Episodes
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Date: January 30th, 2019
This is the third annual Canadian EM Wellness Week from CAEP. Emergency Medicine Ottawa is posting new episodes each day focusing on the humanity in emergency medicine.
Day 1: Finessing your Finances in Residency
Day 2: You’ve Got A Friend in Me – The Importance of Social Wellness and Being a New Parent
Day 3: The Sandwich Generation - An Interview with Ken Milne and Nutritional Advice
Day 4: Intellectual/Occupational
Day 5: Physical
Dr. Bill Hettler, a family physician, originally developed the Wellness Wheel concept in 1976. He also co-founded the National Wellness Institute (NWI). Dr. Hettler identified six dimensions of wellness (occupational, physical, social, intellectual, spiritual and emotional). The NWI defines wellness as an active process through which people become aware of, and make choices toward, a more successful existence.
Definition of Wellness: the quality of state of being in good health especially as an actively sought goal. Merriam-Webster Dictionary
I was honoured to be asked to represent the “sandwich” generation of emergency physicians. Dr. Lisa Fischer interviewed me about taking care of parents and children while still working full time. We discussed how my father’s recent illness and death impacted me and things that helped me cope. You can read the blog by Dr. Fischer on nutritional advice at EMOttawa and you can listen to the podcast as an SGEM Xtra.
I learned five things as a result of being on the edge of burnout:
It’s ok not to be ok
Vulnerability is a sign of strength not weakness
Take care of yourself
Don’t be afraid or ashamed to ask for help
Don’t panic, this too shall pass
You can watch my presentation on burnout at ACEM18, read the SGEM blog, download the slides, or listen to the SGEM Xtra podcast to find out more about burnout.
More resources on wellness can be found at these links (ACEM Member Wellbeing, ACEP Wellness Section, CAEP Resident Wellness and EMRA Wellness Committee).
REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE. -
Missing episodes?
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Date: January 17th , 2019
Reference: Clemency et al. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. AEM December 2018
Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com
Case: A 33-year-old man arrives via emergency medical services (EMS) after initially being found unresponsive with an oxygen saturation of 89%, respiratory rate of six, a systolic blood pressure of 75 mmHg, and pinpoint pupils. The EMS crew observes drug paraphernalia and suspect an intravenous (IV) opioid overdose. They quickly place an IV line and start a fluid bolus of normal saline; supplemental oxygen is applied and 1mg of naloxone IV given. He is alert and oriented times three with normal vital signs by the time he arrives in the emergency department. Sixty minutes after receiving naloxone he is GCS 15 and walking to the desk demanding to be discharged.
Background: There have been close to 400,000 deaths from an overdose involving any opioid (prescription and illicit opioids) between 1999 and 2017. [1] Two-thirds of the all the drug overdoses in the US in 2016 (63,632) involved an opioid (42,249). [2]
Three distinct waves have been observed according to the Center for Disease Control and Prevention (CDC-P):
Wave 1: Increase in prescription opioid overdose deaths in the 1990's [3].
Wave 2: Rapid increase in overdose deaths involving heroin starting in 2010.
Wave 3: Significant increase in overdose deaths involving synthetic opioids (like illicitly-manufactured or prescribed fentanyl) beginning in 2013 [4].
Opioids depress the heart rate and breathing, and overdoses can result in death. Naloxone is the specific treatment for opioid overdoses and is becoming widely available to first responders of all sorts (Police, Fire, First Aiders, lay people and EMS).
Naloxone is an opioid antagonist that binds competitively to opioid receptors in the central nervous system and gastrointestinal tract. It can be administered in multiple ways (intranasal, subcutaneously, intramuscularly, intravenously, nebulization or endotracheal tube).
Some clinicians have recommended observing opioid overdoses for four to six hours. This teaching has been challenged by a systematic review by Willman et al 2017. They concluded: “For patients treated in the ED for opioid overdose, an observation period of one hour is sufficient if they ambulate as usual, have normal vital signs and a Glasgow Coma Scale of 15”.
This recommendation was based on the St. Paul’s Early Discharge Rule.
The Clinical Decision Rule (CDR) was first derived in Vancouver, BC almost 20 years ago [5]. However, this tool has never been externally validated.
We reviewed the Willman et al publication on SGEM#179 and generally agreed with the authors’ conclusions. However, we were conservative in our bottom line recognizing there are patients that can be safely discharged home after an opioid overdose and administration of naloxone. You need to perform a careful clinical examination, be certain to observe the patient’s respiratory pattern and mental status in a non-stimulated state and exercise caution.
Clinical Question: Can the Hospital Observation Upon Reversal (HOUR) rule be used to risk stratify patients for safe discharge from the emergency department after suspected opioid overdose?
Reference: Clemency et al. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. AEM December 2018
Population: A convenience sample of adult patients (18 years and older) who arrived at the emergency department after being treated with naloxone.
Exclusions: Prisoners, under arrest, did not receive a 1-hour evaluation, had an incomplete but otherwise normal 1-hour evaluation, received naloxone in the hospital or requested to be withdrawn from the study. -
Date: January 10th , 2019
Reference: Busse JW et al. Opioids for Chronic Noncancer Pain A Systematic Review and Meta-analysis. JAMA December 2018
Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department and specifically the use of ketamine. His twitter handle is @PainFreeED.
Case: A 45-year-old woman with chronic low back pain due to L4/5 disk herniation for over one-month presents to the emergency department with chief complaint of worsening left sided back pain over past week after doing some heavy lifting at work. She denies bowel or bladder dysfunctions, weakness in her bilateral lower extremities or loss of sensation in her legs. On physical examination, the patient has no sensory deficits but does have pain upon straight left leg raise at L4-S1 distribution. While you are contemplating therapeutic modalities, the patient tells you that she has been taking oxycodone several times a day and occasionally gabapentin, but the pain does not seem to be getting better. She asks you how much longer she needs to continue taking oxycodone to see some improvement.
Background: Opioids are frequently prescribed for patients with chronic non-cancer (nociceptive and neuropathic) pain, however, the prolonged use of these analgesics may not provide significant pain relief but instead may lead to development of significant adverse effects such as tolerance, dependence, misuse, and in some cases, a development of an opioid use disorder.
Therefore, there is a need for high quality research including systematic reviews that can either support or refute the analgesics efficacy and safety in patients suffering from CNCP.
We haver reviewed papers on pain management in the emergency department for many years on the SGEM. One of the first episodes to look at opioids for pain management was SGEM#55. Our bottom line from that episode was that opioid prescribing in the emergency department will continue to be a problem. The study reviewed does not provide enough high-quality information to implement this guideline at my hospital.
The case scenario for this episode is a woman with worsening low-back pain for a month. Many different pharmaceutical treatments have been tried for acute low back pain with limited success. These include acetaminophen, muscle relaxants, non-steroidal anti-inflammatories (NSAIDs), steroids and benzodiazepines.
Acetaminophen: Williams et al (Lancet 2014) showed acetaminophen did not affect recovery time compared with placebo in low-back pain. However, these were not patients recruited from the emergency department.
