The CAEP Daily: Day 2 (June 16)

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This year, CanadiEM has partnered with the Canadian Association of Emergency Physicians, EMOttawa, and the Skeptic’s Guide to Emergency Medicine to help promote #CAEP21: CAEP at the Forks – Rising to the Challenge. From June 15-17, 2021 we will be publishing The CAEP Daily, a journalistic summary of highlights from the conference. Please join the discussion!

Today’s Plenary Speakers:

Emergency Medicine is a Failed Paradigm for the Care of the Critically Ill: A Dialectic Conversation

Speakers: Dr. Scott Weingart & Dr. Ken Milne

Our role as emergency physicians continues to expand. But there-in lies the problem… Are we emergency physicians or emergency room physicians? How do our current systems train and prioritize the care for the critically ill (i.e., “emergencies”) versus the general population in the emergency room, especially when their interests conflict?

Scott Weingart argues that our role in critically ill patients should evolve towards the mastery of stabilization. The faster we get critically ill patients to the ICU, the better. The less we board patients, the safer. And it is okay if some skills like central lines and chest tubes fall to the wayside in favor of intraosseous lines and finger thoracostomies. We need to advocate for patients appropriately being separated between the “sick” and “not sick” and expedite them being at the right centres where the critically ill can be quickly cared for by specialists outside the emergency room.

Ken Milne wonders if this is too narrow an assumption of who is “critically ill.” For instance, are patients suffering from mental health concerns not also in extreme health crises? Patients are the ones who decide what is an emergency to them, not healthcare providers, and in any case, distinguishing between the sick and not sick is challenging. Whatever the problem, emergency physicians are there to “meet ‘em, greet ‘em, treat ‘em, and street ‘em,” which defines our role as emergency physicians.

I Hate Yoga: Making Resilience Actually Work for You

Speaker: Dr. Sara Gray

Canada’s Health Inequity Crisis: Prioritizing Social Determinants of Health in Research and Quality Improvement

Speaker: Dr. Kaveh Shojania

Crises like climate change, COVID-19, racism, inequality, and opiate addiction worsen the disparities already experienced by patients. Unfortunately, baseline social variables like home neighborhood have a serious effect on health outcomes. Even CAEP21’s host city of Winnipeg experiences an 18 year gap in life expectancy between the highest and lowest income neighborhoods.

Unfortunately, the direct impacts of social destiny are rarely at the forefront of research. Ironically, even the presumed benefits of health innovation we do focus on are poorly understood. “Most clinical interventions also turn out not to work, or to confer small benefits, so are not that worth translating into practice anyway.”


With such small gains for very narrow targets, a reconsideration of important health interventions is required. Dr. Shojania advocates for emergency physicians to consider how we can contribute to upstream care for our patients and follow mentors in contextualized quality improvement efforts to improve patient health, not just healthcare.

Here’s What Else You Need To Know Today:

Disaster Medicine – Take Home Points: International Emergency Medical Teams Responding To The Beirut Blast 2020

Speaker: Dr. Johan von Schreeb

The Beirut blast had a complex interplay of hazards and vulnerabilities.

Vulnerabilities in Lebanon included:

  • Dichotomised health system, with majority of resources in private system instead of the public system, resulting in health inequities.
  • 1.5 million refugees.
  • An economic crisis ongoing since 2019.
  • The start of the COVID-19 pandemic

Lessons Observed:

  • Lebanon has impressive national trauma care capacities, so a better assessment of national capabilities is important.
  • 85% of injuries were minor and could be managed in an outpatient setting.
  • Coordination between multiple parties was challenging
  • Re-tasking workers from trauma care to COVID-19 support and primary care was successful and may need further evaluation on which tasks can be re-tasked.
  • Large international organizations can use deployment of field hospitals as a powerful foreign policy tool.
Pediatric Pearls – ALS Update 2020: Has Anything Really Changed?

Speaker: Dr. Mel Chan

There are few key changes in the 2020 PALS update. Please check out the talk for more details! 

Airway & Breathing:

  1. Give a breath every 2-3 seconds (20-30 breaths/minute). This is an increase from the previous recommendation of 10-12 breaths/minute. 
  2. Cuffed endotracheal tubes are recommended over uncuffed tubes. Cuffed tubes have a lower rate of re-intubation. Goal cuff pressure should be about 20-25 cmH20. 
  3. Cricoid pressure is not recommended because it can impede intubation success. 

