Search for tag: "specialty"

Interviewer: Coming up next on The Scope, learn more about a specialized clinic that treats just diseases of the aorta. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Jason Glotzbach is a cardiothoracic surgeon, and Dr. Claire Griffin is a vascular surgeon, both at University of Utah Health, and they're both part of the Aortic Disease Program at University of Utah Health. And today I want to get a better understanding about that specialized clinic, why somebody might be referred there, and the advantage for the patient versus other options.

So, first of all, why is it necessary to have a clinic dedicated to the treatment of aortic disease?

Dr. Griffin: So the aorta is one of the major blood vessels in the body, and any pathology associated with it can be very complex, and it's often not something that regular doctors have a lot of familiarity with. So our training gives us the opportunity to understand not just focused pathology in one particular area, but the whole aorta. And working together means that patients can come to one place and have a variety of opinions that really helps get the full scope of treatment options, natural history of the diseases associated with their aorta, and the full gamut of specialists to help take care of everything in one place.

Interviewer: So what I'm getting is it's a pretty complicated part of your anatomy and you need some pretty specialized people to take care of it?

Dr. Griffin: Yes.

Interviewer: Let's go back to anatomy class, Dr. Glotzbach. Where is the aorta? I know it's somewhere near the heart and it carries blood, but beyond that I don't remember much.

Dr. Glotzbach: Absolutely. That's a good place to start. The aorta is the largest artery in the body. It starts at the heart. So the aorta is the first stop of blood. As it leaves the heart, it goes into the aorta, and then from there it goes up and around the aorta and, through all of its branches, goes to every part of the body.

So the aorta is literally the kind of main superhighway for blood as it travels through our body. And so given that, obviously diseases of the aorta are very critical to the entire body, and so we have arteries in the chest, the abdomen, the legs, all that feeds off of the aorta.

Interviewer: Dr. Griffin, you'd mentioned that it takes, you know, a specialist to kind of understand this. In your general four years of med school, how much of this part of the body is really covered?

Dr. Griffin: So the understanding of most medical students coming out of medical school is probably exactly what Dr. Glotzbach just highlighted. It's the superhighway for blood, it's what takes blood everywhere else, but the understanding of the diseases that are in the aorta and how to treat them, and the thought process behind the approach to them is all something that is specialty training.

Interviewer: And what's the advantage for the patient to come all the way to University of Utah Health, I mean, other than the experience part which, I guess, is a pretty big advantage, right?

Dr. Glotzbach: Oh, we like to think so. I think we like to look at the patient as a kind of individual and tailor the treatment to each individual patient's needs, and I think that that's one of the things that we can do well here, is that we have specialists from multiple different disciplines so that we can think about the disease process in many different angles or from many different perspectives.

Interviewer: When you say "from the patient's needs," what does that mean exactly?

Dr. Glotzbach: Because the aorta is such a complex organ and aortic diseases are very complex in that they are very unique to each person, so one person's disease may not be the same as another person's disease, which is a little bit different than other problems that we focus on. So it's really important to take each patient as an individual and look at exactly what kind of treatment they need, and then hopefully we can provide that in a very targeted, individualized way.

Dr. Griffin: We just have very different thoughts when we approach the aorta. The training that I received, I spend a lot of time thinking about complex endovascular or minimally invasive ways to treat the aorta and its branches. And the approach that Dr. Glotzbach might have from a CT surgery perspective comes more from a major open perspective, and having the two of us working together means that we really constantly open each other's eyes about different ways to approach the same problem.

Interviewer: Yeah, you might be able to do something a little less invasively, perhaps?

Dr. Griffin: Exactly.

Interviewer: Or you might be able to talk to each other and go, "Well, actually we do have to be a little bit more invasive in order for it to be successful?"

Dr. Griffin: And talking about those cases together and making sure that there's open collaboration means that there's never a time that Dr. Glotzbach doesn't weigh in on something or I don't weigh in on something, and so we really get the benefit of both training backgrounds for every patient.

Interviewer: Two heads are better than one.

Dr. Glotzbach: Absolutely.

Interviewer: And you have even more than just the two of you on the interdisciplinary team. Who are some of the other members, and how do they contribute?

Dr. Glotzbach: We have basically the entire division of cardiothoracic surgery and vascular surgery are both committed to making this collaborative effort work. So my division chief, Dr. Craig Selzman is very committed to this, and so he's involved in all these collaborative discussions, and all of my partners on the cardiac surgery side have weighed in on all of these cases and, you know, individual cases and also as programmatically as a whole.