Muscle Relaxants: Friedman et al (JAMA 2015) showed that adding a muscle relaxant (cyclobenzaprine) or oxycodone/acetaminophen to an NSAID (naproxen) alone did not improve functional outcomes or pain one week after emergency department presentation.
NSAIDs: Machado et al (Ann Rheum Dis 2017) demonstrated in a SRMA that NSAIDs did not provide clinically important effects over placebo for spine pain. They included patients with acute and chronic lumbar and cervical pain. However, the point estimate for the subgroup analysis of acute low back pain was less than the pre-specified 10 point between-group difference considered clinically significant.
Steroids: Balakrishnamoorthy et al (Emerg Med J 2014) did a double-blind trial of adult patients in the emergency department with acute low back pain and radiculopathy. In this study, the patients received either a single dose of 8 mg of IV dexamethasone or normal saline in addition to oxycodone. While the steroid treatment was reported to shorten the emergency department length of stay and decrease pain up to six weeks after discharge the difference was only statistically significant not clinically significant and there was not difference in functional capa... -
Date: December 30th, 2018
Happy New Years to all the SGEMers out there in the #FOAMed world. It is time to reflect upon 2018 and look forward to 2019. Last year we named 2017 the year of FeminEM and celebrated 15 amazing women in emergency medicine. This year I am going to highlight five of my personal favourite episodes from 2018.
It was very difficult to pick just five episodes from all the excellent episodes recorded in 2018. One of the questions I am frequently asked (besides do you pick the music first) is which episode I like the best. The answer is always the same...the one I am currently working on at the time.
Another difficulty was not to include an SGEMHOP episode in the top five. These are all fantastic episodes done in collaboration with Academic Emergency Medicine (AEM) and three great guest skeptics (Drs. Bond, Heitz and Morgenstern). It combines the best of both worlds (traditional publication and social media). To give a shoutout to just one SGEMHOP episode felt wrong, so I consciously excluded them being eligible.
Here are my favourite five SGEM episodes from 2018. Do you agree with these selections? What was your favourite SGEM episode this year? Please post your response in the comment section.
#5 Don’t Give Up – The Power of Kindness with Brian Goldman
Dr. Goldman is an Emergency Medicine physician who works at Mount Sinai hospital in Toronto. He is the host of the CBC radio show White Coat Black Art and the author of the bestselling books The Night Shift and the Secret Language of Doctors. Dr. Goldman had a fantastic new book published in 2018 called The Power of Kindness: Why Empathy is Essential in Everyday Life.
I had the pleasure of interviewing Brian at the 2018 Canadian Association of Emergency Physicians (CAEP) conference in Calgary, Alberta this summer. We sat down in a cafe and discussed kindness until they closed and asked us politely to leave. I wanted to know whether kindness was from nature or nurture, if healthcare workers' empathy is dulled over the years and if we can do anything to be more kind.
#4) I Can See Clearly Now the Collar is Gone – Thanks to the Triage Nurse
We all work with some amazing nurses in the emergency department. This SGEM episode featured one of those awesome nurses, Alison Armstrong. She is an emergency department nurse from the London Health Science Centre in London, Ontario. Alison is also a TNCC Course Director, Trauma Program Coordinator and Canadian C-Spine Rule Nurse Champion.
Alison and I reviewed a paper in Annals of EM by the prolific group out of Ottawa. Their observational study wanted to know if emergency department triage nurses can apply the Canadian C-Spine Rule (tool) to adult blunt trauma patients and safely clear the c-spine?
The results were that triage nurses removed 41% of immobilized patients’ collars and missed zero c-spine injuries. The SGEM bottom line was that properly educated emergency department triage nurses can apply the Canadian C-Spine Rule to adult blunt trauma patients and safely clear the c-spine.
#3) Message in a Book by the SGU
Interviewing Dr. Steven Novella this year about his new book was one of the highlights of 2018. Getting the opportunity to speak with him was a box checked off my bucket list.
Dr. Novella is a Yale Neurologist, host and producer of the popular science podcast called the Skeptics’ Guide to the Universe (SGU). It should be obvious that the SGU inspired the naming of this knowledge translation project, the Skeptics' Guide to Emergency Medicine.
The SGU has been a huge part of my skeptical journey and contributed greatly to my critical thinking skills. Listen to the podcast and consider purchasing Dr. Novella's book called the Skeptics’ Guide to the Universe of course.
#2) The Epi Don’t Work for Out-of-Hospital Cardiac Arrests
It takes a team to provide great emergency care. Part of that team are the dedicated, -
Date: December 21st, 2018
Happy holidays to all the SGEMers. For everyone in the Northern hemisphere, let it snow, let it snow, let it snow. For those in the Southern hemisphere, I suggest you listen to the Tim Minchin song about having white wine in the sun. Regardless of where you are, I hope everyone can spend some quality time with family and friends.
2018 has been a year of growth for the SGEM with more than 37,000 subscribers. We needed to upgrade our server twice to prevent it from crashing with all the traffic. The SGEM is also available on all podcasting platforms not just iTunes.
The SGEM has been so successful because of listeners like you, #FOAMed friends, the guest skeptics, SGEMHOP Team (Justin, Corey and Chris), PaperinaPic producer (Kirsty) and my best friend Chris Carpenter.
The goal of the SGEM continues to be to cut the knowledge translation window down from over ten years to less than one year. It does this by doing a structured critical review of a recent publication and then shares the information using the power of social media. We want patients to get the best care based on the best evidence.
As many of you know, 2018 was also difficult year near the end for me with the passing of my father in November. I was on the edge of burnout. This experience taught me that it is OK not to be OK, vulnerability is a strength not a weakness, not to be afraid to ask for help, to take care of myself, and that this too shall pass. Thank you very much for everyone who supported me through this challenging time.
As a holiday gift, please accept this PDF book of Season#5 of the SGEM. You will find links to all your favourite episodes. There is a new PaperinaPic chapter with all of Kirsty Challen's infographics. You will also find a new chapter highlighting the theme music that inspires the SGEM.
Don't Panic...Chris Carpenter's chapter on evidence based medicine, Justin Morgenstern's (First10EM) simplified guide to approaching the literature and Anthony Crocco's SketchyEBM chapter are all still part of the book.
Please feel free to share this 236 page book via your social media networks (email, Facebook, Twitter, Google+, etc).
If you are looking for the inspiring theme music from each of the SGEM episodes you can now find them on Spotify. Of course most of them come from the best musical era, the 1980's.
This knowledge translation project continues to be part of the free open access to medical education movement (FOAMed). I continue to strongly believe we should share our intellectual capital and efforts with everyone around the world with no paywalls. This information should be for anyone, anywhere and at anytime.
I also believe that patients deserve excellent care from the moment they reach out for emergency help, during their acute care, and all the way to their follow-up outpatient management. We should all be striving to have a Number Needed to Treat (NNT) of 1. Every single patient is an opportunity to help and it is a privilege to be involved in their life and sometimes their death.
The SGEM Season#5 was put together with the help of Etai Shachar. Etai is a fourth year medical student from St. George’s University. He completed his clinical training in Detroit, MI where he cultivated a passion for urban emergency medicine (EM). His primary interests in EM include investigating how social determinants of health effect emergency health care outcomes. Etai spends his “free” time whipping around the streets of Toronto on his bicycle, training for triathlon races, and jumping between coffee shops taking part in creative writing projects.
