Tulalip Continuing Education September 18, 2016

7:30-8:00 Registration and Continental Breakfast

Advancements in Dry Eye Therapies 8:00-9:00 Workbook Pages 2-10 Dr. Roya Habibi

Confident Management of Medical Emergencies that Present in the 9:00-11:00 Workbook Pages 11-32 Optometric Practice

Dr. Tad Buckingham

Medical Malpractice – What Every 11:00-12:00 OD Should Know Workbook Page 33

Dr. James Santoro

12:00-1:00 Lunch

Treatment Options for Irregular 1:00-3:00 Corneas Workbook Pages 34-45

Dr. Roya Habibi

Upcoming CE Events Workbook Page 46

To our Tulalip CE Sponsors

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Workbook Page 10 of 46 9/12/2016

Confident Management of Medical Objectives Emergencies that Present in the • Understand the value of proper Optometric Practice preplanning for medical emergencies. • Feel confident about the medical Tad Buckingham, OD, EMT-P - emergency exam September 2016 • Understand the likely medical emergencies that may occur in your practice. • Know the process for verbalizing a patient care transfer.

Case Review Case Review cont.

• 27 y/o male with a family history of • Pt. again gets anxious when asked to get OAG. “Hates Doctors” positioned into the slit lamp. You talk about the importance of accurate IOPs and • Staff state the pt. got sweaty and “He will try”. anxious during autorefraction and FDT • As you get in position you see him visual fields. sweating and breathing more rapidly. As • Pt. is calm and compliant during VAs, you get ready to stop the exam you notice Cover tests, and EOMS. instead of exhaling he bears down, his • Goldmann Tonometry is needed for pupils dilate and his eyes roll back as he pressures. starts shaking in minor movements

Workbook Page 11 of 46 1 9/12/2016

Overview Case Review cont. • Not all medical maladies require 911 • The patient shakes with full body, very • Medical emergencies require a team approach to mitigate. The whole office needs low amplitude, muscle contractions as to take an active role. the slit lamp is moved away. ◦ The 911 caller ◦ The scribe • The full body movement lasts approx 5- ◦ The assistant 10 seconds. The pt. is unconscious. • All health care providers including Emergency Medical Services (EMS) professionals (both Fire and Ambulance) are bound by Federal As the Physician, what do you do? HIPPA regulations. • Paramedics act as extension of their supervising physician. • What occurs when 911 is called?

Medical Emergency Activation Guidelines

• Emergency Activation phone number (911) ◦ Type of medical emergency MEDICAL EMERGENCY ◦ Patient status • List of chart notes/"face sheet" to be copied for EMS PATIENT EVALUATION • The “Face Sheet” should include: ◦ Name, Address, DOB ◦ Contact phone number, Emergency contact name and number ◦ Primary Care Physician, list of allergies (drug and environmental) ◦ List of current medications, ocular and past medical history

Other recommended phone numbers 1) American Association of Poison Control Centers Phone Number: 1-800-222-1222 2) Local Hospital phone numbers for needed consults.

Workbook Page 12 of 46 2 9/12/2016

What is an acute Medical Emergency? Primary Exam-LOC, CABs • LOC (Level Of Consciousness) • An intrinsic or extrinsic influence that ◦ What is the patient’s level of consciousness? has acute durational (and not transient) • Circulation ◦ Is there evidence of circulation? effects on the: • Color? ◦ Level of Consciousness (LOC) • Evidence of Capillary refill? ◦ Cardiovascular system (C) • Distal pulses present? • Airway ◦ Respiratory system (A, B) ◦ Is the airway open? Can the patient talk? • Breathing *The Primary Exam is the core exam used for ◦ Is the patient moving air? • Mechanical evidence of chest rise/fall or abdominal evaluating a medical emergency. movement.

Determine the level of Level of Consciousness Consciousness

• AVPU ◦ Alert ◦ Verbal (responds to …?) ◦ Pain (responds to …?) ◦ Unresponsive

What is the patient’s normal baseline?