Dr. Griffin: Similarly, from the vascular division we have Dr. Larry Kraiss who's our division chief, and then the remaining members of the vascular division all are involved in the collaborative discussion of patient care. And because of other collaborations between our two divisions, as well as the Cardiovascular Center as a whole with cardiology and intervention radiology, there really is a lot of expertise at the University of Utah for this kind of disease pathology.

Interviewer: That's pretty cool. How old is this clinic? It's fairly new, isn't it?

Dr. Glotzbach: You know, we've had this expertise in kind of individualized divisions and aspects of care for years, but the collective pursuit of this as a multidisciplinary thing is really within the last year, we've been trying to build this up. And we've had a lot of buy-in from the leadership of the hospital in the cardiovascular service line, and so we're starting to really get some momentum with this.

Interviewer: One call, and you don't have to look around for all the experts, you're still in one spot.

Dr. Glotzbach: That's the goal. We're really trying to streamline things for the patient and for referring physicians who want to send people here for us to help out with. I think that it can be very complex to navigate a system like University of Utah, these large academic medical centers, and so our goal is to make it kind of a one-stop shop for the patient to come in, and we bring whatever expertise we need for the individual patient. We bring that to the table.

Interviewer: How do patients generally end up in the clinic? I don't imagine that's their first stop.

Dr. Griffin: That's a great question. There are a couple of different ways to find our program, and it really has to do with the kind of problem the patient has. So some of the aortic diseases are picked up by primary care doctors with routine screening evaluations or as incidental findings on CT scans that patients have for other purposes, and those patients really come through the referral process. There's a whole other section of diseases that affect the aorta that are really emergencies or acute findings that take patients to the emergency department, and they would come to us through emergency transport.

Interviewer: Let's talk about the referrals. If there is a patient that has been diagnosed with some sort of aortic issue and the physician doesn't know about the clinic or doesn't make a referral, is there a way a patient could find their way to you in that instance?

Dr. Glotzbach: Absolutely. We have a kind of dedicated administrative pathway where we have one phone number that we can . . . you know, both patients, or physicians, or doctors' offices could call and get an appointment with us. And it doesn't matter whether they end up needing a cardiovascular or cardiac surgeon, vascular surgeon, or both of us, you know. We can streamline that process, and our goal is to have it. So as soon as we hear about a patient, we will get them into our system and get them plugged in with the appropriate providers that can help them with their specific problem.

Dr. Griffin: One of the things that is helpful about our system, and having as much expertise as we do, is that a lot of times people can have really rare disorders of the aorta or its branches, and their primary care doctor or maybe the physician taking care of them doesn't see it enough to feel comfortable managing it, and that's one of the benefits of having such a collaborative effort that it's not rare to us. We're familiar with it, we're comfortable with it, and we're happy to help take care of it.

And in addition, I think that one of the things that's unique about our effort right now is that it's very collaborative, and so we're not competing with each other to take care of these patients. We're working together, and I think that creates an environment not just for the physicians and the patients, but also for all the support staff that really can be focused on patient care and patient outcomes instead of trying to be competing with each other.

Interviewer: And make sure that the patient gets exactly what the patient needs to get back to their life, however it may have been before they ran into the problem?

Dr. Griffin: Exactly.

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Interviewer: Considering a career as a nurse and you want to know what the job's like, the day to day, like a virtual job shadowing experience? Well, we've got that for you next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: The best way to find out what a job is like is to actually find out from somebody that's actually doing the job. If you're wondering what it's like to be a nurse, Matthew Anderson is a nurse at University of Utah Health Care. Thank you for taking the time to explain your "typical day." I put that in air parentheticals because I imagine there's no real typical day, or is there, in nursing?

Matthew: No. Every day is unique.

Interviewer: All right. How long have you been in nursing, first of all? Let's start with a little background.

Matthew: I graduated in 2013 so it's been about two and a half years.

Interviewer: All right. Are you in a particular specialty?

Matthew: I'm in the resource ICU pool so I float to all of the ICUs in the University of Utah system, as well as the ER and the cath lab.

Interviewer: Okay. At the beginning of your day, you don't know where you're going to go?

Matthew: No. Well, the cath lab, I'm PRN there so I know if I'm going there. I'll be pre-assigned to units sometimes. I call in every morning at 5:00 a.m. to find out where I'm going. I could plan on going to surgical ICU. I call in and, "Oh, you're going to burn," or, "You're going to the ER." It varies every day.

Interviewer: All right. Give me a brief description of your job, then. What are you ultimately responsible for in your role?

Matthew: As an ICU nurse, I generally have one to two patients that I'm assigned to. It depends on the acuity of the patient. I'm responsible for executing the orders for the day, taking care of the patient. If they transport anywhere, going with them there. Ultimately, I'm responsible for that patient, making sure protocols are followed, medications are given on time, procedures are done appropriately, etc.

