Feather River Hospital

Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM. The American College of Emergency Physicians Palliative Medicine Sectionassembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine. The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators. Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

Purpose:To evaluate the conformity index for SBRT lung plan in Eclipse (version 11) treatment planning system.Methods:In the Eclipse treatment planning system the conformity index was defined as VRI/TV, where VRI is prescription isodose surface, and TV is the target volume. In 1997, Van't Riet et al introduced TVRI/TV × TVRI/VRI as a conformal index, where TVRI is the target volume closed by the prescription isodose surface. We chose a lung cancer patient who was assigned to be treated with SBRT. SBRT immobilization device was used and non‐gated CT/4DCT was performed. The tumor movement was less than 1 cm based on 4DCT. A MIP image set was generated and used to delineate the internal target volume (ITV). A 5 mm margin was added on the ITV to generate the PTV. The prescription was 5000 cGy in 5 fractions and 100% prescription dose covered 95% of the PTV. A VMAT plan (plan I) was made to achieve the physician's goal. Then a high dose structure was generated by VRI subtracting the TV, a low dose structure was generated by TV subtracting VRI, and medium dose structure was named for the overlapping area between VRI and TV. The other VMAT plan (plan II) was made by adding constraints to high/low/medium dose structures, respectively. The conformity index was determined and compared between plan I and plan II.Results:For plan I, the Eclipse's conformal index was 1.06; the Van't Riet's conformal index was 0.82. For plan II, the Eclipse's conformal index was 1.02; the Van't Riet's conformal index was 0.85. The conformal index was improved in plan II.Conclusion:The high/low dose/medium dose structures may be useful to make more conformal plans to treat lung area using SBRT based on the conformal index values.

Problem Responsibilities of chaplain services at Feather River Hospital (FRH) primarily include completing its mission of whole-person care by providing spiritual and emotional support to the patients and staff. However, the challenge of meeting this goal historically is due to insufficient funding to hire adequate staff chaplains to provide this service. Per conversation with fellow chaplains of other hospitals, this same staffing challenge in meeting the spiritual and emotional component of whole-person care is consistent. However, there is a potential solution. Staff and community volunteers with a spiritual bent have shown interest in filling this gap of spiritual and emotional support, but proper training is essential to creating a consistent quality of care. Method A four-hour Mission Ambassador Training (MAT) was created and presented on three separate occasions, along with two abbreviated MATs for CNAs, between December 2014 and February 2015, for the FRH staff and volunteers. Also, a 30-minute Mission Ambassador Support Group (MASG) was created and implemented monthly from January 2015 through June 2015. The purpose was missional. The training included the learning components of linking theory to practice, fostering both internal and external spiritual and emotional awareness, providing resources, and building a collaborative team with chaplain services. It taught the competencies of roles and responsibilities of a Mission Ambassador volunteer (MA), historical context for spiritual and emotional support in a healthcare environment, recognition and support of spiritual and emotional issues, communication skills, bereavement, and teamwork. The project was evaluated for its diversity in staff participation, and by its participants and the community, using the quarterly National Research Corporation (NRC) survey, Gallup survey, Spiritual Climate survey, FRH standardized program evaluation survey, and the post-MAT support group attendees to determine the effectiveness of both the training and implementation on the staff, patients, and training participants. Results Twenty-two students enrolled in MAT: 8 from chaplain services and 14 from a variety of departments. Results from the NRC, Spiritual Climate, and Gallup were inconclusive. Education and Training Program Evaluation respondents and MAT Support Group surveys indicated the training was beneficial. MASG, on the other hand, was not deemed a success due to pragmatic reasons. Conclusions This project manuscript establishes that an efficient, accessible, competency-based, and mission-focused MAT for non-chaplain and chaplain volunteers may increase the support of the mission of FRH as well as patient satisfaction. This outcome suggests that extensive employment of this training curriculum could have positive missional impact on the entire Adventist Health organization. It may also have implications for other forms of non-chaplain and volunteer chaplain education.

To report microsporidial keratoconjunctivitis in a patient infected with HIV who was treated with topical fumagillin. A 37-year-old white man who was experiencing redness, pain, irritation, decreased vision, and a foreign body sensation occurring in both eyes was referred to the ophthalmology clinic. The patient had a medical history significant for AIDS, Pneumocystis carinii pneumonia, and Cytomegalovirus retinitis. Conjunctival smears were taken and stained positive for the presence of Microsporidia. The patient was diagnosed with bilateral microsporidial keratoconjunctivitis and fumagillin therapy was initiated. After 5 days of therapy, the patient reported significant improvements characterized by a decrease in blurred vision with only slight blurring in the left eye, decrease in headache, and decreased foreign body sensation. The patient continued topical fumagillin therapy for more than 14 months, with only slight blurring in the left eye and no apparent ocular toxicity as a result of fumagillin therapy. Although rare in occurrence, increasing numbers of documented microsporidial infections are being reported in the medical literature, particularly in individuals who are seropositive for HIV. Clinicians need to be cognizant of microsporidial keratoconjunctivitis as another opportunistic infection in this patient population. Although a curative agent has yet to be discovered, fumagillin represents a safe, effective, low-cost, topical agent for the treatment of microsporidial keratoconjunctivitis.