Bone marrow biopsies: A hospitalist bedside procedure service 5-year experience.

BACKGROUND: Bone marrow aspiration and biopsies (BMAB) are a relatively frequent procedure needed in the inpatient setting, especially in a tertiary care center. OBJECTIVE: Procedure-focused hospitalists can provide an excellent option for doing inpatient BMAB. Here we present five years of experience with a hospitalist bedside procedure service (BPS) performing BMAB. DESIGN: In 2016, the BPS partnered with the oncology service to begin performing inpatient BMAB. SETTINGS AND PARTICIPANTS: We evaluated internally collected data from the procedures performed by the BPS from 2016-2020. INTERVENTION: From 2015-2016, faculty members on the BPS team were trained by the oncology department to do a BMAB, which was then offered as an inpatient procedure by the BPS from 2016-2021. MAIN OUTCOME AND MEASURES: Total number of BMAB performed, success rates, bleeding risk profiles of patients, rate of trainee participation, and complication rates. RESULTS: The BPS performed a total of 432 BMAB from 2016-2021. Forty-six (10.6%) were unsuccessful and required referral for CT guidance. Elevated bleeding risk was present in 88 (20.4%) of patients. Trainees assisted in 62 (14.4%) of the procedures.There was one complication (0.2%).

Advancing Internal Medicine Training: Experience of a Bedside Procedure Service as a Resident Elective.

BACKGROUND: In 2007, the American Board of Internal Medicine eliminated numeric procedure requirements for licensing. The level of exposure to procedures during residency, and subsequent competence of graduating residents, is variable. In 2015, our institution developed a bedside procedure service (BPS) with the intent to teach ultrasound guidance and procedural training to internal medicine residents with direct supervision of technique by Hospital Medicine faculty to optimize learning, increase confidence, and improve patient safety. OBJECTIVE: In this study, we review the number and complication rates of resident procedures on a dedicated internal medicine bedside procedure service (BPS) as a resident elective. METHODS: In this retrospective, observational, single-center study, we reviewed internally collected data from BPS procedures performed from 2015-2019. The BPS offers a variety of procedures done with ultrasound guidance at an adult tertiary care referral center. BPS services are available to all inpatient hospital services. A rotation with the BPS was offered as a stand-alone resident elective for the first time in 2015. RESULTS: 69 residents performed a total of 2700 ultrasound-guided/assisted procedures and 146 diagnostic ultrasound scans from 2015-2019. Residents performed an average of 40 procedures during their elective month. There were 5 resident performed procedural complications with an overall complication rate of 0.19%. CONCLUSIONS: Our BPS increased procedural opportunities for residents and allowed for real-time feedback by an experienced faculty member in a one-on-one setting. A dedicated rotation allows the time to focus on becoming proficient in invasive procedures with expert supervision.

Acute Hemoptysis Redefined: A Deadly Presentation.

An aortic aneurysm is a permanent localized arterial dilation with more than 50% of the artery diameter. Among the complications of an aortic aneurysm, one of the rarest is the aorto-bronchial fistula, which presents with massive hemoptysis; this condition is lethal if not treated surgically. We report a 90-year-old man with no significant medical history who presented to the emergency department with abrupt onset of hemoptysis; his chest X-ray displayed left upper lobe opacity with widened mediastinum. CT chest revealed aneurysmatic dilatation of the aorta, left upper lobe opacity suspicious of pulmonary aortic fistula. Thoracic surgery was consulted but due to his poor functional status surgery was deferred. On the second day of hospitalization, the patient developed another episode of massive hemoptysis resulting in hypovolemic shock and expired. This case epitomizes the relevance of broad differential diagnosis for hemoptysis and the prompt assessment and management of the patients with this condition.

Lyme Carditis Buried Beneath ST-Segment Elevations.

Lyme disease is caused by the spirochete Borrelia burgdorferi and is carried to human hosts by infected ticks. There are nearly 30,000 cases of Lyme disease reported to the CDC each year, with 3-4% of those cases reporting Lyme carditis. The most common manifestation of Lyme carditis is partial heart block following bacterial-induced inflammation of the conducting nodes. Here we report a 45-year-old gentleman that presented to the hospital with intense nonradiating chest pressure and tightness. Lab studies were remarkable for elevated troponins. EKG demonstrated normal sinus rhythm with mild ST elevations. Three weeks prior to hospital presentation, patient had gone hunting near Madison. One week prior to admission, he noticed an erythematous lesion on his right shoulder. Because of his constellation of history, arthralgias, and carditis, he was started on ceftriaxone to treat probable Lyme disease. This case illustrates the importance of thorough history taking and extensive physical examination when assessing a case of possible acute myocardial infarction. Because Lyme carditis is reversible, recognition of this syndrome in young patients, whether in the form of AV block, myocarditis, or acute myocardial ischemia, is critical to the initiation of appropriate antibiotics in order to prevent permanent heart block, or even death.

Octreotide for the Management of Gastrointestinal Bleeding in a Patient with a HeartWare Left Ventricular Assist Device.

HeartWare is a third generation left ventricular assist device (LVAD), widely used for the management of advanced heart failure patients. These devices are frequently associated with a significant risk of gastrointestinal (GI) bleeding. The data for the management of patients with LVAD presenting with GI bleeding is limited. We describe a 56-year-old lady, recipient of a HeartWare device, who experienced recurrent GI bleeding and was successfully managed with subcutaneous (SC) formulations of octreotide.