The Skeptics Guide to Emergency Medicine
The Skeptics Guide to Emergency Medicine
Dr. Ken Milne
Meet 'em, greet 'em, treat 'em and street 'em
SGEM#341: You Make Me Feel Like a Natural Treatment
Reference: Li, T., & Gal, D. (2023). Consumers prefer natural medicines more when treating psychological than physical conditions. Journal of Consumer Psychology 2023, Date: February 23, 2024 Guest Skeptic: Ethan Milne is a Marketing PhD student at the Ivey Business School (Western University). He researches how moral outrage and status-seeking personalities motivate social media aggression, and how retribution can motivate consumer donations. Case: A 20-year-old male presents to the emergency department with palpitations. After a good history, directed physical examination and appropriate investigations you suspect he is suffering from a major depressive disorder (MDD) with a comorbidity of anxiety.  He is not a threat to himself or others and wants assistance. You arrange for him to be followed up by his family physician to discuss possible treatment options which include medications. He expresses concern that taking a synthetic drug to treat his depression wouldn’t allow him to be his authentic self. Background: Major Depressive Disorder, commonly known as depression, is a significant mental health condition. Depression is a leading cause of disability worldwide and is a major contributor to the overall global burden of disease. It affects an estimated 5-10% of the population at any given time, with variations depending on demographic factors such as age and gender. It is generally more common in women than in men and can occur at any age, although it often first appears during late adolescence to mid-20s [1]. The National Institute of Health (NIH) estimates that around 8.3% (21.0 million) of US adults over 18 have experienced a major depressive episode in the last year. Various factors can increase the risk of developing MDD, including genetic predisposition, personal or family history of depression, major life changes, trauma, stress, and certain physical illnesses and medications. Depression has been reported to be most prevalent among young women aged 12-17 (29.2%) [2]. The current diagnostic criteria for MDD are outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR). These criteria serve as a guideline for clinicians to diagnose depression. To be diagnosed with MDD, a person must experience at least one of the two symptoms for at least two weeks: * Depressed Mood: Most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). * Loss of Interest or Pleasure: Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day. The person must also have five or more of the following symptoms during the same 2-week period, and these symptoms represent a change from previous functioning. * Significant Weight Loss or Gain (or decrease or increase in appetite nearly every day) * Insomnia or Hypersomnia: Trouble sleeping or sleeping too much nearly every day. * Psychomotor Agitation or Retardation: Noticeable by others, not merely subjective feelings of restlessness or being slowed down. * Fatigue or Loss of Energy: Nearly every day. * Feelings of Worthlessness or Excessive or Inappropriate Guilt: Nearly every day, not merely self-reproach or guilt about being sick. * Diminished Ability to Think or Concentrate (or indecisiveness, nearly every day) * Recurrent Thoughts of Death: Recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Feb 24
48 min
SGEM#430: De Do Do Do, De Dash, Dash DAShED – Diagnosing Acute Aortic Syndrome in the ED.