Please download and share the PDF of the SGEM Season#5 book via social media. You can down load Season#1, Season#2, Season#3, Season #4 and Season#5 by clicking on the links or the book covers.
One last thing. Could you please write a review on iTunes, like the SGEM on Facebook and follow the SGEM on Twitter. -
Date: December 13th , 2018
Reference: Murata et al. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018
Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Associate Professor for the University of Leicester's SAPPHIRE group. He specialises in Paediatric Emergency Medicine and is a passionate believer that education exists to be shared (#foamed).
Damian is part of the Don't Forget the Bubbles (DFTB) team. They published an epic paper to determine the transit time of a Lego head (Tagg et al). The primary outcome was the FART (Found and Retrieved Time) score. Bowel habit were standardized before the trial started using the SHAT (Stool Hardness and Transit) score. The story was picked up by the BBC, Forbes and even talked about by James Corden on the Late, Late Show.
Case: An 18-month-old presents having had a febrile convulsion (febrile seizure) at home. The seizure lasted no more than a minute and now having been in the department for a couple of hours the infant is back to their normal selves. Observations are normal except a low-grade fever and there is a clear focus in a right otitis media for an infection. You start to counsel the parents with likely outcomes for the future and immediate safety netting advice. You tell the parents that regular antipyretics won’t stop another febrile convulsion occurring and they should really only be used to help their child when they are distressed with a fever. After you leave the room a student who had witnessed the consultation asks you why you said you couldn’t stop febrile convulsions when a recent publication from Japan has clearly shown that regular rectal acetaminophen significantly reduces the risk of recurrence?
Background: Febrile seizures are very common and very, very scare for care-givers and parents. During winter periods a typical emergency department may well see a child a day presenting with a febrile seizure
There was a SRMA by Rosenbloom et al. (Eur J Paediatr Neurol 2013) that concluded antipyretics were ineffective in reducing the recurrence of febrile seizures in children.
SGEM#95 covered this paper with Pediatric Super Hero Anthony Crocco. Our bottom line was that antipyretics appear to offer no significant improvement in the recurrence rates of febrile seizures in children.
Fever fear is a real concern for parents and they often come to the emergency department for evaluation and reassurance.
The American Academy of Pediatrics guidelines say “fever, in and of itself, is not known to endanger a generally healthy child. In contrast, fever may actually be of benefit; thus, the real goal of antipyretic therapy is not simply to normalize body temperature but to improve the overall comfort and well-being of the child.”
Standard advice has always been that the regular administration of an antipyretic won’t reduce the risk of recurrence but a recent publication in Pediatrics has challenged this position.
Clinical Question: Does the regular administration of acetaminophen reduce the risk of immediate recurrence of a febrile seizure in children?
Reference: Murata et al. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018
Population: Infants and Children 6 to 60 months old attending an Emergency Department at a single Japanese City Hospital
Exclusions: Patients with 2 or more FSs during the current fever episode, seizures lasting >15 minutes, patients with epilepsy, chromosomal abnormalities, inborn errors of metabolism, brain tumor, intracranial hemorrhage, hydrocephalus, or a history of intracranial surgery, patients who had been administered diazepam suppository, patients whose parents requested the use of diazepam suppository, patients who had taken antihistamines or patients with diarrhea.
Intervention: Rectal acetaminophen (10mg/kg) at presentation and every six ho... -
Date: December 4th, 2018
Guest Skeptic: Dr. Steven Novella is a Yale Neurologist, host and producer of the popular science podcast called the Skeptics Guide to the Universe and executive editor of Science Based Medicine blog.
This is an SGEM Xtra book review. I had the privilege of interviewing Dr. Novella about the new book by the Skeptics' Guide to the Universe (SGU). I would like to recognize the influence the SGU had on inspiring the SGEM. The SGU has been a big part of my skeptical journey and contributed greatly to my critical thinking skills.
Listen to the SGEM podcast on iTunes or your favourite podcast app hear Dr. Novella and me discuss how SGU got started, their new book, how to encourage critical thinking with students and colleagues, how he discusses pseudoscience with colleagues and patients and a few other topics.
Five Frivolous Questions for Dr. Novella:
Star Trek or Star Wars?
Best Captain, Picard or Kirk?
If you could have one today, flying car or transporter?
Dinner with Newton or Galileo?
Would you rather visit Mars or a moon of Jupiter?
The SGEMers can order a copy the SGU book for themselves and as a gift by clicking on this BOOK LINK or on the picture below.
The SGEM will be back next episode with a structured critical review of a recent publication trying to cut the knowledge translation window from over ten years to less than one year using the power of social media.
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. -
Date: December 6th , 2018
Reference: Perkins et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.
Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.
Case: A 51-year-old man experiences a cardiac arrest on the street. You are the first provider on scene with Emergency Medical Services (EMS) and start high-quality Cardiopulmonary Resuscitation (CPR). A cardiac defibrillator is hooked up and the patient is in ventricular fibrillation. He is unsuccessfully shocked. An oral airway is placed, peripheral intravenous (IV) line started successfully and the paramedic asks her partner if you want to administer IV epinephrine?
Background: The AHA has five steps in the Chain-of-Survival for out-of-hospital cardiac arrest (OHCA).
Step One– Recognition and activation of 911
Step Two– Immediate high-quality CPR
Step Three– Rapid defibrillation
Step Four– Basic and advanced EMS
Step Five– Advanced life support & post arrest care
We are going to discuss Step Four that focuses on rapid access to advanced cardiac life support (ACLS) skills such as intubation and intravenous drug therapy.
This step is controversial, and we have covered it on the SGEM with the classic OPALS trial by Legend of Emergency Medicine Dr. Ian Stiell (SGEM#64). This was a before and after study to see if advanced cardiac life support (ACLS) techniques, including IV epinephrine, would improve survival to discharge.
While there was an improvement in return of spontaneous circulation (ROSC) and survival to hospital admission there was not an increased survival to hospital discharge. There was also no increase in survivors with good neurological outcomes with ACLS.
There have been a number of papers published since OPALS that support the findings of not using ACLS drugs like epinephrine for OHCA (Olavseengen et al. JAMA 2009, Hagihara et al. JAMA 2012 and Cournoyer et al. AEM 2017).
We reviewed the Cournoyer et al cohort study as part of the #SGEMHOP series with Academic Emergency Medicine (AEM). It demonstrated better ROSC with ACLS but not better survival to hospital discharge (SGEM#189).
A limitation of these studies is their observational nature. There is one randomized control trial on epinephrine for OHCA by Jacobs et al. published in Resuscitation 2011. This Australian trial showed better ROSC with epinephrine but not better survival to hospital discharge in 534 patients.
Unfortunately, the trial failed to achieve their sample size for a variety of reasons which left it underpowered. This means there is a lack of high-quality data to rely upon in deciding whether or not to use epinephrine in OHCA situations.
Clinical Question: Does the use of epinephrine in cardiac arrest improve survival rates with a favourable neurological outcome?