Workbook Page 13 of 46 3 9/12/2016

Alert Altered Consciousness • Patient is conscious and aware of their • Verbal surroundings ◦ Patient appears unconscious but responds to loud verbal stimuli. • An alert patient is further evaluated to • "Patient is stuporous responding to verbal stimuli" assess for any levels of confusion • Pain ◦ Four specific questions are asked ◦ Patient appears unconscious but responds to a shake • Alert to “Person”; "What is your full name?" or sternal rub stimuli. • Alert to “Place”; "What city are you in now?" • "Patient is stuporous responding to physical stimuli." • Alert to “Time”; "What month is it now?" • Alert to “Event”; "Why are you here?" • Unresponsive • If the patient is not 4/4 the are considered ◦ The patient is unconscious and will not respond to any confused. stimuli • "The patient is comatose." ◦ Describe the confusion level; “Pt. is confused 2/4” *To determine the depth/length of coma check for incontinence

The AMS(Altered Mental Status) The AMS(Altered Mental Status) • S/Sx • Medical Causes ◦ The patient will present with an altered mental ◦ Diffuse Brain Dysfunction • Generalized severe metabolic or toxic disorders status that will vary from confusion to frank depress/inhibit overall brain function (Alcohol abuse, coma. Diabetes, sedative drugs, uraemia, or septicemia). • The deeper the coma the more probable urinary ◦ Direct effect within the brainstem incontinence • A lesion within the brainstem itself damages/inhibits the RAS(Reticular Activating System) ◦ Pressure effect on the brainstem • A mass lesion within the brain compresses the brainstem inhibiting the ascending RAS(Reticular Activating System).

Workbook Page 14 of 46 4 9/12/2016

Circulation Pulse • Location – gives you an estimate of the BP ◦ Radial • Radial pulse cannot be felt: <80 mm Hg systolic BP ◦ Carotid • Carotid pulse cannot be felt: <60 mm Hg systolic BP (pressures below 60 mm Hg cannot sustain organ health) • Rate (per min.) ◦ < 60 = Bradycardia (normal, heart block, MI, Pharmacopeia) ◦ > 100 = Tachycardia (exercise, emotion, pain, fever/infection, blood loss, pharmacopeia ) • Rhythm ◦ Regular(normal) or Irregular(arrhythmia) • Strength ◦ Bounding (high BP), Regular, Thready/weak (low BP), Absent

Blood Pressure Airway • Acute Hypotension ◦ Symptomatic patient with a systolic BP < 100 mm Hg (blood loss, poor cardiac output, metabolic imbalance) – weak, dizzy, lightheaded. • Acute Hypertension ◦ Symptomatic patient with a systolic BP > 210 mm Hg or a Diastolic of > 120 mm Hg (Malignant HTN) – < 20% 1 year survival rate without Tx

Workbook Page 15 of 46 5 9/12/2016

Airway problems

• Conscious ◦ Partial Choking – Encourage coughing Respiratory ◦ Complete Choking – Heimlich maneuver • Unconscious ◦ Is pt. snoring – Tongue is obstruction • Head tilt chin lift ◦ Secretions/saliva • Position patient on their side to promote drainage from the mouth

Respiratory Respirations

• Inadequate Breathing may be compensated by • Rate body positioning and accessory muscle use. ◦ Normal respiratory rate for healthy adults is 12 – 20 per minute. • A rapid respiratory rate that starts to brady • Rhythm down with accompanied patient fatigue is an ◦ Regular or irregular indication of impending respiratory failure! • Depth ◦ Shallow or deep breaths • Listen to the lung sounds. Can you appreciate wheezes or wet lung sounds? • Use of accessory muscles ◦ Nasal flaring, use of neck or intercostal muscles, and Body positioning. • Is the respiratory pattern regular? How is the Tidal volume? • Lung sounds – Do you hear: ◦ Clear, Wheezing (spastic airway), or Wet – bubbly or gurgling (Pulmonary edema) • Does the patient also have chest pain?

