June 2020 Issue 1

CRACKIN’ THE CASECWRU PA Newsletter

Acute respiratory distress syndrome: An overview for physician assistants2

If we all take a moment and think back to the anatomy of the heart and lungs, we can remember that there are pulmonary arteries and capillaries delivering deoxygenated blood from the heart down to the millions of alveoli where gas exchange occurs. It is very important that this delicate alveolar-capillary barrier does not become disrupted or damaged, as it can impair vital gas exchange leading to “respiratory distress.”

In Acute Respiratory Distress Syndrome (ARDS), the damage that occurs to our alveolar-capillary barriers has an inflammatory etiology. When this occurs, fluid from the pulmonary capillaries begins to leak out into the alveolar sacs making it difficult for oxygen and carbon dioxide to diffuse across. In addition, the inflammation can directly damage our alveolar cells, leading to a decrease in production of surfactant and problems with lung inflation and deflation.(cont. pg. 2)

Effective patient education techniques for preventing unintended pregnancies3

Unexpected pregnancies account for almost half of all U.S. pregnancies and are mostly due to incorrect or no birth control use, also known as contraception. In order to effectively teach patients about preventing unintended pregnancies, clinicians should familiarize themselves with common misunderstandings, current recommendations, and specific patient education techniques.

For starters, providers should understand their patients’ perspectives (cont. pg . 2)

What’s Inside:● 3 research summaries● Q&A with PA student about ISCTL● Crack the case - Vomiting● June Awareness Month

What is Crackin’ the Case Newsletter?Crackin’ the Case is a CWRU newsletter created by physician assistant (PA) students and dedicated towards highlighting PA research relevant to current topics in the CWRU PA classroom. We hope to

promote evidence-based medicine, student research, and disease awareness.

Meet the Authors:

Aaron: Working for the Arizona Respiratory Center on Pediatric Asthma Trials as an undergraduate student opened my eyes to the rewarding aspects of clinical research, and allowed me to complete my honors senior thesis on exercise-induced asthma. I believe scientific research provides enormous benefits to the medical profession, paving the way for our ability to provide patients with the most up-to-date information. I really hope that this newsletter helps illuminate the incredible job PAs around the country are doing to contribute to medical research as well as helping to advance the profession. Nancy: Hello! My main healthcare experiences include being an Emergency Department scribe, dermatology medical assistant, and EMS volunteer. Having done research on traumatic brain injury in the past and taught as a teaching assistant in a Mammalian Physiology lab, I am excited to promote research in the PA profession with this newsletter in order to engage PA students and others in evidence-based medicine. Mea: Over the past two years I have been very active in research focusing specifically on Pediatric Neuro-ophthalmology. I have had the opportunity to present three of my projects at national conferences and my interest in research continues to expand. My goal is to continue to be an active member in the research community and raise awareness of the amazing role that PAs play in advancing medicine through research.

Effective patient education techniques for preventing unintended pregnancies3

(cont. pg. 1)...about pregnancy and discuss any medical myths with their patients. For example, the most common reason that sexually active women give for not using contraception is that they do not think that they could get pregnant.

Based on current recommendations, primary care clinicians should also initiate reproductive education in their patient discussions. In terms of timing, providers should discuss pregnancy risks and prevention with teens before having sex for the first time, which will reduce the likelihood of an unintended pregnancy. Other recommendations include HIV screenings for patients ages 15 to 18, first female reproductive visit between ages 13 and 15, etc.

One important aspect of the patient interview is the sexual history. Developing a standard introduction may help providers ease into the conversation with their patients. Providers can also ensure confidentiality in order to gain patient confidence. In regards to contraceptive methods, the goal is to guide the patient toward the most effective method that is appropriate for that patient.

By keeping these recommendations into consideration, both providers and students will better understand patients’ needs and given effective patient education.

Acute respiratory distress syndrome: An overview for physician assistants2

(cont. from pg. 1) ...So, already this is painting a pretty awful scenario! No one wants to imagine being in a condition like this, where they could become hypoxic, short of breath, cyanotic, tachycardic, and even require the assistance of a ventilator to open up their lungs. The quicker you treat ARDS, the better the prognosis and lower the mortality. As patients get better, radiographic imaging of the lungs should show a decrease in pulmonary infiltrates and oxygen saturation should rebound to more normal levels.

Amidst the COVID-19 pandemic, ARDS is getting enormous publicity due to its unfortunate prevalence in high-risk patients suffering from coronavirus infection. There is a lot of fascinating research surrounding its treatment, such as recruitment maneuvers and prone positioning, that we encourage you to learn about if interested. ARDS altogether is a complicated disease, and learning more about the anatomy and physiology of the lungs will allow us to begin comprehending this serious condition that we very well may encounter in our clinical rotations.

Image 2 - Phases of ARDS2

What was your experience getting involved in research before PA school and how did that help lead you into choosing a career as a PA?

I initially had an interest in pursuing a career in industrial research early on in my undergraduate education. I was an undergraduate researcher at Purdue studying the molecular mechanisms that lead to pancreatic cancer. Post-undergrad, I was a technician in the regulatory department at Dow AgroSciences. However, I realized that the industrial world was not a good fit. I gradually grew an interest in medicine and patient care, and also missed the academic side of research. While applying for PA school, I worked at the University of Chicago and our lab focused on the immunology involved in sepsis.

What is your knowledge of PAs being involved in research and how has that changed throughout school?