Reference: Perkins et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.
Population: Adult patients with OHCA that ACLS was started by paramedics
Excluded: Pregnancy, age <16 years, cardiac arrest due to anaphylaxis or asthma or the administration of epinephrine before the arrival of the trial-trained paramedic
Intervention: Epinephrine 1mg IV every 3 to 5 minutes
Comparison: Placebo (0.9% saline) IV every 3 to 5 minutes
Outcome:
Primary: Survival at 30 days.
Secondary: Survival to hospital admission, length of stay in the hospital and in the intensive care unit (ICU) , survival at hospital discharge and at three months, and neurological outcomes at hospital discharge and at three months.
Authors’ Conclusions: “In adults with out-of-hospital cardiac arrest, the use of epinephrine resulted in a significantly higher rate of 30-day survival than the use of placebo, but there was no significant between-group difference in the rate of a favorable ne... -
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Date: November 24th, 2018
As you may know, I was invited to give a keynote address on burnout at the Australasia College of Emergency Medicine 2018 Annual Scientific Meeting (#ACEM18) in Perth, Australia. This turned out to be a very meta event.
A few months leading up to the presentation my dad, Dr. Ken Milne Sr. got seriously ill. While he faced this with his usual grace and dignity, I was living on the edge of burnout.
He was admitted to hospital shortly before I was scheduled to leave for Australia. We had a number of discussions and he insisted that I go and not cancel the trip. We reviewed my keynote presentation in the hospital and he gave me the thumbs up. He was very proud and was telling all his treating physicians about his son's honour to be talking at an international medical meeting.
I agreed to go to Australia with his blessing but promised I would live stream the presentation to his hospital bed on the SGEM Facebook page. During the talk I gave him a big shout out and shared my story about being on the edge of burnout.
Working in the emergency department we are on the edge of life and death and that can lead to burnout. Dr. Michelle Johnston (Dustfall) did a fantastic job the during the ACEM18 opening presentation highlighting what we do everyday.
The word burnout was coined by Burnout was a term coined by Herbert Freudenberger in 1974. He defined it as “a state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards”.
There are a number of other ways to define burnout but one of the most widely known and used to assess burnout is the is the Maslach Burnout Inventory (MBI) Score. It was designed by Christina Maslach and Susan Jackson and published in 1981.
Three Components to the Maslach Burnout Inventory:
Emotional Exhaustion
Depersonalization
Reduced Feelings of Personal Accomplishment
A recent study of US physicians showed that more 50% had at least one symptom of burnout. The highest prevalence of burnout (70%) was reported by emergency physicians (Shanafelt et al 2015). One of the most common reasons cited for burnout is the electronic medical record (EMR) (Shanafelt et al 2016).
Burnout can have negative consequences on physicians. It may lead to depression, suicidal ideation, illness, and increased alcohol use.
Burnout has also been associated with negative impacts on patient care including self-perceived medical error, risk of medical errors, and quality of care. If we are not healthy we cannot take good care of our patients.
Some solutions have been suggested to mitigate physician burnout. West et al 2016 published a SRMA in the Lancet on interventions to prevent and reduce physician burnout. One intervention shown to have a positive impact on reducing burnout is mindfulness-based approaches. A recent study done in Australia looked at the efficacy of mindfulness to mitigate burnout (Ireland et al 2017). It provided some evidence that mindfulness can help decrease stress and burnout scores. Whether or not mindfulness training translates into long lasting changes and better patient care remains to be seen.
Burnout Advice from Legend of Emergency Medicine Dr. Richard Bukata:
Pace yourself
Don't Overspend
Become and Expert in Something
Find a Safe Confidant
Life Outside Medicine
If burnout is 70% there is something wrong with the system. We cannot just focus on the individual and try to make them more resilient. We need to stop blaming the person for not being strong enough. It is important to support the individuals and give them tools like mindfulness while at the same time addressing the fundamental problems with the system.
Another very important message from the talk was to be kind to each other. There is a great book by Dr. Brian Goldman called The Power of Kindness: Why Empathy Is Essential in Everyday Life. -
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Date: November 10th , 2018
Reference: Kaltiso et al. Evaluation of a Screening Tool for Child Sex Trafficking Among Patients with High-Risk Chief Complaints in a Pediatric Emergency Department. AEM October 2018.
Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and clinical lecturer in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.
You may have noticed there was no music for the introduction. Part of the SGEM brand is to have some fun and engaging theme music to help with knowledge translation. This topic of child sex trafficking is very serious and disturbing. I struggled with what would be an appropriate song choice. After thinking about it and not coming up with something acceptable I went to twitter to ask my #FOAMed friends.
It was Minh Le Cong (@Ketaminh) who suggested no music for this episode and perhaps a period of silence. Mitochondrial Eve (@BrowOfJustice) agreed and said that she uses silence to great effect frequently. I hold both of these wise people high regard and value their opinion. I listened, and I heard what they said and that is why there was silence rather than song to introduce this SGEMHOP episode on child sex trafficking.
TRIGGER WARNING:
As a warning to those listening to the podcast or reading the blog post, there may be some disturbing things discussed. The SGEM is free and open access trying to cut the knowledge translation down to less than one year. It is intended for clinicians providing care to emergency patients, so they get the best care, based on the best evidence. Some of the material could be considered explicit, graphic, offensive, and/or upsetting. As a trigger warning, if you are feeling upset by the content then please stop listening or reading. There will be resources listed at the end of the blog for those looking for assistance.
Case: A 15-year-old girl presents to the emergency department with pelvic pain. She is with a parent and after the initial introductions and history, you have her parent leave the room to ask more sensitive questions. Upon further history, you discover that she has been having pelvic pain with genital discharge and has had more than ten sexual partners in their lifetime. Eventually, you discover that she has also been drinking alcohol and endorses that she has exchanged sex for drugs in the past.
Background: Child sex trafficking (CST) is a global human rights violation and occurs when a minor is engaged in any sex act which involves an exchange of something of perceived value, whether monetary or non-monetary (1,2).
Examples of CST include prostitution of children by others, “survival sex” (runaway/homeless children having sex in exchange for shelter or something else needed to survive), working in sex-oriented businesses, or production of child sexual abuse materials (3,4).
Statistics from the United States Human Trafficking Reporting System indicate that 85% of identified sex trafficking victims were US citizens/legal residents and 55% were minors (5).
Statistics on trafficking in persons in Canada from 2016 reveal the following (Juristat Bulletin):
Number of police-reported incidents of human trafficking on the rise and is at the highest level since data became available in 2009 (0.94/100,00 people)
One in three police-reported human trafficking incidents is a cross-border offence
More than half of human trafficking incidents involve another offence, usually prostitution
The vast majority (95%) of the victims of human trafficking are women, 72% are under 25 years of age and most of the people accused of human trafficking are male (81%).
Risk factors associated with CST include a history of abuse, substance use, juvenile justice system involvement, a history of running away from home and LGBTQ status (6-12).
Victims of CST are at risk for a myriad of health-related consequences, -
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Date: November 6th , 2018
Reference: Sprigg et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018
Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s eighth visit to the SGEM.
