Novel application of telemedicine and an alternate EHR environment for virtual clinical education: A new model for primary care education during the SARS-CoV-2 pandemic.

BACKGROUND: Restrictions to direct patient contact resulting from the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic left some medical students near graduation in need of a required critical care medicine (CCM) sub-internship. A group of educators deployed a virtual curriculum utilizing telemedicine and electronic health record (EHR) technologies. METHODS: Nine students participated in a formal curriculum of high-value critical care medicine topics designed to meet the learning objectives of the in-person experience. Students obtained patient histories and directed physical examinations virtually via telemedicine. They followed assigned patients, submitted clinical documentation, and practiced electronic order entry using a non-production EHR copy. At conclusion these students completed the same evaluation used for "in-person" CCM rotations earlier in the year. RESULTS: Students rated the virtual rotation comparably to the traditional rotation in most evaluated criteria. Lower rated areas included "perform minor procedures", "patient counseling", and "interprofessional experiences". Students' narrative responses specifically noted strengths of the "student focus" and the ability to practice in an EHR copy. DISCUSSION: Students and preceptors generally found that the virtual curriculum provided adequate educational opportunities. Certain areas were clearly lacking, as expected. Students felt the dedication of the faculty to the students' educational needs was the most important factor contributing to the success of the program. The results suggest several ways telemedicine and EHR technologies might enhance clinical medical education in the future. CONCLUSION: This methodology was successful in providing elements of a CCM rotation experience. This technology could prove efficacious for primary care rotations where in-person training is not feasible due to the SARS-CoV-2 pandemic.

Correction of hyponatremia by infusing D5W (5% dextrose in water solution) prefilter in patients receiving continuous renal replacement therapy: A case series.

Patients with severe hyponatremia and renal failure who require continuous renal replacement therapy (CRRT) are at risk for overcorrection of their sodium level due to preformulated isotonic replacement or dialysate fluids. Rapid correction of hyponatremia can lead to serious neurologic complications including osmotic demyelination syndrome (ODS). There is limited data available in preventing overcorrection of severe hyponatremia with CRRT. It has been proposed to use reduced effluent volume to avoid overcorrection. However, there are instances where the CRRT prescription cannot be reduced due to other metabolic derangements. Herein, we present four cases using a calculated amount of dextrose 5% solution (D5W) prefilter as preblood pump to prevent overcorrection of hyponatremia while delivering recommended effluent volume of at least 20-25 mL/kg/hr in majority of cases. In each case, the rate of sodium correction did not exceed 8 mEq/day using D5W prefilter. Even in patients whose hyponatremia was initially overcorrected, adding calculated amount of amounts of D5W prefilter decreased the sodium level back down to prevent the risk of ODS. We also review a simplified equation to determine the D5W rate depending on the prescribed effluent volume.

Ocular dialysis disequilibrium-Management of intraocular pressure during hemodialysis of open angle glaucoma: A case report and review of the literature.

It has been shown that patients with end-stage renal disease (ESRD) have an increased risk for changes in intraocular pressure during hemodialysis, or ocular dialysis disequilibrium which can cause pain or discomfort during treatment and lead to decreased vision over time. This is a case of an elderly male with ESRD who was having headaches, nausea, and eye pain during hemodialysis due to increased intraocular pressures. Using a higher sodium prescription resolved his symptoms and normalized his intraocular pressures. This case illustrates that modification in dialysate tonicity can decrease changes in intraocular pressures while patients are on hemodialysis, a vision saving consideration for patients.