has hypoxia he has this further sickling of the red blood cells and his pulmonary it might be vasculature. So his, his worsening pulmonary function so his lung function is worsening. Then he drops down here. So that because he is worsening pulmonary function, his desaturization of his systemic blood is getting worse. Makes sense right because that's happening and he goes back over here so it makes him more hypoxic. So he's in he's like almost stuck in this spiral of acute chest syndrome and sickle cell disease so it's a very serious condition that needs to be treated very quickly and aggressively. So I'm going to stop sharing I want to go back to our video and show you the actual outcomes for this patient. So yes he was treated with oxygen fluids early on a biotics blood transfusions nebulizers of uterine definitely admission to the hospital. For sure. And then let's take a look at some of the standards of care, because I want to show you all that you were thinking appropriately. They're in your medical minds. I love it that your suggests to work up of labs and imaging was awesome and correct and of course, we talked about to suggest the treatment of what he needed. Moving on to some of these key points so what we need to know is that this patient had a prior history of sickle cell disease. He also had a serious condition called asthma on top of that so this patient was already so predisposal predisposals to the acute chest syndrome being that he had sickle cell disease also has a history of asthma so he's already not breathing well. He presented with the pain that he stated was typical typical for sickle cell disease most most patients that have sickle cell have chronic pain. That's very common for them. But the issue was that he had the fever that he had the low oxygen saturation that he had his bronchorus breath sounds in his lungs. And he had those patchy infiltrates on his chest X right. So they immediately treated him with oxygen with fluids with broad spectrum antibiotics for pneumonia. Broad spectrum because at that point in the are they probably weren't very sure, you know, what bacteria was causing the pneumonia so you know that usually can take a couple of days to come back to see what you know they would probably ask the sputum culture to see what antibiotics are sensitive to whatever strain of bacteria that is so that's why in the beginning they treat with a broad broad spectrum antibiotic. And of course transuse blood for sure, for that low hemoglobin. And again as I said that accused chest syndrome is an emergency has a very high mortality rates. If it's not treated aggressively and very quickly. You can see some of these editors notes here. And he did this patient did look, you know, ill, of course. He did seem very short of breath. And so, I wanted to see. And so as we said they need to be, you know admitted to the hospital for pain control oxygen IV fluids, and, and until he is well enough to go home. Right. So that ends our. Stop sharing here. All right, so that ends. I see questions. There are lots of questions. All right, so this ends our, my presentation so now I want to start with the questions and answers, and I apologize if you are. Again that the chat feature is not working so I'm just going to type here and use utilize the question answer feature for any questions that you have about this. Again, I just want to thank you all for joining us. I really love these webinars that we're all doing here. I think they're fun and they're very informative for sure. So any questions about this case. So I see one here coming from Valerie so if given a blood transfusion. Does transfused blood cells become sickled as well. Yes, they do. Once they are in the body so. You know, something with that trait that it is with sickle cell that even though he's getting transfused healthy red blood cells once they're in his system that trait is going to sickle some of those red blood cells as well unfortunately. Okay, so let me see any other questions. Okay. Pull this over here. Could you show the x-ray for a quick second please. Yes, definitely. Let me just answer this one other question. How do you ensure you do not misdiagnosis the patient had co morbidities. That's a really good question. I think that's something that's always on, you know, a provider's mind nurse practitioner physicians assistant adopter and they're the ones that are making the diagnosis so you have to just rely on what the patient's what their underlying health conditions are and what what your clinical experience is so. Yes, he had asthma, but based on the fact that he has a history of sickle cell disease based on the fact that he had pneumonia that was confirmed by the chest x-ray. Then, you know, we know that he has some type of infection and that he's probably in this acute chest syndrome spiral. So let me just bring up this chest x-ray quickly. And so no, there is unfortunately no cure for sickle cell disease, unfortunately. Yes, a blood transfusion is the transfusion just to increase the oxygen. No, so the transfusion is also to increase the red blood cells that will also help with oxygen is like oxygen, getting oxygen to the different tissues in the body, but the blood transfusion is really just to help more with his red blood cell count to help with his energy levels that will help increase his energy level and it will help him get better, better overall so it's not just to increase oxygen levels. So let me just bear with me here a moment. I just want to pull off this chest x-ray because somebody wants to see it. It's an anonymous attendee. Hang on here just a moment. Try to move this out of the way. Let me go back up here. All right, so here is the chest x-ray. Let's see any other