Workbook Page 16 of 46 6 9/12/2016

Respiratory - Hyperventilation

Lung Sounds • S/Sx Hyperventilation o Common causes are emotions, anxiety, and panic disorders. o May be compensation for acidosis o Most commonly seen in women between the ages of 14 and 40. Rarely observed in pediatrics and patients over 40 years old. If the pt. is suffering from Hyperventilation:

• Tx • If etiology is not anxiety, 911 as indicated. • Place patient in the position of comfort • Calm patient with voice and mannerisms • Coach pt.’s respirations with breathing “in through the nose and out from the mouth”

Respiratory Distress Skin • Temperature – assessed by touch ◦ Hot, Warm (normal), cold • Color ◦ Red, Flushed, Jaundiced, Pink(normal), Cyanotic, pale • Moisture ◦ Dry, normal, moist (diaphoretic) • Capillary Refill time ◦ Can be used to evaluate Circulation when assessing CABs. ◦ Blanch skin with skin pressure. When pressure is released color return within 2 seconds indicates normal perfusion.

Workbook Page 17 of 46 7 9/12/2016

Abnormal Skin Colors Common Chief Complaints

• Allergic reactions / Anaphylaxis • Altered mental status (AMS) • Breathing difficulty • Diabetic emergencies • Stroke • Seizures • Chest pain • Cardiac Arrest

ALLERGIES/ANAPHYLAXIS

ALLERGIES/ANAPHYLAXIS - HYPOGLYCEMIA - NARCOTIC OVERDOSE - SEIZURES - CARDIAC ARREST

Workbook Page 18 of 46 8 9/12/2016

Urticaria Angioedema Allergies/Anaphylaxis

***Anaphylaxis - A severe type of allergic reaction that involves two or more body systems (e.g. Urticaria and difficulty breathing)

•S/Sx ◦ Diffuse or focal Pruritus (Itching) ◦ Urticaria (Hives) ◦ Angioedema (Dermal and subdermal swelling) ◦ Nausea/Vomiting ◦ Abdominal Cramps/Diarrhea ◦ Anxiety ◦ Shortness of breath/Bronchospasms ◦ Dizziness/Hypotension ◦ Tightening airway/facial and laryngeal edema

Allergies/Anaphylaxis Allergies/Anaphylaxis

• Tx profile depends on timing, severity • Rapid Cutaneous reactions (Pruritis, and location of the reaction Urticaria, slight Angioedema) • Local reactions tend to be more mild ◦ Occur 20 minutes - 1 hour of allergy compared with diffuse reactions exposure ◦ Monitor closely for increasing severity • Mild Cutaneous reaction (Pruritis, ◦ Oral antihistamines may be helpful in Sx Urticaria, slight Angioedema) alleviation. ◦ Occurs > 1 hour after allergy exposure ◦ Follow up with the patient’s primary care ◦ Usually Mild physician may be appropriate ◦ Tx with OTC topical or oral antihistamines

Workbook Page 19 of 46 9 9/12/2016

Allergies/Anaphylaxis Allergies/Anaphylaxis • Respiratory distress with airway edema or • Severe histamine related reactions and anaphylaxis hypotension with a systolic BP < 90. ◦ Occur in 5 – 10 minutes of allergy exposure ◦ Position patient supine, if tolerated, if systolic BP is < ◦ Cause bronchiolar constriction (wheezing), increased 90. capillary permeability, and vasodilatation without airway • Will not be tolerated with frank respiratory distress compromise ◦ 100% Oxygen administration • “chest feels tight” “hard to get air in” ◦ Administer Epinephrine 1:1000 IM ◦ 911 ◦ Consider injectable Dyphenhydramine ◦ Position of comfort ◦ Repeat vital signs ◦ Consider administering Epinephrine 1:1000 IM ◦ If no improvement is seen in 3-5 minutes one repeat dose of epinephrine may be given.