Circulation:

  • Epinephrine boluses should be given WITHIN five minutes from the start of chest compressions

Sepsis

  • Fluid should be administered in 10 mL/kg boluses with a reassessment before the next bolus is given.
  • In fluid refractory septic shock, epinephrine or norepinephrine can be used. If you don’t have those available, then dopamine is the next agent to consider.


Post ROSC Care

  • Check out the excellent checklist from the AHA (Table 3) 

Education Science Update

  • Spaced learning or traditional PALS courses can be used. However, if a PALS course is used, then consider repeated booster sessions to help improve knowledge and skill retention.


More details can be found in the guidelines and this stellar CanadiEM post.

Art of Resuscitation – Keeping Your Head Screwed On: Cut Throat Cases In The Emergency Department

Speaker: Dr. Evelyn Dell

3 step approach to penetrating neck trauma:

1.      Airway Management

  • Do you need to manage the airway?
    • If so, now vs. 15 mins from now vs. elective.
    • In a perfect world, use fiber optic, but use the approach that you are most comfortable with.
    • Consider that there may also be a hemo/pneumothorax and you may need to deal with this before you intubate.

2.  Hemorrhage Control

  • You can use a finger or foley(s) to help control penetrating neck wounds
  • Think about activating your Massive Transfusion Protocol.

3.  “No Zone” approach: Use hard and soft signs instead of the traditional 3 zones of the neck

Hard Signs (HARD NECKS2)Soft Signs (SOFT D3H3)
H: hemoptysis / hematemesis – severe
A: airway obstruction / stridor
R: radial pulse reduced
D: dense hemiplegia
N: neck bubbling
E: expanding hematoma
C: subcutaneous air – severe
K: *kacophony (bruit/thrill)
S2: severe bleeding / severe shock not responding to fluids
S: subcutaneous air (not massive)
O: oropharyngeal blood (not massive)
F: focal neuro deficits
T: tube leak
D: dysphonia
D: dysphagia
D: dyspnea
H: hemoptysis (mild)
H: hematemesis (mild)
H: hematoma (non-expanding)
Disposition: to operating roomDisposition: CT-Angiogram
Medical Education – CMPA and Medical Education: What Does The Future Hold?

Speaker: Dr. Lisa Calder

There are three main areas of focus for the CMPA

  1. Education – There is an existing robust inventory informed by experiences with medico-legal cases. 
  2. Research 
  3. Medico-legal advice/assistance

There are three main drivers for medico-legal risk:

  1. Diagnostic error
  2. Team communication
  3. Loss of situational awareness
Medical Education – Academic branding: Developing Your Program’s Digital Identity

Speaker: Dr. Michael Gottlieb

Whether or not you want, there is a specific perception (good or bad) about your residency program. You should aim to control your message. Having a clear brand can help students know where to apply, interview and rank. It helps you to match the right resident, shape program culture, and unite your group around a common vision.

5 key components to program branding:

  1. Identity – This is your group’s mission, vision and values. Who are you? What makes you unique as a program? What is truly special about your program and what are your strengths? 
  2. Image – What others perceive about your program. 
  3. Positioning – clear and consistent messaging about your brand. 
  4. Experience – Your residents are your brand ambassadors.
  5. Auditing – this is the process of reviewing each aspect of your brand and finding the strengths and weaknesses. Google your program, see the reviews, ensure the external perception aligns with your mission and vision.
Medical Education – Innovations In Clerkship Education

Speaker: Dr. Teresa Wawrykow

There is a huge variation across the country in what year medical students do their EM clerkships, the duration of the rotation and the number of shifts in a rotation. This presents a huge challenge for supporting the best education during a clerkship. 

Resources that could be helpful to supplement the clinical rotation include: 

  1. Case-based asynchronous learning: back and forth case discussion during the week of a rotation. Longitudinal, interactive and asynchronous. 
  2. EM oral case presentation online module – allows students to practice their case presentations prior to a shift. https://emocp.squarespace.com/aem
  3. Case-based asynchronous learning: back and forth case discussion during the week of a rotation. Longitudinal, interactive and asynchronous. 
  4. EM oral case presentation online module – allows students to practice their case presentations prior to a shift. https://emocp.squarespace.com/aem
  5. Case-based asynchronous learning: back and forth case discussion during the week of a rotation. Longitudinal, interactive and asynchronous. 
  6. EM oral case presentation online module – allows students to practice their case presentations prior to a shift. https://emocp.squarespace.com/aem
Medical Education – A Guide For Transition To Practice

Speaker: Dr. Fareen Zaver

The transition from resident to unsupervised practice is an exciting time; but like any life change it is extremely stressful. You can’t prepare for the strong sense of isolation you will feel in the first few months as staff, even if you are staying in the same place you trained. You will not be able to rely on the same feedback and support you had as a resident.