Reference: McLatchie et al and DAShED investigators. Diagnosis of Acute Aortic Syndrome in the Emergency Department (DAShED) study: an observational cohort study of people attending the emergency department with symptoms consistent with acute aortic syndrome. EMJ Nov 2023. Date: February 11, 2024 Guest Skeptic: Nirdosh Ashok Kumar, Emergency Medicine Specialist – Aga Khan University Hospital, Karachi, Pakistan. Case: A 66-year-old female with a history of smoking, hypertension, and type-2 diabetes presents to the emergency department (ED) with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She is bradycardic, hypotensive, and tachypneic. She is received in the resuscitation room. Monitors have been attached, and intravenous (IV) access has been achieved and IV analgesia has been given. The ECG shows sinus tachycardia with non-specific ST-T changes. The chest x-ray is unremarkable. However, she is still in severe pain. A post-graduate year 2 (PGY-2) resident asks you if it could be a ruptured abdominal aortic aneurysm, aortic dissection, or angina. Background: The diagnosis of acute aortic syndrome (AAS) is commonly delayed or missed in the ED. AAS has been referred to as the “lethal triad” that incorporates aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) [1].  It is a rare condition with a high mortality rate and can present in atypical ways. It affects approximately 4,000 people per year in the United Kingdom [2] and 43,000 to 47,000 people per year in the USA [3]. The annual incidence rate of AD ranges between 2.9 and 7.2 per 100,000. [4-8] The misdiagnosis rate is estimated to be between 16% and 38%6,[9-19] with a diagnostic delay of up to 24 hours for 25% of cases, and mortality follows a linear increase of 0.5% per hour in the first 48 hours. [20] A retrospective observational study from Canadian researcher, Dr. Robert Ohle was published in CJEM in 2023. This study found that between 2003 and 2018, there were 1,299 cases of AAS in Ontario, the largest province in the country. It reported an overall annual incidence rate of 0.61 per 100,000 people which is much lower than previously reported rates. The study also highlighted the significant mortality rate associated with AAS, with a one-year mortality rate decreasing from 47.4% to 29.1%, and ED mortality at 14.9%​​. [21] When looking specifically at atraumatic chest pain presentations to the ED, it is estimated the incidence of AAS is one in 980. [22] It can be like looking for a needle in a haystack of chest pain patients. The gold standard for diagnosing AAS is to perform a CT aorta angiogram (CTA). However, scanning everyone chest pain patient would have a very low diagnostic yield [23,24], expose many patients to unnecessary ionizing radiation and end up being very costly. It would be great if there was a validated clinical decision tool (CDT) to help clinicians be more selective in using CTA to diagnose AAS. Some CDTs have been devised and tested for diagnosing AAS. [25,26] The Aortic Dissection Detection Risk Score (ADD-RS) is one CDT that has been derived and tested. Four studies with methodologic limitations were included in an SRMA of the ADD-RS and published in AEM 2020. [27] The authors concluded that patients with an ADD-RS score of ≤ 1 with d-dimer < 500 ng/mL have high sensitivity for ruling out AASs. However, it is unclear if it is good enough for clinicians to use, better than clinical gestalt [28,29], and an impact analysis has not been done to determine if it would lead to fewer CTAs and d-dimers being performed. Clinical Questions: What are the characteristics of ED attendances with possible AAS, how effective are existing clinical decision tools (ADD-RS, Canadian Guideline, Sheffield, AORTAs) and the use of CTA in an undifferentiated cohort of...
Feb 11
35 min
SGEM #429: It’s CT Angio, Hi. I’m the Problem. It’s Me. For Pediatric Oropharyngeal Trauma
Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 Date: January 30, 2024 Guest Skeptic: Dr. Alexandra (Ali) Espinel is an Associate professor of pediatrics and otolaryngology at Children’s National Hospital and George Washington University. She is also the director of the Pediatric Otolaryngology Fellowship at Children’s National Hospital. Case: You’re working the morning shift in the emergency department (ED) when you encounter a 3-year-old boy and his family. His parents tell you that he was getting ready to go off to daycare and brushing his teeth while standing on a step stool by the sink. He slipped and the toothbrush poked him in the back of the mouth. Initially, his parents noticed that he was bleeding from his mouth and saw what looked like a wound towards the back of his throat. The boy cried immediately afterwards but has otherwise been acting like himself. On your exam, you notice a small penetrating intraoral injury just lateral to the soft palate without evidence of continued bleeding. His parents ask you, “Is he going to be, okay? We’re glad he’s not bleeding anymore. Do you think he needs any imaging to see if he hurt anything?” Background: Kids like to put things in their mouths. Kids like to run around. Sometimes, kids may fall while having something in their mouth which may cause damage to their oropharynx. The ensuing damage can vary. It could be blunt trauma or penetrating trauma. We get concerned about injuries to the soft palate because of possible deep space neck infection and the risk of injury to the carotid artery behind it which has been associated with thrombosis, dissection, and cerebral infarctions. These super scary complications have been reported in the literature but seem relatively rare. We have many clinical decision tools for imaging in pediatric head trauma [1] or abdominal trauma [2]. But we do not have any of the same tools for oropharyngeal injury which means that there is wide variation about which imaging studies are ordered. Clinical Question: What is the role of CT angiography (CTA) in the diagnosis and management of pediatric oropharyngeal trauma?  