Hypoglycemia Low blood sugar

Causes Unstable Diabetes, Isulinomas, renal or liver HYPOGLYCEMIA failure, drug or alcohol induced, Insulin induced Symptoms Confusion or abnormal behavior, diplopia, diaphoresis, palpitations, seizures, coma

Capillary Blood Glucose measurements: < 60 mg% or <100 mg% in a symptomatic patient

Workbook Page 20 of 46 10 9/12/2016

Hypoglycemia Tx

Patient evaluation Determine CABs and level of consciousness Measure CBG with Glucometer Call 911 if the patient is confused and cannot follow directions. NARCOTIC SIDE * Many diabetics will be able to feel their CBG level dropping and be able to self treat before they experience an altered EFFECTS level of consciousness

Capillary Blood Glucose measurements: < 60 mg% or <100 mg% in a symptomatic patient a. If the patient can control their own airway give 24 grams oral glucose (1 tube). Recheck CBG after 5 minutes and repeat treatment if blood sugar remains low. b. If the patient cannot control their airway call 911.

Opioid Side Effects

◦ Central Nervous System Emotional well being, euphoria, Drowsiness, sedation ◦ Respiratory System Reparatory depression ◦ Ocular System Pupil Constrtiction NARCOTIC OVERDOSE ◦ Gastrointestinal Nausea/Vomiting, Constipation ◦ Skin System Histamine release (Morphine) causing itching (not a true allergic response) ◦ Cardiovascular Decreased blood pressure and pulse ◦ Genitourinary Urinary retention ◦ Endocrine Hormonal and sexual dysfunction

Workbook Page 21 of 46 11 9/12/2016

Narcotic Overdose

Causes Accidental or intentional overdose of Opiate substances via ingestion, injection, inhalation, or transdermal absorption Signs/Symptoms Depends on substance and route. Subdued euphoria SEIZURE ACTIVITY with a flattened emotional response, miotic pupils, altered mental status, respiratory depression, hypercarbia, low BP, coma, death. May see needle track marks or multiple - transdermal patches on the skin VASOVAGAL SYNCOPE Tx Evaluate CABs, LOC. Call 911 if patient has altered mentation and support ventilation. Pt. will need early injection of the opiate antagonist Naloxone (IM, IN) to reverse acute opiate manifestations

Seizures Generalized seizures

• Three seizure types are: ◦ Generalized (Epileptic) • A Generalized seizure presents, sometimes following a vague warning, as a loss of consciousness with tonic clonic movement . • The patient often bite their tongue and can be incontinent of urine or feces. • This may last from a few seconds to several minutes • This type of seizure is usually followed by a post ictal phase characterized by drowsiness, confusion, or coma lasting from minutes to an hour.

Workbook Page 22 of 46 12 9/12/2016

Seizures Seizures • Tx ◦ 911 as indicated ◦ Partial Seizures ◦ During the seizure clear the area around the patient so they do not injure themselves during the tonic clonic • Simple or complex phase. Protect the head and neck. DO NOT attempt to • Simple partial seizures are focal seizures without place a bite stick or other device, in the patient’s mouth, impairment of consciousness. during the tonic clonic phase. • Complex partial seizures are focal seizures with an ◦ Monitor the patient’s level of consciousness and ABCs impairment of consciousness. post seizure. ◦ Unclassified Seizures ◦ While the patient is unconscious, post seizure, place in the • Present as seizures that do not fit into on of the "recovery position". above categories. ◦ Assess the patient’s CBG ◦ If available, place appropriate 100% oxygen administration device in accordance with the presenting oxygen saturations. ◦ Reassess vitals

Post Seizure positioning Vasovagal Syncope

Workbook Page 23 of 46 13 9/12/2016

Vasovagal Syncope Vasovagal Syncope ◦ Vasovagal Syncope, known as fainting, may likely occur in the office setting. It often occurs, • Tx in highly anxious patients, as a response to ◦ Perform emergent evaluation certain office procedures such as eye drop ◦ Immediate recumbent recovery, with Vasovagal administration or Goldmann tonometry. syncope, will be seen. • Tingling extremities, dizziness, BP falls ◦ If Coma does not resolve. • Diaphoresis, skin pallor, and eyes may roll upward • Call 911 and assess CABs. with pupil dilation and a loss of consciousness. • Position the patient supine • Myoclonic jerks, which quickly resolve, may be seen. • Place appropriate 100% oxygen administration device in • Do not misdiagnose these movements as seizures accordance with the presenting oxygen saturations. • Vasovagal syncope WILL NOT cause incontinence • Check patients CBG or result in tongue trauma! • Reassess vital signs