questions. Can you explain what is shown in the x-ray again? Okay, so here we have the lungs left side and the right side. And I'm sorry, this is the left and this is the right. I apologize for that. So what you can see here is the darker material like the darker spaces is healthy lung tissue. It's darker, but as you can see, starting in the darker black space, there's these small white patchy infiltrates and that is indicative of a beginning of a pneumonia. If that makes sense to you. So how different would the workup be if he was unaware that he had sickle cell disease? I mean, the workup probably wouldn't be much different. We're all, we know we're always going to do chest x-ray. Someone comes into the ER and they're like, I'm having chest pain. I have shortness of breath and they have a low oxygen level. Definitely going to do a chest x-ray. Definitely going to do blood work. So the workup wouldn't have been any different than if he had not had sickle cell disease. Is stem cell transplant also a possible cure? So there is no cure for sickle cell disease. So there again, there's no cure for sickle cell disease. A lot of these patients, you know, like I said, I have chronic pain. They're on chronic pain medications. They have to get frequent blood transfusions. And really just kind of support the treatment is really trying to just support their overall health. And so they most this, as you can see them, I didn't show you guys this, but he, this patient was on hydroxorrhea, which is a medication that patients that have sickle cell disease sometimes take. So, so there's medications involved with that as well. So how long does a person with sickle cell disease live? That's a good question. I know they definitely have a lower expectancy of life. Unfortunately, just because of all the complications that are involved with sickle cell disease, you know, you have this acute chest syndrome, you have, you know, multiple you're more susceptible to viral and bacterial infections you. I've had some patients of mine that had sickle cell disease that ended up, you know, losing a leg or losing an arm or, you know, having some amputations because of blood clotting. And so, you know, then there are, you know, they're in a wheelchair. And so there's, it kind of just takes a tumble. And so their, their health just continues to tumble. So, I don't know what the exact life expectancy is for patients with sickle cell disease but it's definitely lower than somebody who doesn't have it. Does the pneumonia make him more likely to be hospitalized in the future? Yes, absolutely. His sickle cell disease makes him more likely to be hospitalized in the future for sure. I don't know how does a person manage living with sickle cell disease. So, you know, it's just, again, trying to live as healthy and as clean as you possibly can. So no smoking, good nutritional support. Let me just take this off here. So we can see each other. Good nutritional support, you know, vaccines to keep you, you know, well, good hand hygiene. So you're really just trying to maintain your health and try to not get ill, basically. Well, you're welcome. Any other questions? So what age is sickle cell usually diagnosed? So sickle cell is usually usually diagnosed in children. So, you know, in so sense it's an inherited disease. So, if one parent is known to have or both parents are known to have it usually children, their children are then tested. So they are able to kind of get a jump and a handle on things before they start having symptoms. Yes, and sickle cell disease is hereditary for sure. Questions, let's see. Yes, so sickle cell disease is definitely something you are born with. It's hereditary. It is either, you know, you can get the gene from one parent or two parents. And so it's hereditary for sure. All right, so that looks like that's the end to our questions and answers. Again, I just want to thank you all for spending your evening here with us. I want to let you know if you, you know, are not already a current student here with advanced clinical training, we would love to have you. We are offering you a discount code for $200 off any one of our certification programs. And that discount code is webinar 2000. Let me just put it here. I'm sorry webinar 200. There it is. I'm going to just put it in there. There's your discount code. And again, it's $200 off any one of enrollment into any one of our certification programs. Let me see here. So the next webinar we're doing monthly webinars now. And I'm really excited about that I, I, we don't have the exact date set for our next webinar but it will be in November. And it will probably be one of our empty mentors or PA mentor that we also have at advanced clinical training as well presenting so we like to give everybody a little bit of variety so you can learn from all of us here and that's the best way to learn in my view so again webinar 200, go over to advanced clinical training and take a look at us and thank you so much for for joining. So like I said going to send out those one you get one hour of clinical shadowing experience certificate so that will be sent to the email that you use to sign up for this webinar within 24 hours to keep a lookout for that. Let me see there's some more questions. Yes, advanced clinical.org. So go over there and take a look at us. Take a look at our programs and, like I said there's the certified patient care tax certified medical assisting. We also have the certified pharmacy tech as well. Yes, we are recording this webinar and I will have to ask one of our directors, if there is access to this recording or not but thank you all so much for joining us, and I hope to see you all next month. All right. Goodbye everybody. Good night.