See One Do One Teach One UNIVERSITY OF

See One, Do One, Teach One? UNIVERSITY OF MISSOURI Family & Community Medicine A More Thoughtful Approach to Procedural Training in Family Medicine UNIVERSITY OF MISSOURI Family & Community Medicine

Presenters Peter Koopman, MD Assistant Professor of Clinical Family and Community Medicine University of Missouri School of Medicine-Columbia And Erik J. Lindbloom, MD, MSPH Associate Professor of Family and Community Medicine University of Missouri School of Medicine-Columbia

See One. UNIVERSITY OF MISSOURI Family & Community Medicine

Do One. UNIVERSITY OF MISSOURI Family & Community Medicine

Teach One. UNIVERSITY OF MISSOURI Family & Community Medicine

Why Change? • Personal Story. • Residents consistently give feedback that they would like better procedural training. • Procedural precepting is different from much of the precepting we do in that it is both manual and cognitive. • We have tools for cognitive precepting (One minute preceptor)-Why not procedural? UNIVERSITY OF MISSOURI Family & Community Medicine

A More Thoughtful Approach To Resident Procedural Teaching • Not So Random ACTS of Teaching • A-Assess • C-Confirm • T-Teach • S-Stand Back and Summarize UNIVERSITY OF MISSOURI Family & Community Medicine

A-Assess DIAGNOSE ASSESS TREAT TEACH UNIVERSITY OF MISSOURI Family & Community Medicine

A-Assess • Assess resident’s familiarity and comfort with particular procedure. • Assess if resident has seen, done or taught. • Assess resident’s approach to procedure. UNIVERSITY OF MISSOURI Family & Community Medicine

C-Confirm • Confirmation of manual aspects of procedure in question. • Confirm with book or video resources. • Confirm what tools and supplies? UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Free • You. Tube: www. youtube. com • You. Tube Downloader: http: //youtubedownload. altervista. org/ • Mediclips: http: //medclip. com/ • Medical Videos: http: //www. medicalvideos. us/ UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Free UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Free UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Free UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Pay Sites • New England Journal: http: //www. nejm. org/multimedia/medic al-videos • Elsevier: http: //www. clinicalanswer. com/procedu res/ UNIVERSITY OF MISSOURI Family & Community Medicine

Video Resources-Pay Sites UNIVERSITY OF MISSOURI Family & Community Medicine

Book Resources UNIVERSITY OF MISSOURI Family & Community Medicine

T-Teach • Teach from your experiences. • Teach what you have found helpful -OK to be anecdotal. • Teach practical tips. UNIVERSITY OF MISSOURI Family & Community Medicine

Sample Slides: This Is NOT About Lumber Puncture

Overview • CT/MRI have decreased the need for LP, but have also increased the safety of the procedure • Indications, contraindications • Equipment, prep, technique • Complications • Labs • Billing UNIVERSITY OF MISSOURI Family & Community Medicine

Indications: Suspected… • • • CNS infection (meningitis, encephalitis) Subarachnoid hemorrhage Multiple Sclerosis Guillain-Barré Acute demyelinating disorders (e. g. transverse myelinitis, encephalomyelinitis) • Systemic lupus erythematosus • Meningeal carcinomatosis UNIVERSITY OF MISSOURI Family & Community Medicine

Indications: Also… • Unexplained altered level of consciousness, polyneuropathy • Symptomatic relief (pseudotumor cerebri, normal pressure hydrocephalus) • Spinal analgesia • Intrathecal antibiotics, chemotherapeutics • Imaging (e. g. myelography, cisternography) UNIVERSITY OF MISSOURI Family & Community Medicine

Contraindications • Local skin infection (absolute contraindication) • Evidence of increased intracranial pressure on imaging (OK for pseudotumor cerebri and NPH) • Supratentorial mass lesions • Severe bleeding diathesis, coagulopathy, or anticoagulated (relative contraindication) UNIVERSITY OF MISSOURI Family & Community Medicine

Equipment • Spinal tray, which should include: § (Pass around while listing) • Also good to have an extra spinal needle ready to go • Sterile gloves UNIVERSITY OF MISSOURI Family & Community Medicine

Prep • Hey, did you get consent? • Pretty sure it’s infection? Get the antibiotics going! • To image or not to image? Well… UNIVERSITY OF MISSOURI Family & Community Medicine

“It’s a really fine line between stupid and clever. ” David St. Hubbins • Risk of cerebral herniation and sudden death from an LP with no imaging and focal neuro signs as high as 40%. • Papilledema, no focal neuro signs: 5% • Documented increased pressure (greater than 20 cm H 2 O), no focal signs: 1. 2% • What would be considered “focal”? § Good question. Get the imaging. UNIVERSITY OF MISSOURI Family & Community Medicine

Landmarks: Aiming for L 3 -L 4 UNIVERSITY OF MISSOURI Family & Community Medicine