Cardiac Arrest • Follow the AHA guidelines • 75% of all cardiac arrests are caused by either Ventricular Fibrillation or Pulseless Ventricular Tachycardia ◦ These arrhythmias are readily treated with CARDIAC ARREST IMMEDIATE defibrillation ◦ Defibrillation is used to convert these arrhythmias to a life supporting rhythm • AHA studies show that immediate CPR and defibrillation within 3-5 minutes can achieve 50-74% survival for adults with sudden witnessed VF cardiac arrest. • PLEASE have a defibrillator in your office.

Workbook Page 24 of 46 14 9/12/2016

Recommended CPR and the AED Medical evaluation equipment and pharmacopeia

***Need is governed by available resources

• Anaphylaxis treatment • Automated External Defibrillator • Testing/Monitoring equipment • Oxygen and oxygen administration

Epinephrine 1:1000

Anaphylaxis Tx Supplies •Administer (IM/SQ): • 0.3 - 0.5mg (>30 Kg / 66 lbs)

• 0.15mg (15 – 30 Kg / 33 – 65 lbs)

• 0.01 mg/kg/dose (< 15 Kg / 32 lbs)

Workbook Page 25 of 46 15 9/12/2016

Obtaining Epinephrine from an ampule Hold the ampule upright and tap its top to dislodge any trapped solution. Using Epi 1:1000 1mg/ml ampule • Check Expiration date • Not cloudy; no color or precipitate

Use thumb to break along scored edge of neck. Draw up the medication You may place gauze around the neck.

Using a syringe, insert the needle into the ampule and draw the plunger back until you reach the correct dosage Filter needle?

Workbook Page 26 of 46 16 9/12/2016

Obtaining Epinephrine from a MD vial Clean the vial’s rubber top

Using 30 ml Epi 1:1000 1mg/ml vial • Check Expiration date • Not cloudy; no color or precipitate

Prepare the syringe Insert the needle into the rubber top and inject the air from the syringe into the vial.

Pull back the plunger to the appropriate dosage. You will inject the same volume of air into a Withdraw the appropriate volume multi-use vial as you will withdraw medicine. of medication. Do not fill with more than the correct dosage.

Workbook Page 27 of 46 17 9/12/2016

Epi Pen and Epi Pen Jr. Sharps Containment

Use as directed

Barrier Devices Cardiac Arrest Tx Supplies • Gloves • Pocket Mask or BVM • Scissors/Trauma shears • Drying towel

Workbook Page 28 of 46 18 9/12/2016

AUTOMATED EXTERNAL DEFIBRILLATOR

•The Defibrillators are either fully automated or guide the Testing/Monitoring Equipment operator with voice prompts.

•For every minute defibrillation is delayed, in VF and pulseless VT, patient survival decreases 10%

•AED may require a prescription

BLOOD PRESSURE MONITORS GLUCOMETER

Manual and automatic BP cuffs are available. Measures Capillary Blood Glucose (CBG) levels from a Most Automated BP systems also evaluate small blood sample. the pulse rate Acute Low CBG level: < 60 mg%

Acute High CBG level: > 250 mg%

***Your office may need a CLIA (Clinical Laboratory Improvement Amendments) waiver to perform and bill for the procedure.

Workbook Page 29 of 46 19 9/12/2016

OXYGEN SATURATION(SAO2) MONITOR Oxygen and Oxygen

SaO2 uses light technology to Administration evaluate hemoglobin saturation. It cannot determine what is binding with the hemoglobin.