I initially thought PAs being involved in research was a rare occurrence. However, being a student at Case exposes us to many academic institutions where PAs are critical members of clinical trials and medical education research, both of which I have an interest in.

Briefly describe your research experiences during PA school (i.e. iSCTL, Capstone, etc.) and how you feel they will impact your career as a PA?

My iSCTL project focused on developing an online module exposing healthcare students to opioid use disorder, the screening tools and clinical skills used for detection. Students then went through a video recorded patient encounter (using patient actors), and were quizzed on the skills they had

learned. My group’s Capstone project developed ways to use the EMR to help providers identify patients with obesity and monitor treatment plans to help patients manage their weight. Unfortunately, this could not be implemented because of the Covid-19 pandemic, but we hope that this will be trialed in the future.

Is there a favorite topic or field of medicine that interests you the most that you would like to contribute to from a research perspective?

I have an interest in the field of immunology and we can better understand it to develop new treatments. I also have an interest in medical education and future ambitions to become a faculty member or clinical educator for a PA program. The skills I developed in the iSCTL program could help me innovate PA education with the use of technology and innovation.

How do you believe PA advocacy in medical research can benefit the profession?

PA school opened my eyes to the various research opportunities, but a lot of members of the research community are unaware of this, and are only aware of physician scientists in terms of practitioners being involved in research. Advocacy increases our exposure and lets the research community know that a lot of PAs have research experience that can make them a critical part of a research project. Also, I think it could increase awareness that could help PAs earn funding to pursue their own research interests.

Q&A with PA Student

This Q&A features Tyler Louviere, PA Class of 2020, and focuses on his experience with research and current projects.

June 2020 Issue 1

June 2020 Issue 1

Crack the Case - VomitingA 21 year-old male comes into your medical clinic for non-bloody, non-bilious vomiting that started today. Patient states he has vomited 3 or 4 times since this morning and has been having persistent abdominal pain and intense feelings of nausea for the past 3 days. The patient ate Chipotle for lunch with spicy red sauce. He states that he has eaten Chipotle before without any problems. He also claims to have no food allergies, but does have mild lactose intolerance for which he takes Lactaid before certain meals. Patient states he has not been feeling well for about a month, but feels better when taking hot showers. He has no pertinent family history. Patient denies any drug use. Patient works as a banker. Upon physical exam, you note the patient has a mal odor, appears pale, dehydrated, and is in mild distress. There is slight abdominal pain with palpation. Drug screen is positive for THC and opioids. Labs show hypochloremia, hypokalemia, and increased blood pH.

A. What is the likely diagnosis?B. What is a common differential diagnosis?C. What is the main treatment for this condition?D. What is a feared complication of this condition if left untreated?

June Awareness

Alzheimer’s and Brain Awareness:CME ARTICLE Updated guidelines for the diagnosis of... : Journal of the American Academy of PAs

National Aphasia Awareness:A fresh look at memory loss: Reexamining frontotemporal... : Journal of the American Academy of PAs

National Congenital CMV:An introduction to gastrointestinal tract CMV disease : Journal of the American Academy of PAs

Scoliosis Awareness:Scoliosis: A straightforward approach to diagnosis and... : Journal of the American Academy of PAs

World Sickle Cell Day:https://journals.lww.com/jaapa/Abstr act/2019/09000/Current_and_emerging_treatments_for_sickle_cell.15.aspx

PTSD Awareness Day:Post-traumatic stress disorder in veterans: Treatments and... : Journal of the American Academy of PAs

Deaf and Blind Awareness Week:https://journals.lww.com/jaapa/Abstract/2018/09000/Telemedicine_and_diabetic_retinopathy.15.aspxOtosclerosis: An update on diagnosis and treatment : Journal of the American Academy of PAs

Summary References and Links

1. Clues to a misleading ECG : Journal of the American Academy of PAs

2. Acute respiratory distress syndrome: An overview for... : Journal of the American Academy of PAs

3. Effective patient education techniques for preventing... : Journal of the American Academy of PAs

Be the first to email the correct answers and win a prize! Email: aaron.harvey@case.edu

Clues to a misleading ECG1

The 12-lead ECG is helpful for interpreting cardiac rhythms and identifying abnormalities and disturbances in the conduction system. Misplacement of ECG leads, whether placed on the wrong limbs or in the incorrect places, leads to incorrect interpretations of results and can dramatically affect the diagnosis and eventual treatment plan for a patient. There are two groups of leads that are used to record an ECG: 6 limb leads and 6 pericordial leads. Limb leads include 3 bipolar leads (I, II, III) measuring the difference in potential between two leads placed on two adjacent extremities and 3 unipolar leads (aVR, aVL, and aVF) measuring the cardiac voltage at one site compared to the central terminal.

It is estimated that 0.4% to 4% of all recorded ECG’s have misplaced leads. The most common ECG lead misplacement is reversing placement of limb leads, especially reversing the RA (right arm) and LA (left arm) leads. This mistake produces incorrect P wave and QRS results in lead I which is uncommon even in patients with known cardiac disease. Electrodes for limb leads can be placed anywhere on the correct limb to give an accurate result. However, if the limb leads are accidentally placed on the torso, the voltage recorded will be affected.

Although lead misplacement is difficult to identify, there are clues to look for along the way to help make the correct ECG interpretation. Practitioners should be familiar with characteristics of normal ECG results, as well as be able to identify various types of inaccurate results due to lead misplacement. It will be important to keep these clues in mind even while learning the basics of how to interpret an ECG.