Landmarks UNIVERSITY OF MISSOURI Family & Community Medicine

Why the L 3 -L 4 Interspace? UNIVERSITY OF MISSOURI Family & Community Medicine

Positioning • Edge of bed in lateral recumbent (preferred for pressure measurement) or sitting position • Slight flex of neck anteriorly and “roll up into a ball” with knees drawn to abdomen • Shoulders and pelvis vertical without tilt! • Landmarks clear? Mark if necessary. UNIVERSITY OF MISSOURI Family & Community Medicine

Positioning • Open the tray, put on the gloves • Assemble your manometer and stopcock • Open the tubes and set them upright • Prepare the skin at 3(!) interspaces and drape UNIVERSITY OF MISSOURI Family & Community Medicine

Positioning

The Sharp Stuff • Using small syringe and tiny needle, raise a wheal with lidocaine, and then aim deeper with small amount (may obscure landmarks – did you mark? ) • Using posterior spinous process and umbilicus as landmarks, insert the spinal needle angled approx 15% cephalad UNIVERSITY OF MISSOURI Family & Community Medicine

The Sharp Stuff • Keep needle level with sagittal midplane, bevel cephalad • If you hit bone, stop, withdraw needle slightly, change angle • Advance for 3 -4 cm for average patient • Withdraw stylus and check hub for fluid • No fluid? Replace stylus, advance needle a bit, recheck UNIVERSITY OF MISSOURI Family & Community Medicine

The Sharp Stuff • Ideally feel a “pop” as needle penetrates § Advance another 1 -2 mm farther before withdrawing stylus § Rotating needle sometimes helps • Radiating pain down leg? Dry tap? Blood not fading? § Stop, withdraw, regroup, try a different interspace § Bloody CSF from subarachnoid hem won’t clot UNIVERSITY OF MISSOURI Family & Community Medicine

Hooray! You have fluid dripping. Now what? • Place stopcock with manometer onto needle hub • Have patient relax position a bit • Pressure can fluctuate a bit with pulse and respiration UNIVERSITY OF MISSOURI Family & Community Medicine

Let it Flow • Once opening pressure is noted, turn stopcock to allow flow to tubes • 2 -3 ml each of 3 tubes • Fourth tube: specials or freezing • Replace stylus, remove needle, cover site with dressing/Band-Aid, supine 2 hours(? ) UNIVERSITY OF MISSOURI Family & Community Medicine

Or Really Let it Flow • Therapeutic LP for pseudotumor: enough to reduce closing pressure to 10 cm H 2 O (usually 25 -35 ml) • Diagnostic LP for NPH: 35 -50 ml with transient neuropsych improvement UNIVERSITY OF MISSOURI Family & Community Medicine

Complications (…other than sudden death…) • Post-LP headache in 10 -25% § Usually within 2 days, worse when sitting upright, self-resolves after a few days § Can occur up to 12 days later, can last longer than a week and be debilitating § Oral or IV caffeine (500 mg) may help (x 2) § “Blood patch”: 15 ml of autologous blood into dural space; usual immediate relief. (Why? ) UNIVERSITY OF MISSOURI Family & Community Medicine

Complications (other than sudden death) • Seizures • Traumatic (“bloody”) tap: usually selflimited, but can lead to hematoma • Meningitis • Nerve root aspiration: remember to replace stylus when withdrawing needle • Local pain • Paresthesias: rarely chronic… but can be. UNIVERSITY OF MISSOURI Family & Community Medicine

Peds Pearls • It’s all in the hold • Upright option: neonates/young infants § Overflexion of neck can lead to resp arrest • • Topical anaesthetic with EMLA helps Less likely to feel “pop” Infants only need 1. 5 inch needle Epidermoid tumors reported in neonatal period, after not using stylus UNIVERSITY OF MISSOURI Family & Community Medicine

Billing • CPT: § 62270 (spinal puncture, lumbar, diagnostic) § 62272 (spinal puncture, therapeutic) • ICD-9: § 320. 9 (322. 9) Bacterial (suspected) meningitis § 047. 9 Aseptic meningitis § 852. 00 Subarachnoid hemorrhage § 348. 2 Pseudotumor cerebri § 357. 0 GBS § 340 MS UNIVERSITY OF MISSOURI Family & Community Medicine

Emphasis During Faculty Workshops(? ) • • • Indications, contraindications Technique pearls, perhaps “off book” Complications Labs Billing UNIVERSITY OF MISSOURI Family & Community Medicine

S- Standback/Summarize • Stand back –gloved-to provide support. • Let resident do procedure unless assessment tells you otherwise. • In hospital setting let senior resident teach and support their teaching • Summarize procedure pluses and minuses at end and debrief. Give feedback. UNIVERSITY OF MISSOURI Family & Community Medicine

A Four Daughters Production UNIVERSITY OF MISSOURI Family & Community Medicine