Reference: Curry SD, et al. Systematic Review of CT Angiography in Guiding Management in Pediatric Oropharyngeal Trauma. Laryngoscope. March 2023 * Population: Patients <18 years old with trauma to the oropharynx. They included meta-analyses, systematic reviews, randomized control trials (RCTs), case-control and cohort studies, case series and case reports. * Excluded: Oropharyngeal trauma combined with other severe head injury or multisystem trauma, not primary research, non-English publication * Intervention: CTA * Comparison: No CTA * Outcome: radiologic and clinical outcomes including infection, injury to vasculature, cerebrovascular injury, and neurologic abnormalities. * Type of Study: Systematic Review and Meta-Analysis of diagnostic studies. Authors’ Conclusions: “Imaging with CTA yielded radiological abnormalities in a few instances. These results do not support the routine use of CTA in screening pediatric oropharyngeal trauma when balanced against the risk of radiation, as it rarely resulted in management changes and was not shown to improve outcomes.” Quality Checklist for Systematic Review Diagnostic Studies: * The diagnostic question is clinically relevant with an established criterion standard. Yes * The search for studies was detailed and exhaustive. No. * The methodological quality of primary studies was assessed for common forms of diagnostic research bias. Yes. * The assessment of studies was reproducible. Yes
Feb 3
18 min
SGEM#428: Don’t Worry, Be Happy – The Safety of Nitroglycerin Administration in RVMI
Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023 Date: January 24, 2024 Guest Skeptic: Dr. Rupinder Sahsi is a fellow EBM enthusiast with academic appointments at McMaster University and Wright State University who works as an emergency physician in Kitchener-Waterloo, Ontario, Canada. He is also an assistant medical director for EMS at the Centre for Paramedic Education and Research in Hamilton, Ontario, Canada. Case: You are an advanced care paramedic dispatched to the scene of a 53-year-old female with chest pain. She developed retrosternal chest discomfort shortly after she came in from using her snowblower. You provide her with two tablets of ASA to chew while your partner acquires an ECG, which ultimately shows clear ST elevation in the inferior leads and some ST changes in V1-V2 that make you wonder if your patient is having an acute myocardial infarction (MI) with right-sided ventricular involvement (RVI). Your patient rates their pain as an 8/10 and looks visibly uncomfortable. Do you give nitroglycerin? Background: You have likely heard the caution to avoid nitrates in acute myocardial infarctions that have right ventricular involvement. What is that based upon? As is often the case, when you go back to the primary literature, you discover we are standing on pillars of salt and sand. The evidence for this recommendation is a single observational study of 40 patients published in 1989 [1]. Yet, the findings in those 40 patients went on to be the evidence commonly cited by the American Heart Association (AHA) [2] and the European Society of Cardiology (ESC) [3] in their recommendation against the use of nitrates in acute MIs if there is right ventricular involvement. The pathophysiologic rationale was that nitrates would cause vasodilation and thus reduce RV preload, decreasing left end diastolic volume, and ultimately resulting in clinically important hypotension. Many times, pathophysiology has been used to explain something in medicine only to be discovered later that the body is much more complicated than we thought. That 40-patient study by Ferguson et al did show a statistically significant increased likelihood of hypotension in RVMI patients who received nitrates, but to me, the study design was just plain weird. * This was a retrospective trial that looked at 40 patients with inferior MIs. Twenty of them had hypotension after nitrates and 20 of them were not hypotensive. They looked back and saw that a higher proportion of patients with inferior MI and hypotension had ECG evidence of RV involvement. Sounds okay, but by having equal numbers of hypotensive and non-hypotensive patients, they’ve exaggerated the incidence of hypotension. It’s not 50-50. In all comers with MI, the rate is probably closer to <3%. On top of that, there was no standardization of the nitrate dose or route of administration, so it’s hard to know how to extrapolate the findings to our standard nitrate admin protocols. I was not surprised by this information. Fanaroff et al looked at the ACC/AHA guidelines from 2008-2018 [4]. They found 26 guidelines with 2,930 recommendations. Only 9% were Level A while 50% were Level B and 41% were Level C. Compare that previously mentioned 40-patient study to the 2016 Canadian study by Robichaud et al which was 22 times larger (n=1,004) than the Ferguson study [5]. It looked at the administration of a standardized amount of nitroglycerin in MI patients with various vascular territories involved. It shows no statistical difference in adverse events between patients with and without RVMI – a relative risk of 1.02 (95% CI: 0.49 to 2.15) p-value = 0.95.