Interviewer: Because these patients have more needs, is that why you only have two patients each day?

Matthew: Yeah. They're generally . . . intensive care units are generally very sick. I can have two patients that are both on a ventilator. If I just have one patient, it's generally because they're on continuous dialysis or something like that, that requires a higher acuity. They might be on multiple medications to control their blood pressure so I'm titrating those medications and stuff. It just depends.

Interviewer: And those two patients would keep you pretty busy during the day.

Matthew: Oh, yeah.

Interviewer: Okay, all right. What are some of the other things that you might do during a typical day in your role?

Matthew: I generally wake up at 5:00 a.m. I call in to the staffing coordinators to find out where I'm going. I call in and find I'm going to surgical ICU. Then, I get ready. In ICUs, we have a safety briefing. We meet in a room together. We kind of talk about the patients. The charge nurse [inaudible 00:02:38] all the patients. Then, we get our assignments and we go and get a report from the off-going nurse. Then, the day starts.

The morning on a day . . . I work pretty much all day shifts. Day shift, the busiest time is the morning. That's when you're doing your first assessments. You're really getting the baseline of the patient because you haven't met them before then. Sometimes, since I float around, I don't really have a lot of continuity of care. If you work on a unit, you might have cared for the patient multiple times before. For me, it's generally getting . . . this is my first time seeing the patient. Then, I'm giving meds. Then, just kind of the day goes from there. If they have to travel to the MRI scanner, CT scanner, X-ray. If they're intubated, that's a whole production. You've got to get the respiratory therapist involved. You've got to get transport there. That can set your whole day back just on transport.

Interviewer: You coordinate all of that.

Matthew: Yeah absolutely. The [HUC] kind of helps with that. Then, bathing the patient. Doing any sort of procedures for the patients. Depending on the ICU, you have multiple assessments throughout the day that you're doing. You're documenting vital signs. You're checking their intake and output. You round with the doctors and kind of go over the plan. If they write new orders, you have to implement those orders. There's kind of one thing after the other.

Sometimes you have a little down time. It just depends on the day and how sick your patients are and everything like that. Yeah, it can be busy nonstop because of admits, discharges, travels. Even just the regular care of bathing your patient, medications and stuff usually takes up most of your time. Most days are pretty busy. Keep you on your feet.

Interviewer: Yeah that sounds really busy. You mentioned you get to collaborate with some of the physicians. Who do you get to collaborate with and how rich is that collaboration?

Matthew: We do multi-disciplinary rounds. Some units have more people involved than others. For example, on the burn unit, they have a conference room they sit in. You have your dietitian there. You have your physicians there. Your attending physician since we're a teaching hospital, you have your attending physician. You have your residents. They have a nurse practitioner there as well. You have your social worker. You have your charge nurse. You just kind of go through everything.

In most units now, they're actually doing nurse-directed rounds because a lot of times it seemed like before the resident would present the patient and then you'd be like, "Actually, this isn't right. Oh, this is different now." You'd have to update about half what they said. Now the resident will generally do the history and kind of introduce the patient and then the nurse will present all of the systems and what the patient's actually doing because that's the most recent u-to-date report of the patient. It kind of [inaudible 00:05:07] things.

Then, you can also, just right then and there, say, "This is what I need." You list off your few things that you see that you need and recommendations that they order. Yeah, it's really good. We're really a team and they ask for my input, what I think is going on with the patient. It's really kind of a collaborative thing. You have your dietitian and your pharmacist. It's just a really awesome interdisciplinary team there that can make the best decisions for the patient.

Interviewer: Yeah, it sounds like you're not just taking orders. You're actually very actively involved in caring for the patient.

Matthew: Yeah, absolutely.

Interviewer: Yeah, that's awesome. What makes your work environment different here at University of Utah Health Care compared to maybe if you were someplace else? Do you have any idea of that?

Matthew: The staffing here is great. I know some places, they can kind of try and cut corners and save money with maybe not having as many HCAs or something. I feel like we have really appropriate staffing. The RN to patient ratio is generally very good as well as the HCA to patient ratio is generally very good. You have help when you need it. Sometimes, actually, we joke, especially in the emergency department, that sometimes you have too much help. You have a trauma I that comes in and you just there really only should be five or six people involved directly with that care. You have everybody and their dog wants to come watch. You say, "Everybody that's not involved in the care, step across that line and let us do our job. You can watch, but get back over there." Sometimes you have too many people around.