Tips:

  1. Mentorship: You need formal, informal and near peer mentorship. Near peer mentorship removes the hierarchy that can exist in other forms of mentorship. It allows for a culture of safety of just the first and second year staff to discuss difficult cases or adverse patient outcomes, patient complaints or difficult interactions. It normalizes all the challenges as you hear your peers having to deal with the same issues and will give you ideas on how to tackle the problems.
  2. Get a career coach: Coach4md has a network of Canadian physician coaches.
  3. Learn about money/financials: Beat the Bank by Larry Bates is a good starting resource.
  4. Do not burn yourself out: Make sure to protect time for you to really become that amazing staff AND enjoy so much of life that you have had to put on hold all these years! To do this, you may need to learn to say no to some exciting opportunities as you start out.
Core EM – DOACs

Speaker: Dr. Kerstin de Wit

There are a few general principles when starting anticoagulation in the ED, including the following:

  1. Bloodwork: A CBC should be done to rule out microcytic anemia (suggests GI bleed) and Plt >50. Creatinine clearance should be >30 and should be calculated in elderly women where eGFR may overestimate renal function (formula is on MDCalc). Patients with creatinine clearance <15-20 may need hospital admission for IV heparin.
  2. Recent bleeding: A good way of asking this question: “Have you ever had blood in your gut, urine or brain?” Do a patient chart review to double-check.
  3. Antiplatelet drugs: most patients should not be on ASA and an anticoagulant as this increases bleeding risk without adding benefit, and the ASA should be withheld. Exceptions to this include a drug-eluting stent within 3 months or recent TIA/stroke.
  4. Drug interactions: common culprits include phenytoin, carbamazepine, rifampin, antifungals and anti-HIV drugs.

Thombosis Canada has a great website and app that can help with thrombosis-related questions. This includes patient information to help with discharge. 

Further reading:

This post was copy edited and uploaded by Kara Tastad

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Kevin Junghwan Dong

Kevin Junghwan Dong

Kevin Dong is an Emergency Medicine physician in Hamilton, Ontario. His interests include medical education, mentorship, and producing video/podcasts. He completed the Digital Scholar Fellowship in 2019 and he is currently the CanadiEM Director of Multimedia.
Sonja Wakeling

Sonja Wakeling

Sonja is a PGY-2 in Emergency Medicine at McMaster University and a Junior Editor with CanadiEM. Her academic interests include medical education (with a budding interest in simulation), quality improvement, and resource utilization. If you can’t find her in the resus or trauma bay of her local ED, she may be tending to her growing houseplant collection or cycling along the excellent paths in Hamilton
Sonja Wakeling

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Alkarim Velji

Alkarim Velji

Dr. Alkarim Velji is an Emergency Physician at the University of Alberta. He has an interest in medical education, simulation, and integration of technology in education. He recently completed a Masters of Education in Health Sciences Education.
Alkarim Velji

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Patrick Boreskie

Patrick Boreskie

Dr. Patrick Boreskie is a chief Emergency Medicine resident at the University of Manitoba in Winnipeg. He is a CanadiEM Digital Scholars Fellow and International Conference on Residency Education Chief Resident. He has a particular interest in knowledge translation, gerontology, and ultrasound.
Patrick Boreskie
- 1 month ago
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Fareen Zaver MD

Fareen Zaver MD

Fareen Zaver is an Emergency Physician based in Calgary. She is the Co-Director for the CanadiEM Digital Scholars Fellowship and is the Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro) series
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Daniel Ting

Daniel Ting

Daniel Ting is an Emergency Physician and Clinical Instructor at the University of British Columbia, based in Vancouver. He is the Editor-in-Chief of CanadiEM and a Decision Editor at the Canadian Journal of Emergency Medicine. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. No conflicts of interest (COI).
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