Jan 27
28 min
SGEM #427: I Want a Treatment with a Short Course…for Pediatric Urinary Tract Infections
Reference: Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 Date: October 30, 2023 Guest Skeptic: Dr. Ellie Hill is a pediatric emergency medicine physician at Children’s National Hospital in Washington, DC and Assistant Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences. Her research interests include improving the diagnosis of urinary tract infections in children. Case: A 4-year-old girl comes to the emergency department complaining of pain with urination. She has not had any fevers or flank pain. The last time she had these symptoms a year ago, she was diagnosed with a urinary tract infection (UTI) and started on antibiotics. You obtain a urinalysis that demonstrates 43 white blood cells, positive leukocyte esterase, and positive nitrites. You tell the family the results of the urinalysis and let them know that she likely has another UTI, and you plan to prescribe some antibiotics. Her parents reply, “Last time she had to take over a week of antibiotics for her UTI, and she had bad diarrhea. Is it possible that we do a shorter treatment if she needs antibiotics?” Background: Does it seem like antibiotic courses are getting shorter these days? We covered short-course treatment for pediatric pneumonia in the SAFER trial with Dr. Andrew Tagg back on SGEM #338 and the SCOUT-CAP trial on SGEM #359. UTIs are one of the most common bacterial infections in childhood that we see in the emergency department [1]. The American Academy of Pediatrics (AAP) released guidelines for the management of febrile infants and children 2 to 24 months back in 2011 [2]. In those guidelines, they included the statement “The clinician should choose 7 to 14 days as duration of antimicrobial therapy.” However, the optimal antibiotic duration for the treatment of UTI is still uncertain [3]. Clinical Question: What is the efficacy of short-course (5-day) vs standard-course (10-day) antibiotic therapy for children with urinary tract infections? Reference:  Zaoutis T, et al. Short-course Therapy for Urinary Tract Infections in Children: the SCOUT randomized clinical trial. JAMA Pediatr. Aug 2023 * Population: Children 2 months to 10 years with and without febrile UTI exhibiting clinical improvement after 5 days of antimicrobials * Excluded: Second uropathogen (>104 CFU by catheterization or suprapubic aspiration, or >5×104 CFU by clean catch), hospitalization for bacteremia, admission to ICU, urine culture with pathogen resistant to initially prescribed antimicrobial, catheter-associated UTI, history of UTI within 30 days, phenylketonuria, congenital or anatomy abnormality of the GU tract other than grade I to II vesicoureteral reflux, duplicated collecting systems, or hydronephrosis, previous GU surgery, unable to tolerate PO medications, immunocompromise, Type I hypersensitivity or anaphylaxis to study products, gestation <36 weeks for children younger than 2, inability to attend follow up * Intervention: Additional 5 days of antimicrobial therapy (10 days total, standard course) * Comparison: Additional 5 days of placebo (5 days total, short-course) * Outcome: * Primary Outcome: Treatment failure is defined as symptomatic UTI at or before the first follow-up visit (day 11 to 14) * Secondary Outcomes: UTI after first follow-up visit,...