Normal SaO2 Levels: 96% - 100%

Mildly decreased SaO2 levels: 91% - 95% (nasal cannula)

Levels indicating Resp. failure: <91% (mask)

OXYGEN OXYGEN ADMINISTRATION

•100% Oxygen Nasal Cannula •Used to treat generally all medical 1-6 LPM 24% -44% emergencies

•Does not require an Rx Mask 6 – 15 LPM 35% - 55% •Life-threatening medical emergencies are usually accompanied by low tissue oxygen Bag Valve Mask (BVM) levels (not enough oxygen to tissue 12 – 15 LPM > 90% and organs).

•All patients suffering from a medical emergency will benefit from supplemental oxygen

Workbook Page 30 of 46 20 9/12/2016

The efficient patient transfer

• Introduce yourself to the Emergency The Patient Transfer responders PUTTING IT TOGETHER • Introduce the patient by name and age • State a brief but direct Chief Complaint • Describe the pt.’s LOC and CABs • Describe vital signs taken • Further description of Chief Complaint • Mitigation actions and patient reactions to therapy

An Example After the Medical Emergency • “Hi, my name is Tad Buckingham, Optometric Physician. This is my patient John Doe. John is 55 • Optometric Physicians/Staff members may years old and has a chief complaint of new onset left experience short or extended duration sided weakness. John is alert and oriented ¾. He is confused about his current location. John’s ABCs emotional trauma depending on the type of are all intact. His Blood pressure is 208/110 with a medical incident. Talk with your staff! pulse that is strong and regular at 110. His ◦ Was the Medical/Traumatic emergency involving: respiratory rate is at 24min. with room air SaO2 of • A patient? 90. John’s skin is sweaty. His left side is weak and • A patient’s family member or RP? he is slurring his speech. John also reports a • A Walk-in? severe headache. I had him placed in a position of • A Staff member? comfort with supplemental oxygen at 10 lpm. His • The Optometric Physician? SaO2 rebounded to 98% and he had a CBG of 112. Here is his copied “face sheet.” Do you have any • Contact your local Fire Department for questions? resources that will help resolve these issues.

Workbook Page 31 of 46 21 9/12/2016

Questions?

Capt. Tad Buckingham, OD EMT-P [email protected] (503) 459-9247

Workbook Page 32 of 46 22

TULALIP CONTINUING EDUCATION SUNDAY—SEPTEMBER 18, 2016 Instructor: James W. Santoro, OD, JD

Ethics/Jurisprudence

Learning Objectives: i. To Offer a Summary of the Current State of Medical Malpractice ii. To Give the O.D. a General Understanding of Legal Concepts May Help Avoid Malpractice Situations

COURSE OUTLINE

1. Introduction

2. Course Goals

3. Burden of Proof—Civil Malpractice Case

4. #1 Claim Filed Against ODs

5. Elements to Prove in a Medical Malpractice Case

6. Types of Monetary Damages: Special and General Damages

7. Defenses to a Medical Malpractice Claim

8. Statistics of Claims Filed

9. Case Presentations

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UPCOMING

EVENTS

GWCO – Join us for our annual “Bus CE Event” Saturday, October 1 Take a ride out to Pacific University and be challenged with cases from Lorne Yudcovitch and James Kundart. Refreshments and a tour of the College of Optometry is included. This event is included with your registration to GWCO.

Homecoming CE – Saturday, October 15 Pacific University Jefferson Hall “The Ocular Surface and More” 5 hours of CE, $100 John Clement, Tracy Doll, Derek Louie, Jeong Kim

Glaucoma Symposium – Saturday, January 14, 2017 Woodinville, Washington, 7 hours of CE $250 Howard Barnebey and Murray Fingeret For more Information contact: [email protected]

2017 ISLAND EYES CONFERENCE January 22 – 28, 2017 Kauai Marriott Resort Up to 31 hours of education Pat Caroline, Bradley Coffey, David Kading, Nate Lighthizer, Danica Marrelli, Lorne Yudcovitch and Robert Reed For more conference Information contact: [email protected]

Can’t make it to a meeting? We offer 1, 2 & 3 credit classes online. https://online-ce.opt.pacificu.edu/

Workbook Page 46 of 46