The teaching environment is definitely different. When we have new residents that come around in July, you really have to tell them what to do because sometimes they're like little . . . some are really good and some are like little, lost puppies. You're like, "You should order this and this and this." And they say, "Okay. Yes, sir."

Interviewer: You're kind of in charge in that situation of the teaching of the new doctors.

Matthew: Yeah, absolutely. The attending physician ultimately is, but the nurses keep them in line, for sure. I actually had a friend who was doing his ICU rotation as a resident. He says the nurses determine the outcomes. It's not the doctors. That was in his . . . Obviously, it's a collaborative thing. Especially with those newer doctors, the nurses need to know their stuff and keep them on task for sure and keep them orientated. If something's not right, you say, "Nope, I'm going to talk to the attending physician. That's not right."

Interviewer: Yeah. What is your favorite thing about your job?

Matthew: The patients, absolutely. That's the reason I'm here is to work with patients. I've had pulls to go into management, but I want to stay at the bedside. I want to stay clinical and work directly one-on-one. Behind every door, there's a story. It's amazing, kind of what you can learn from each individual patient. At the beginning of the shift, I've never met this person before, but within a few hours, I can be holding their hand and crying with them, especially if it's near the end of life or just kind of just listening to the spouse maybe if the patient's not responsive and just kind of talking to them and just really being compassionate, talking to them. That doesn't happen every day, but every day, I get to work one-on-one with that patient and have direct contact with them and hopefully alleviate their suffering. Sometimes, I have to do painful things. Really, just being there to try and be the best nurse that I can to help them heal the best way that they can.

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Interviewer: You think you or maybe your kids have pinkeye. How will you know for sure and what should you do about it? We'll talk about that next on The Scope.

Announcer: This is From the Front Lines with emergency room Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. Pinkeye. Let's talk about how you would diagnose a case of pinkeye and then what you would do about it because I hear it could be kind of difficult to diagnose like a school nurse, for example, might not be able to tell the difference from allergies or not. Is that the case?

Dr. Madsen: That is the case. And that's always what I'm thinking in my mind. So the most common thing we have is someone comes in and they say, "My eye hurts" or "My eyes hurt". I look at their eyes, they're red. So a couple of questions I ask and I say, "First of all, did this start in both eyes or did it start in one eye and spread to the other?"

If it starts in one eye, that's more likely what we would call pinkeye. And pinkeye is a bacterial infection often. Sometimes it's a viral infection but it's really tough to tease out which are bacterial and which are viral. Of course the ones we worry more about are the bacterial infections because we're going to treat those with antibiotic drops, but you figure it's not going to necessarily start in both eyes at the same time. It kind of start somewhere. It's going to start in one eye and then maybe you're rubbing that eye and then it spreads over to the other eye. So typically with pinkeye, that's the case.

Interviewer: Okay, so one eye hurts before the other generally.

Dr. Madsen: Exactly.

Interviewer: Red like bloodshot red, what's that red look like?

Dr. Madsen: So the red . . . Yes, that's tough to distinguish from allergies.

Interviewer: There's nothing really unique about it, huh?

Dr. Madsen: Not particularly. It can look a lot like allergies where just if you've ever had like allergies, just seasonal allergies, your eyes are bloodshot, they hurt, they itch, pinkeye looks very similar. With pinkeye though, we often see more discharge or more drainage from the eye. This kind of stuff that's not so much, just your eyes watering, which you have with allergies, but stuff that's kind of a little more whitish in color that looks more like you would imagine an infection looks.

So someone who says they wake up and my eyes are like matted shut. Again, allergies, we can sometimes see that but it's usually more with pinkeye. They have to pry their eye open or their kids' eye or they use like a washcloth and hold it on there to kind of loosen that up and pry it open. That's pretty typically with pinkeye and that helps me out to make that diagnosis.

Interviewer: All right. So then what does treatment look like? You said if it's a bacterial cause, then you would use antibiotic drops. It's hard to tell though, so you just . . .

Dr. Madsen: It is.

Interviewer: You just use antibiotic drops across the board or . . .?

Dr. Madsen: Typically yes, and you don't want to over-treat with antibiotics, but in practical terms, if I were to try and get a culture of the eye, send that to the lab, it takes couple days to get the result. It's not really that useful. So even though it might be viral, it's often bacterial so we treat with antibiotic drops. It means using drops several times a day or often for a week just make sure this clears up. Most people are going to have improvement in their symptoms after two or three days.

Interviewer: What if it's viral though and you're using the drops, they're not doing anything, will it just get better on it's own or . . .?

Dr. Madsen: It will.

Interviewer: Really?