DISCLAIMER: The views and opinions of this podcast do not represent the United States Government or the US Air Force.
Case: Your next patient is a stroke alert for a 67-year-old male living at a nursing home presents with severe right sided upper and lower extremity weakness noticed one hour ago while eating a meal. He obtains a stat head CT which shows an intracerebral hemorrhage. In addition to controlling his elevated blood pressure, you wonder if there is more you can offer this patient to improve his outcome and odds of survival. A resident points out that tranexamic acid (TXA) has been shown to decrease mortality for other hemorrhagic conditions, and questions if that could be helpful.
Background: Stroke due to intracerebral hemorrhage (ICH) comprises approximately 20% of all strokes, but about half of all stroke deaths worldwide. Currently the only intervention known to adjust mortality in these cases is blood pressure management.
Lowering BP in ICH cases of was covered on SGEM#73: How Low Can You Go. The AHA Guidelines were updated since those episodes and recommend the following (Hemphill et al Stroke 2015):
For ICH patients presenting with SBP between 150 and 220 mmHg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mmHg is safe (Class I; Level of Evidence A) and can be effective for improving functional outcome (Class IIa; Level of Evidence B). (Revised from the previous guideline)
For ICH patients presenting with SBP >220 mmHg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusion and frequent BP monitoring (Class IIb; Level of Evidence C). (New recommendation)
SGEM#172: Don’t Bring My Blood Pressure Down (Intensively) – The ATACH2 Trial did not support intensely lowing blood pressure. There was no statistical difference in death or disability between intensive blood pressure reduction (SBP 110-139 mm Hg) vs. standard blood pressure reduction (SBP 140-179 mm Hg) in patients with acute intracerebral hemorrhage.
TXA is a cheap drug that has been shown to improve mortality in trauma (CRASH-2), presumably due to its antifibrinolytic effect.
TXA has been discussed on the SGEM a number of times for epistaxis, trauma and post-partum hemorrhage:
SGEM#53: Sunday, Bloody Sunday (Epistaxis and Tranexamic Acid)
SGEM#80: CRASH-2 (Classic Paper)
SGEM#210: (Don’t) Let it Bleed – TXA for Epistaxis in Patients on Anti-Platelet Drugs
SGEM#214: Woman – The TXA Trial for Post-Partum Hemorrhage
Before this trial was started there were apparently only two small randomized control trials using TXA with a total of 54 patients. They provided no clear evidence for benefit or harm.
Clinical Question: Does administration of tranexamic acid reduce hematoma expansion and improve outcomes in adults with stroke due to intracerebral hemorrhage?
Reference: Sprigg et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet. 2018
Population: Adults with acute intracerebral hemorrhage admitted within eight hours of symptom onset.
Exclusion: Intracerebral haemorrhage secondary to anticoagulation, thrombolysis, trauma, or a known underlying structural abnormality; patients for whom TXA was thought to be contra-indicated; pre-stroke dependence (mRS score >4); life expectancy less than three months; and GCS score less than five. A complete list of exclusion criteria is available in previous publication. -
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Date: October 30th , 2018
Reference: Raskob GE et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. NEJM 2018
Guest Skeptic: Dr. Anand Swaminathan is an assistant professor of Emergency Medicine at the St. Joseph’s Regional Medical Center in Patterson, NJ. He is a deputy editor for EM: RAP and, associate editor for REBEL EM.
Case: A 43-year old woman with a history of breast cancer currently undergoing chemotherapy presents with mild chest pain. She is hemodynamically stable except for a heart rate of 105 and her pain is increased when she takes a deep breath. The chest x-ray is unremarkable, and you order a CT pulmonary angiogram (CTPA) which demonstrates a right segmental pulmonary embolism. You write a prescription for low molecular weight heparin (LMWH) and advise the patient that she will be taking shots for a couple of months. She tells you that a friend of hers had a clot in her leg and was given an oral blood thinner. She wants to know if you can prescribe that pill, so she doesn’t have to take a shot.
Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy at this time for both symptomatic and asymptomatic VTE is with LMWH based on results from the CLOT trial (Lee 2003).
In non-cancer patients, new oral anticoagulants (NOACs) like rivaroxaban have been shown to be effective in treatment without increasing bleeding events. The NOACs also add ease of use for the patient.
We covered using rivaroxaban on SGEM#126 with VTE guru Dr. Jeff Kline. This study suggested it was safe and effective to dry start (no LMWH needed) in certain patients with DVTs and PEs.
Though these agents are frequently used in the treatment of cancer-associated VTE, there is a dearth of evidence supporting this practice, in fact, none of the major agents - dabigitran, rivaroxaban, apixaban or edoxaban have undergone a well-done, randomized controlled trial.
Clinical Question: Is edoxaban non-inferior to LMWH in the treatment of cancer-associated VTE?
Reference: Raskob GE et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. NEJM 2018
Population: Adult patients with active cancer or cancer diagnosed within the previous two years with acute symptomatic or asymptomatic deep-vein thrombosis (DVT) or pulmonary embolism (PE).
Exclusions:See link to the list of exclusions in the Supplementary Appendix
Intervention: LMWH for five days followed by oral edoxaban 60 mg daily for at least six months.
Comparison: Subcutaneous (SQ) dalteparin 200 IU/kg daily (maximum dose 18,000IU) for one month followed by 150 IU/kg daily for at least five months.
Outcome:
Primary: Composite of recurrent VTE (DVT or segmental or more proximal PE) or major bleeding (overt bleeding associated with 2g/dL drop in hemoglobin or a transfusion of two or more units of blood during twelve-month follow up.
Secondary: Clinically relevant non-major bleeding (CRNB), event-free survival, VTE-related death, all-cause mortality, recurrent DVT, recurrent PE. The complete list can also be found in the Supplementary Appendix.
Authors’ Conclusions: “Oral edoxaban was noninferior to subcutaneous dalteparin with respect to the composite outcome of recurrent venous thromboembolism or major bleeding. The rate of recurrent venous thromboembolism was lower but the rate of major bleeding was higher with edoxaban than with dalteparin.”
Quality Checklist for Randomized Clinical Trials:
The study population included or focused on those in the emergency department. Unsure.
The patients were adequately randomized. Yes
The randomization process was concealed. No
The patients were analyzed in the groups to which they were randomized. Yes -
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Date: October 17th , 2018
Reference #1: Aycock, Westafer et al. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med 2018 (CRD42017056195)
Reference #2: Weisbord SD, Gallagher M, Jneid H, et al; PRESERVE Trial Group. Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine. NEJM 2018 (ClinicalTrials.gov NCT01467466.)
Guest Skeptic: Dr. Lauren Westafer is a board certified emergency physician at Baystate Medical Center and instructor in the Department of Emergency Medicine at the University of Massachusetts Medical School. She is author of the blog, The Short Coat, and cofounder of the emergency medicine podcast, FOAMcast. Lauren is currently funded by an NHLBI K12 grant (1K12HL138049-01) studying the implementation of evidence-based diagnosis of pulmonary embolism in the emergency department.