Jan 20
18 min
SGEM#426: All the Small Things – Small Bag Ventilation Masks in Out of Hospital Cardiac Arrest
Reference: Snyder BD, Van Dyke MR, Walker RG, et al. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation 2023. Date: January 11, 2024 Guest Skeptic: Dr. Chris Root is an EMS fellow in the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque, NM. He is also a flight physician with UNM’s aeromedical service, Lifeguard Air Emergency Services. Prior to earning his MD, he worked as a paramedic in the New York City 911 system. Case: You are dispatched to an out-of-hospital cardiac arrest (OHCA). The patient is a 54-year-old man who collapsed in front of his family after complaining of chest pain for several hours. On your arrival, first responders from the fire department are performing high-quality basic cardiac life support. You continue with compressions and defibrillations and your partner places an advanced airway. Your EMS agency has equipped you with small-volume adult bag-valve masks (BVMs), the first responders have been utilizing a standard adult BVM thus far during the resuscitation. Your partner asks you which of the two BVMs you should use to continue the resuscitation. Background: There is continuing debate regarding the appropriate ventilation strategy for OHCAs. Common commercially available BVMs can deliver volumes that exceed normal tidal volumes. Some have argued in favor of using smaller BVMs to avoid hyperventilation. The issue of BVM ventilation in the context of pre-oxygenation for endotracheal intubation was discussed on SGEM#281. Airway management in OHCA has also been covered in SGEM#247 and SGEM#396. We have looked at OHCA more than a dozen times on the SGEM. For a full list of check out the links below to the SGEM blogs:  * SGEM#50:Under Pressure Journal Club: Vasopressin, Steroids and Epinephrine in Cardiac Arrest * SGEM#54:Baby It’s Cold Outside: Pre-hospital Therapeutic Hypothermia in Out of Hospital Cardiac Arrest * SGEM#59:Can I Get a Witness: Family Members Present During CPR * SGEM#64:Classic EM Paper: OPALS Study * SGEM#107:Can’t Touch This: Hands on Defibrillation * SGEM#136:CPR – Man or Machine? * SGEM#143:Call Me Maybe for Bystander CPR * SGEM#152:Movin’ on Up – Higher Floors, Lower Survival for OHCA * SGEM#162:Not Stayin’ Alive More Often with Amiodarone or Lidocaine in OHCA * SGEM#189:Bring Me to Life in OHCA * <a href="https://thesgem.
Jan 13
26 min
SGEM #425: Are You Ready for This? Pediatric Readiness of Emergency Departments
Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 Date: Dec 11, 2023 Guest Skeptic: Dr. Rachel Hatcliffe is a pediatric emergency medicine attending at Children&#8217;s National Hospital in Washington, DC. Her research focuses on prehospital care of children with anaphylaxis.  Guest Authors:  Dr. Kate Remick is a pediatric emergency medicine physician and Assistant Professor of Pediatrics at Dell Medical School at the University of Texas at Austin. She is an executive lead for the EMS for Children Innovation and Improvement Center. She has held leadership positions with state and national professional organizations to promote high quality emergency care for children. Dr. Hilary Hewes is a pediatric emergency medicine physician and an Associate Professor of Pediatrics at the University of Utah/Primary Children’s Hospital with interests in prehospital care, pediatric trauma and injury prevention, and disaster medicine and preparedness.  She is the co-Principal Investigator for the EMS for Children Data Center. Dr. Marianne Gausche-Hill is a pediatric emergency medicine physician and the interim CEO of the Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center. She is also a Professor of Pediatrics and Emergency Medicine at David Geffen School of Medicine at UCLA. She is nationally known for her work as an EMS researcher and educator.  Case: After your shift in the emergency department (ED) one day, the medical director pulls you aside. She says that they’ve noticed a slight increase in the number of sick pediatric patients coming in recently and the difficulty in finding a hospital to accept the ones who need admission. As a seasoned clinician, she wants your opinion and asks you, “How prepared do you think we are in handling sick children?” and “Do you have any thoughts about how we can improve?” Background: Back in August of 2022, we announced the start of #SGEMPeds for SGEM Season 11. One of the key motivations was the recognition that we needed to get out of the ivory towers of academic pediatric emergency medicine centers as most children are cared for outside of academic centers. We wanted to spread the gospel of evidence-based medicine so that children get the best care, based on the best evidence, regardless of where they receive care.  