Dr. Madsen: It will. Yes, with the viral it will just get better on its own and the antibiotic drops probably aren't going to do a whole lot for it but, again, it's hard to say because maybe after two or three days, you're feeling better and it could be that the virus got better on its own or maybe the drops treated the bacteria. But it's not the sort of thing, again, where a culture would be that helpful because it's going to take two or three days to get the results back. If it's bacterial, it could get significantly worse and really progressing, cause some issues wherein you can get infections around the eye or extending behind the eye as well.

Interviewer: And untreated, could it cause long term problems if you didn't go into anything about it or would it eventually just clear up regardless?

Dr. Madsen: It could clear up but the concern with the bacterial infections would be something that progresses, again, to where it spreads around the eye.

Interviewer: Infects the rest of, yes, other parts of your eye.

Dr. Madsen: Exactly. And so that's why even though in my mind I say, "Okay, this could be a viral infection," I'm also saying, "I want to treat this as likely a bacterial infection because the possibilities with the bacterial infection could be pretty significant." And I don't necessarily want to tell this person, "Wait two or three days and then come back when you have a significant infection around your eye that might require even something like IV antibiotics or hospital admission," if it got to that point and got that serious.

Interviewer: And don't need to go to an emergency room for this sort of thing. Urgent Care or a primary care provider probably would be able to take care of it.

Dr. Madsen: Absolutely.

Interviewer: And you could . . . even if you have to wait a day?

Dr. Madsen: Yes. Even if you had to wait a day, you're probably okay. I think the challenge for most parents is if their kid gets pinkeye, they're not going to let the kid come to school because it is highly contagious. You've got to make sure you're washing your hands, your kid's washing their hands. Kids get this at school, they pass it to other kids. So a parent's probably not going to want to wait a day to get in to see their primary care doctor. They'll go to an Urgent Care. If you have to come to the ER, you come to the ER. Either way, I'm guessing most parents want to get that treated and get their kid back to school and get them out of the house as soon as they can.

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updated: October 2, 2018
originally published: August 19, 2016

Dr. Troy Madsen: I'm Dr. Troy Madsen, emergency physician at the University of Utah hospital, today how the ER works.

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Dr. Troy Madsen: So one of the questions I get asked a lot as an ER doctor, is how does and ER work? Well the biggest thing to keep in mind, is when you go in the ER, number one, you're seeing an emergency physician. So we're the doctors that work in the ER, that's what we do on a day-to-day basis. We work there, we treat patients, and if anyone would ask what is our specialty, it's treating emergent conditions. So I know a little bit about a lot of things, and in another sense, I don't know a lot about a few things. So it's kind of a trade-off, but that's who you're seeing. So I'll come in the room, I'll see you as an emergency physician, and then we'll go through, what are you here for? Are you having abdominal pain, chest pain, have you been injured? And then kind of sort through it from there. And once we get some test results back, if we find something that's concerning, that's when we get specialists involved.
So in a sense, you know we do kind of triage things, you hear about triage nurses, who kind of distill things down or sort through things, and decide what's really serious and what's not. That's kind of what were doing as ER doctors is sorting through, okay what you have wrong, who we need to get involved? If you come in with the abdominal pain, and we do a CT scan and you have appendicitis, I'll call the surgeon once we get the results back. Now let's say you have an arm that's injured or it looks like it's broken, we'll get the x-rays, once we know it's broken we'll call the orthopedic surgeons. So in that sense, you're coming in the ER, you're seeing us, then we're bringing the other people down to get you the help you need. There are a lot of other people you see on the way there, we have nurses that will see you, sometimes you'll see a triage nurse at the front desk.

In our emergency department we actually have one of the doctors that sits out front, so we can see you more quickly, and try and get you treatment more quickly as well. But you may see EMTs, these are technicians in the ER who may start your IV, you may see radiology technicians, who are taking you to x-rays. So there's a lot of support staff their, but we're all kind of working toward that same goal, under the guidance of the emergency physician, try to figure out what's wrong, is it something we can treat in the ER and send you home, or is it something that we need to get someone else involved. So nurses are absolutely integral part of the emergency department. And I can tell you, having worked a lot of different places, what a huge difference great emergency department nurses make. And I can say in our emergency department they truly are the best nurses I've ever worked with, and we're really fortunate to have them.
The nurses are really responsible, they're kind of my eyes and ears in the ER. I may be taking care 15 different patients at once, I may be stuck in a trauma, I really rely on these nurses to come to me and say, hey this patient in bed ten, is really sick, we need you in there right now. The nurses are the ones that are at the bedside, who know what's going on with the patient, they're starting the IV, giving them medication, sending off the laboratory results, giving really the treatment these patients need, under my direction, and they really are the key to a successful emergency department.