Case: A 64-year-old woman with type-2 diabetes. She presents to the emergency department with chest pain and some shortness of breath. The acute coronary syndrome work-up is negative but she is Well’s high and needs a CTPA to rule-out a pulmonary embolism. Her GFR is 50 and you are wondering if the contrast needed for the CT will cause an acute kidney injury (AKI) and if so, can you do anything to mitigate causing an AKI?
Background: There has been a huge increase in the number of CT scans performed with more than 75 million CT scans performed in the US in 2013. Some scans require intravenous contrast (CTPA and CTCA) while in other cases it may improve image quality.
There has been a lot of ink spilled over contrast-induced nephropathy (CIN). It came out of case reports and non-controlled studies. Historically the CTs were done with high osmolar contrast material and these non-controlled studies showed a rise in AKI. However, we now use iso-osmolar or low osmolar contrast and we are not seeing kidneys die as a result.
Multiple observational studies have been published demonstrating that AKI in the modern era does not exist. Part of the difficulty with this topic is the inconsistent definition of contrast-induced nephropathy. A common definition is an increase in creatinine level by 25% or an absolute increase of 0.3 to 0.5 mg/dL within 3 days.
These are all disease-oriented outcomes (change in laboratory values) not patient-oriented outcomes like death or need for dialysis.
Clinical Question #1: Is CT contrast associated with acute kidney injury?
Reference: Aycock, Westafer et al. Acute Kidney Injury After Computed Tomography: A Meta-analysis. Ann Emerg Med 2018 (CRD42017056195)
Population: Adult humans
Exclusions: Pediatrics, non-human studies, studies of contrast enhanced procedures (ex: coronary angiography), interventional studies, case reports, review articles, clinical guidelines, other meta-analyses
Intervention: Contrast enhanced CT scans
Comparison: Noncontrast CT scan
Outcome:
Primary Outcome: Incidence of acute kidney injury
Secondary Outcomes: Mortality or need for renal replacement therapy
Authors’ Conclusions:“We found no significant differences in our principal study outcomes between patients receiving contrast-enhanced CT versus those receiving noncontrast CT. Given similar frequencies of acute kidney injury in patients receiving noncontrast CT, other patient- and illness-level factors, rather than the use of contrast material, likely contribute to the development of acute kidney injury.”
Quality Checklist for Systematic Review Prognostic Studies:
The prognostic question is clinically relevant for ED patients? Yes
The individual study patients were sufficiently homogeneous with respect to prognostic risk for the outcome? No
The individual study assessment for the outcome used objective, reproducible, and unbiased criteria? Yes
The individual study period of follow-up was sufficiently long and complete? Unsure
The search for studies was detailed and exhaustive? Yes -
[display_podcast]Date: October 10th , 2018Reference: Karlow et al. A Systematic Review And Meta-Analysis of Ketamine as an Alternative to Opioids for Acute Pain in the Emergency Department. AEM Oct 2018.Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME Editor for Academic Emergency Medicine.Case: You are caring for a 38-year-old male (Larry) who presented to the emergency department with lower back pain. During your evaluation, he tells you he doesn’t want any narcotic pain medication. You wonder if there are alternative options, and a colleague reminds you that ketamine has recently gained a lot of exposure as a possible alternative.Background: The amelioration of pain and suffering should be one of the top priorities of emergency physicians. In 2001, JACHO made pain the 5th vital sign to address the issue of oligoanalgesia, which unfortunately created many problems.Opiates became a very common treatment for acute pain in the ED setting after JACHO and the introduction of new and powerful opioids like oxycodone.However, in recent years, an increased desire for alternatives has been prompted in an attempt to reduce opiate usage. The pendulum is swinging to opiophobia. This can leave the patient left in the middle with ineffective pain management.One alternative or adjunct to limit the use of opioids in the ED is low dose ketamine (LDK). Several studies have been performed evaluating low dose ketamine (LDK) for acute pain, with a variety of methodological designs, time endpoints, and doses.We have covered some of those papers and watched the literature develop over the years on the SGEM. SGEM#111: Comfortably Numb – Low dose Ketamine as Adjunct for ED Pain ControlSGEM Bottom Line: High-quality published evidence to support the use of sub dissociative-dose ketamine to quickly reduce acute pain in emergency department settings is lacking, but lower quality studies inconsistently demonstrate effectiveness with uniformly low risk of adverse effects. SGEM#130: Low Dose Ketamine for Acute Pain Control in the Emergency Department (reviewed two ketamine papers)SGEM Bottom Line: For patients who have a contraindication to opioids such as allergy or hypotension, sub dissociative ketamine would be a reasonable option to consider for treating acute pain.SGEM Bottom Line: While further validation in other settings is needed, this study suggests ketamine as a relatively safe option for patients who do not achieve analgesia with high doses of morphine or are unable to tolerate them. SGEM#198: Better Slow Down – Push vs. Short Infusion of Low Dose Ketamine for Pain in the Emergency DepartmentSGEM Bottom Line: Slowing down the rate of low-dose IV ketamine infusion to 15 minutes significantly reduces rates of the feeling of unreality and sedation with no difference in analgesic efficacy when compared to IV push over 3 – 5 minutes. Clinical Question: Is ketamine, at a dose of 18 years old receiving LDK for acute pain Exclusions: Did not report visual analog scale (VAS) score or numeric rating scale (NRS) pain scale measurement, co-administration of pharmacologically active substance less than 20 min after IV ketamine/opioid administration, included a placebo group Intervention:
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Date: October 5th , 2018
Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018
Guest Skeptic: Alison Armstrong is an Emergency Department Nurse, TNCC Course Director, Trauma Program Coordinator and Canadian C-Spine Rule Nurse Champion.
Case: There are two case scenarios this week to try and capture the two common ways patients present to the triage nurse.
Case 1: A 51-year-old male patient presents to triage in a collar on a back-board via EMS following a rear-end motor vehicle collision (MVC) at a stop light. He was a belted driver with no past medical history and GCS 15. The driver of the car that hit him was texting and did not appear to slow before striking the rear of the patient’s car at about 50 km/hr. The patient complains of left shoulder and neck pain.
Case 2: A 45-year-old female presents to triage at 20:30 walking stating that she fell from a chair this morning. She went to work all day as she thought she was unhurt initially, but pain has started to set in so she stopped by the emergency department on the way home complaining of right wrist and neck pain and stiffness all over. She is worried she may have a serious injury to her neck.
Background: Clearing the c-spines is a regular activity in the emergency department (ED). This can be done clinically using the Canadian C-Spine Rules/Tools or with imaging. The vast majority of these patients (>99%) do not have a fractured cervical spine diagnosed.
Blunt trauma patients transported via EMS often arrive on a backboard, c-collar and head restraints. They remain this way often complaining to the nurse until they can be assessed by a physician and have their c-spine cleared.
There are protocols to get blunt trauma patients off spine boards urgently. However, they still can remain in c-spine precautions for a long time waiting to be assessed. This adds to patient discomfort, occupies valuable acute ED space and can contribute to crowding.
The Canadian C-Spine Rule (CCR) is a clinical decision instrument developed to allow clinicians to clear the c-spine without imaging (1). This instrument has been validated to be safe and decrease use of diagnostic imaging (2,3).