But does that always happen? Are general emergency departments ready to care for children? Two previous studies conducted assessing the state of nationwide pediatric readiness were conducted in 2003 and 2013. [1,2] Today we&#8217;re covering the third study. Pediatric readiness is important because it is associated with decreased mortality in ill and injured children. [3, 4] Conflict of Interest Disclosure: Dennis is an Emergency Medical Services for Children (EMSC) fellow in the Knowledge Management domain.  &nbsp; Clinical Question: What was the state of pediatric readiness in emergency departments across the United States during the COVID-19 pandemic? Reference: Remick KE, et al. National Assessment of Pediatric Readiness of US Emergency Departments during the Covid-19 Pandemic. JAMA Netw Open. July 2023 * Population: ED leadership across the United States. It included 3,647 readiness assessments performed, representing 14.1 million annual pediatric ED visits.  * Excluded:  EDs that are not open 24 hours a day or 7 days a week. Veterans Affairs and prison hospitals. * Intervention: Web-based open assessment questionnaire containing 92 questions.  * Comparison: Previous pediatric readiness scores.  * Outcome:
Jan 6
41 min
SGEM#424: Ooh-Ooh, I Can’t Wait – To Be Admitted to Hospital
Reference: Roussel et al. Overnight stay in the emergency department and mortality in older patients, JAMA Intern Med 2023 Date: December 18, 2023 Guest Skeptic: Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic. Case: An 85-year-old patient (Ms. McG) presents to your emergency department (ED) after being found by family on the ground at her independent living facility. Her family was concerned because she has had multiple recent falls, and she wasn’t answering the telephone that morning.  They found her in a pool of blood with a scalp laceration and complaining of left hip pain. Although she had exhibited occasional disorientation and gradually diminishing physical activity over the last 5-years, she was still functionally independent.  While your ED evaluation, computed tomography (CT) imaging of her head and spine demonstrated no traumatic injury and an x-ray of her pelvis showed no fracture or dislocation, she was unable to bear weight due to her hip pain, so you ordered a CT to further evaluate for occult fracture. Advanced imaging was unavailable until morning by the time that test was ordered.  Suspecting an occult fracture, you consult Orthopedic surgery for admission, but they wanted to wait for the CT the next day.  You then consult Internal Medicine/Hospitalist who also want to wait for CT imaging in case the admission is more appropriate on the Orthopedic surgery service.  After all these consultant calls it is now after midnight and you are concerned that the patient will be in the ED all night and what the consequences of a preventable episode of overnight ED boarding might have on the patient and the rest of the department since the waiting room still has 20 patients awaiting evaluation. Background: Falling is the most common cause of traumatic injury resulting in older adults presenting to the ED [1]. Approximately 20% of falls result in injuries, and falls are the leading cause of traumatic mortality in this age group [2-4]. Older adults who are admitted to the hospital after a fall will be readmitted to the hospital within one-year in 44% of cases and 33% will die within one-year. Because it is such a serious topic, we have covered it several times on the SGEM: * SGEM#89: Preventing Falling to Pieces * SGEM Xtra: Don’t Bring Me Down – Preventing Older Adult Falls from the Emergency Department * SGEM#351: How to Stop Geriatrics from Free Fallin’ * GEMCast: How to Help Prevent the Next Fall in Your Older Patients * Geriatric ED Collaborative Falls Resources: Falls and Mobility EDs are becoming more and more crowded. The Canadian Association of Emergency Physicians (CAEP) flagged this issue 10 years ago in 2013. They published a position statement with several suggested solutions. Unfortunately, things have only gotten worse, and it does not seem to be an isolated problem in Canada. The American College of Emergency Physicians (ACEP) held a summit of stakeholders across health care in September of 2023. They got together a wide range of leaders in various organizations to...