Canadian C-Spine Rule (CCR)
The CCR applies to alert (GCS=15) and stable trauma patients where cervical spine injury is a concern
Dangerous Mechanism
Fall from elevation>=3 feet/ 5 stairs
Axial load to head (diving)
MVC high speed (>100km/hr), rollover, ejection
Motorized recreational vehicle
Bicycle collision
Clinical Question: Can emergency department triage nurses apply the Canadian C-Spine Rule to adult blunt trauma patients and safely clear the c-spine?
Reference: Stiell et al. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Annals of EM Oct 2018
Population: Alert adults presenting to the ED ambulatory or by EMS with acute blunt trauma occurring within the previous 48 hours with posterior neck pain and were in stable condition. Alert and stable was defined as a Glasgow Coma Scale (GSC) score of 15 with normal vital signs.
Exclusions: Age less than 16 years, penetrating trauma, acute paralysis, or known vertebral disease
Intervention:
Phase 1 (Certification): All ED nurses who performed triage activities had didactic training and then had to demonstrate competence by accurately assessing ten patients before being certified.
Phase 2 (Implementation): All triage nurses who had become certified were empowered by a medical directive to “clear” the cervical spine of patients, allowing them to remove cervical spine immobilization of CCR–negative patients and triage them to a less acute area.
Comparison: None
Outcomes:
Primary Outcomes:
Clinical: Proportion of eligible trauma patients who had their cervical spine cleared by ... -
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Date: September 21st, 2018
Reference: Kawano et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Annals of EM May 2018
Guest Skeptic: Andrew Merelman is a critical care paramedic and first year medical student at Rocky Vista University in Colorado. His primary interests are resuscitation, prehospital critical care, airway management, and point-of-care ultrasound.
Case: A 46-year-old man has a cardiac arrest at home, witnessed by family. Bystander CPR is initiated prior to EMS arrival. EMS arrives on scene and initiates high quality basic life support (BLS). One defibrillation for ventricular fibrillation (VF) is provided but the patient remains in VF. As part of their protocol, they attempt vascular access to administer epinephrine and an antidysrhythmic. They wonder whether it would be better to attempt a peripheral intravenous (IV) line or intraosseous access first?
Background: Cardiac arrest care has evolved drastically over the past couple of decades, but not in the way many may have expected. We now know that an emphasis on the basics (high quality chest compressions and defibrillation) are the most important aspects of resuscitation. More advanced skills such as airway management, vascular access, and cardiac medications are being de-emphasized.
It was the classic OPALS paper covered on SGEM#64 by the Legend of Emergency Medicine Dr. Ian Stiell that demonstrated no advantage to ACLS vs. BLS for out-of-hospital cardiac arrest (OHCA).
There have been other SGEM episodes that question the efficacy of various interventions:
Man vs. mechanical CPR for OHCA (SGEM#136)
ACLS for OHCA (SGEM#189)
Not Stayin’ Alive More Often with Amiodarone or Lidocaine (SGEM#162)
Remote ischemic conditioning for OHCA (SGEM#116)
Pre-hospital therapeutic hypothermia (SGEM#21, SGEM#54, SGEM#82 and SGEM#183)
The resuscitation science community has been struggling to find advanced interventions that can show a benefit in mortality and, most importantly survival with good neurological outcome.
Intraosseous access has become a mainstay of cardiac arrest care due to its speed and reliability. However, no randomized trial has compared intravenous access to intraosseous access with a primary outcome of good neurologic function.
Clinical Question: Is intraosseous vascular access in the pre-hospital setting for OHCA associated with better neurologic outcomes compared to intravenous vascular access?
Reference: Kawano et al.Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Annals of EM May 2018
Population: Out-of-hospital, non-traumatic, adult cardiac arrest patients
Excluded: Unsuccessful attempt or more than one access site. Patients were also excluded if incarcerated or pregnant, those with DNR orders, and those with arrests presumed to be the result of exsanguination or severe burns.
Intervention: Primary intraosseous vascular access
Comparison: Primary intravenous vascular access
Outcome:
Primary Outcome: Favourable neurological outcome (modified Rankin Scale [mRS] score 3)
Secondary Outcomes: Return of spontaneous circulation (ROSC) and survival to hospital discharge.
Authors’ Conclusions: “In adult out-of-hospital cardiac arrest patients, intraosseous vascular access was associated with poorer neurologic outcomes than intravenous access.”
Quality Checklist for A Chart Review:
Were the abstractors trained before the data collection? Unsure
Were the inclusion and exclusion criteria for case selection defined? Yes
Were the variables defined? Yes
Did the abstractors use data abstraction forms? Unsure
Was the abstractors’ performance monitored? N/A
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Date: September 17th, 2018
Reference: Meltzer, A. et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Internal Med, 2018.
Guest Skeptics: Dr. Tony Seupaul, Professor and Chair, University of Arkansas for Medical Sciences Department of Emergency Medicine. Dr. Daniel Holleyman, Chief Resident at University of Arkansas for Medical Sciences Emergency Medicine Residency.
Case: A 51-year-old man presents to the emergency department (ED) with five-hour history of acute onset left flank pain. The pain comes in waves, radiates into his left groin and is associated with nausea and vomiting. He noticed darkening of his urine, but does not have dysuria, fever, testicular pain, or penile discharge.
You work him up and the urine analysis shows large blood, negative nitrites, negative bacteria. CT abdomen/pelvis without contrast is done which identifies a 7mm radiopaque stone in the left distal ureter. The patient receives 15mg ketorolac IV (SGEM#175) because you know there is a ceiling to the analgesic effect of non-steroidal anti-inflammatory drugs (NSAIDs). His pain improves significantly, and he is ready for discharge. He is given a referral to Urology for follow up of his ureteral stone, a prescription for oral antiemetics, and advised to take over-the-counter (OTC) NSAIDs. He asks if there is anything he could do or take to help the stone pass faster?
Background: We have covered renal colic many times on the SGEM. This has included the medical expulsive therapy using alpha blockers, lidocaine for pain control, pushing IV fluids or diuretics to pass stones, ultrasound vs. CT scans for diagnosis, and even acupuncture vs. morphine for renal colic pain.
SGEM#4: Getting Un-Stoned (Renal Colic and Alpha Blockers)
SGEM#32: Stone Me (Fluids and Diuretics for Renal Colic)
SGEM#71: Like a Rolling Kidney Stone
SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic
SGEM#154: Here I Go Again, Kidney Stone
SGEM#202: Lidocaine for Renal Colic?
SGEM#220: Acupuncture Morphine for Renal Colic
The SGEM bottom lines on the management of renal colic from those previous episodes were as follows:
Expulsive therapy is unnecessary for ureteric stones < 5mm.
You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones.
There is some weak evidence that Tamsulosin MAY help passage of larger stones (5 to 10 mm).
Bedside emergency department ultrasound is safe and has several advantages over CT for the diagnosis of kidney stones.
Lidocaine cannot be recommended for the treatment of renal colic at this time.
The evidence does not support the claim that acupuncture is superior to morphine for renal colic.
Clinical Question: Does initiation of Tamsulosin at the time of diagnosis in ED patients with symptomatic ureteral stones less than 9mm increase the rates of stone passage in the following 28 days?
Reference: Meltzer, A. et al. Effect of Tamsulosin on Passage of Symptomatic Ureteral Stones: A Randomized Clinical Trial. JAMA Internal Med, 2018.
Population: Emergency Department patients older than 17 years of age with symptomatic ureteral stone less than 9mm as determined by CT
Excluded: There were 19 exclusions that can be found in the ClinicalTrial.gov website NCT00382265
Intervention:Tamsulosin 0.4mg daily for 28 days
Comparison: Placebo
Outcome:
Primary: Passage of the stone within 28 days, determined by visualization or physical capture of the stone by patient
Secondary: Assessment of stone passage by follow up CT; number who crossed-over to open-label Tamsulosin; proportion who returned to work; rate of surgical procedures; rate of hospitalization; percentage returning to the ED; duration of analgesic medication use; time to passage of stone.
Authors’ Conclusions: “Tamsulosin did not significantly increase the stone passage ra... -
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Date: September 10th, 2018
Reference: Gurley et al. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Non-Resident Cases. AEM September 2018
Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the Director of Simulation Education at Markham Stouffville Hospital in Ontario. He is the creator of the excellent #FOAMed project called First10EM.com
Case: You are giving an introductory lecture on evidence-based medicine to the incoming class of residents, and after you finish you notice some excited chatter at the back of the room. Thinking that you have found some EBM keeners/gunners, you wander over to join the discussion, but find yourself in a heated discussion. One of the senior residents was recently named in a lawsuit, and the junior residents are worried. How likely are they to be sued? What can they do to prevent such a harrowing event? The residents turn to you, hoping that you can provide some insight on this topic.
Background: Unfortunately, physicians are not perfect. Mistakes are made occasionally, and those mistakes can harm our patients.
Medical care provided by trainees involves some added risks. In an internal medicine setting, problems with handoffs, teamwork, and lack of supervision were identified as issues in trainee malpractice cases.
In Canada, we have a national organization called the Canadian Medical Protective Association (CMPA). The CMPA has approximately 97,000 members representing 95% of Canadian physicians.
There are about 10,000 files opened every year with 38% involving payouts. Only 8% of cases end up in court. There has been a 5% decrease in cases over the last decade.
It is important to note that our medical-legal environment in Canada is much different than in the United States. It is a much more litigious system south of the border. The paper we will be talking about today come out of the US.
Clinical Question: What are some of the key factors in malpractice claims against trainees, and how do those compare to malpractice cases that don’t involve trainees?
Reference: Gurley et al. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Non-Resident Cases. AEM September 2018
Population: The Comparative Benchmarking System (CBS) database: a large database of malpractice claims covering more than 400 hospitals and more than 165,000 physicians.
Intervention: Malpractice claims involving trainees (residents) in an emergency department setting over a three-year period from 2009-2012.
Comparison: Malpractice claims not involving trainees in the same time period.
Outcomes: Coded information covering a number of domains.
Average Payment
Case Severity (low, medium, high or death only)
Allegation Category (Diagnosis Related, Medical Treatment, Surgical Treatment, Medication Related or other)
Procedure Involved (yes/no and if yes what procedure)
Final Diagnosis (ex: cardiac related, orthopedic related, etc)
Contributing Factors (ex: communication, clinical judgement, documentation, etc)
This is the first SGEMHOP for Season#7 and of course we have the lead author here ready to give her conclusions to the study and Talk Nerdy to us.
Dr. Kiersten Gurley is a Clinical Instructor at Harvard Medical School. She is also an Attending Emergency Physician and Assistant Quality Improvement Director in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center.
Authors’ Conclusions:“There are higher total incurred losses in non-resident cases. There are higher severity scores in resident cases. The overall case profiles, including allegation categories, final diagnoses and contributing factors between resident and non-resident cases are similar. Cases involving residents are more likely to involve certain technical skills, specifically vascular access and spinal procedures, which may have important implications regarding supervision. -
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Date: September 5th, 2018
Reference: Franklin et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM March 2018.
Guest Skeptic: Dr. Ben Lawton is a paediatric emergency physician in Brisbane Australia. He divides his time between a tertiary children’s hospital and a community hospital that is busy enough to have its own paediatric emergency department. He is part of the Don’t Forget the Bubbles team.
Case: Elsie is five months old and presents on day two of a bronchiolitic illness. She has taken just under half of her usual feeds so far today and has a respiratory rate of 58 breaths per minute and oxygen saturation of 90% on room air with moderate work of breathing. She is not clinically dehydrated and has a temp of 38.2C with clear rhinorrhea, red ears, a red throat and equal air entry with widespread crackles and wheeze. She was born at term, is immunised and has no significant medical history. Her parents Dave and Tony have driven 20 minutes from home to bring her to the regional hospital where you work. Your hospital has an inpatient paediatric ward but is a 90-minute drive from the nearest children’s hospital with PICU facilities.
Background: We have covered bronchiolitis before on the SGEM#167 with expert Dr. Amy Plint. That episode looked at how bronchiolitis was managed in community hospitals. The bottom line was that there seemed to be a knowledge gap when it comes to managing bronchiolitis in the community setting (previous evidence as suggested a knowledge gap also exists in the academic pediatric hospitals).
Although the vast majority of infants with bronchiolitis can be managed with supportive care at home, due to its high incidence, it is the number one reason for infants to be hospitalized (Njoo et al 2001, Langley et al 2003, Craig et al 2007 and Shay et al 1999).
Since bronchiolitis is a clinical diagnosis, there is no test, including viral testing and radiography, which rules it in or out (Schuh et al 2007). Sadly, despite multiple guidelines (NICE, AAP, CPS), there has also been no “magic bullet” in terms of treatment.
Hypertonic saline has been tried for acute bronchiolitis. A systematic review of this treatment modality was covered on SGEM#157. The bottom line at that time was that the data did not support the routine use of hypertonic saline for mild to moderate acute bronchiolitis.
The American Academy of Pediatrics guideline says that oxygen therapy in infants with saturation of 90% or greater may not be needed (Ralston et al Pediatrics 2014)
“Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]).”
Clinical Question: Will Elsie benefit from the use of heated humidified high-flow oxygen via nasal prongs in preference to low flow oxygen via standard nasal cannula?
Reference: Franklin et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM March 2018.
Population: Infants less than 12 months of age with bronchiolitis and needing supplemental oxygen based on their institutional practice.
Bronchiolitis was defined using the American Academy of Pediatric criteria as symptoms of respiratory distress associated with symptoms of a viral respiratory tract infection.
Exclusions: Critically ill infants who had an immediate need for respiratory support and ICU admission; infants with cyanotic heart disease, basal skull fracture, upper airway obstruction, or craniofacial malformation; and infants who were receiving oxygen therapy at home.
Intervention: Heated humidified high-flow oxygen via nasal prongs (HFOT) at 2L/Kg/min with FiO2 titrated to maintain oxygen saturation of 92%-98% or 94%-98% depending on the institutional p... - Show more