Dec 30, 2023
40 min
SGEM Xtra: Doctor, Doctor – We Need More Family Doctors
Date: December 12, 2023 Reference: OCFP News. More Than Four Million Ontarians Will Be Without a Family Doctor by 2026. Nov 7, 2023 Guest Skeptic: Dr. Mahaleh Mekalai Kumanan attended Dalhousie University for her undergraduate studies, Master of Health Administration degree and medical school before completing her residency at the University of Western Ontario. She is currently the President of the Ontario College of Family Medicine (OCFP). This is an SGEM Xtra. I had the opportunity to interview the President of the OCFP about the current state of family medicine and some possible solutions. Please consider listening to the SGEM Podcast and hear what Dr. Kumanan has to say. It has been an interesting couple of months. The College of Family Physicians of Canada (CFPC) in September widely communicated they were going to implement an additional year of training for family medicine residents. There was an outcry from individuals and organizations (SRPC, CFMC, RDC, OMA &amp; Ministers of Health) asking the CFPC to pause and reconsider. This included a statement from the OCFP. To its credit the CFPC listened, reflected, and responded in a very appropriate way. The CFPC President (Dr. Mike Green) apologized and announced they are not implementing an additional year of training. This took a great deal of insight and humility. Well done CFPC. Now it is time to address some immediate issues with Family Practice. Some listeners may be wondering why we are discussing this on an emergency medicine podcast. Well, it is because we are all on Team Patient. Family Medicine is the foundation of healthcare. Without strong primary care patients will eventually end up in the ED. I suspect Ontario is not the only province and Canada is not the only country struggling with these problems. As of September 2022, data by INSPIRE-PHC posted on the Ontario Community Health Profiles Partnership (OCHPP) shows nearly 2.3 million Ontarians are without a family doctor – that’s up from 1.8 million in March 2020, or up from 1.6 million in 2018. INSPIRE-PHC research, led by Dr. Kamila Premji, also shows 1.74 million Ontarian&#8217;s have a doctor who is nearing retirement. In addition, the number of medical school graduates choosing to pursue family medicine is the lowest it’s been in 15 years. Using updated research, the OCFP now predicts that Ontario will exceed its previous forecast as the crisis in family medicine intensifies. Approximately 1 in 4 Ontarian&#8217;s – or 4.4 million – will be without a family doctor by 2026. OCFP: Three Solutions to the Crisis * Ensure Ontarians have a family doctor working alongside a team, so patients can get the help they need faster. * Improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care.
Dec 23, 2023
27 min
SGEM#423: Where is the Love? Microaggression in the Emergency Department
Reference: Punches et al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023 Date: December 14, 2023 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Case: A 57-year-old Chinese woman presents to the emergency department (ED) with chest pain. She speaks some English, but it is her second language. It is a very busy day, and you proceed to ask her questions in rapid succession. You roll your eyes when you must repeat yourself and ask in a louder and louder voice in order to get a response. Background: Patient experiences of care are associated with health outcomes and may impact perspectives of ED care and the patient recovery process.(1-5) Perceptions of discrimination in healthcare are linked to delays in seeking medical treatment, nonadherence to clinician recommendations, and mistrust of clinicians and the healthcare system.(6-7) We looked at deaf and hard-of-hearing patients in the ED on SGEM#383. Microaggressions are discriminatory behaviors that may be subtle or unintentional but may disempower affected individuals leading to differential care and worse healthcare outcomes.(7-10) Discrimination, implicit bias and microaggressions are common in healthcare encounters involving persons from marginalized groups.(11-17) Microaggressions and discrimination towards patients have been studied in other healthcare settings, but there has been little research on this topic that specifically investigates EDs.(10-11) The ED is a unique part of the healthcare system due to its inherent chaotic environment, time constraints and lack of prior patient-staff interaction. Clinical Question: How can patient perceptions of microaggressions that occur during an ED visit inform potential interventions and prevent future occurrences? Reference: Punches el al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023. As this is a qualitative study, we will use a modified PICO question (PIC): * Population: Adult, English speaking patients visiting one of two urban emergency departments in a Midwest US city. * Interest: Exploring patient experiences of discrimination during their ED visit. * Context: Improving patient care and reducing microaggressions from ED staff This is an SGEMHOP episode, and it is our pleasure to introduce Dr. Lauren Southerland. She is an Associate Professor in the Department of Emergency Medicine at The Ohio State University. Her research interests include clinical process improvement in the ED and implementation science, and she focuses on the care of vulnerable populations, most often older adults or others lacking capacity or capabilities. This study used a mixed methods sequential explanatory approach whereby the researchers collected quantitative data on experiences of discrimination using the DMS tool, followed by qualitative data through a semi-structured interview. As many of us have over the past four years, we were looking at our emergency care and interested in whether our practice was contributing to disparities. Additionally, many of us in medicine have witnessed or experienced microaggressions, and we wondered if our ED care was contributing to patients feeling discriminated against.  So, we looked at the available research and found that no one really had a good answer for our question,...
Dec 16, 2023
42 min
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