The CAEP Daily: Day 3 (June 17)

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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:

Lessons Learned in Social Innovation

Speaker: Dr. Alika Lafontaine

Dr Alika LaFontaine explains that social innovation is the process of navigating systems, people, and beliefs towards a new way of doing things. A new system and set of allies are necessary to improve the care of the Indigenous population.

Unfortunately, the cycle of social and racialized crisis events does not necessarily lead to meaningful change. 

Using the Indigenous Health Alliance and Safe Space Network as examples, Dr LaFontaine goes through the Kubler-Ross Change Curve and how familiarity with its application to social innovation can help us lead our departments to reduce health disparity.

He also discusses our biases, “intellectual scotomas” creating an inability to perceive distortions in perception that are obvious to others. Recognizing our biases and understanding the resistance to change that occurs after social and racial crises are imperative as we move forward as a society and profession. Which role do you play after social stressors like the In Plain Sight report, Stop Asian Hate, or Black Lives Matter movements occur? Are you the agitator? The bandwagon jumper? The visionary? Tune into this session for further guided reflection, facilitated by an award winning expert in institutional bias, racism, and reflective practice.

Did SARS CoV2 kill evidence based medicine?

Speaker: Dr. Simon Carley

Over the pandemic, clinicians started to accept results from papers that were published in high impact journals without performing their own critical appraisal. Rapid knowledge translation was amplified by social media and an increase in pre-print and press release articles. Unsurprisingly, in the context of all this pivoting, trust in governments and healthcare workers dropped significantly.

However, the pandemic highlighted the rise of the “platform adaptive trial” and how the setup of a strong research infrastructure before the health crisis dramatically reduces the response time when one occurs. The inclusion criteria and outcomes are defined as part of the study design but multiple interventions can be changed to assess how they perform in this defined population. RECOVERY is a successful example of a platform adaptive trial.  

We inevitably have another pandemic coming. We’ve learnt how poorly evidenced treatments can rapidly disseminate and we’ve learnt how to build trials that help us to overcome the speed of the pandemic. In the end, as Maya Angelou says, “Do the best you can until you know better. Then when you know better, do better.”
For more information, check out Dr. Carley’s paper and the COVID Evidence Based Network.

How will COVID-19 reshape Canada’s health care priorities?

Speaker: Andre Picard

Andre Picard delivers a fitting summary to CAEP21 by discussing how COVID-19 will change Canadian healthcare.

Case and death numbers continue to improve, but the upcoming fallout in mental health, economic crisis, and the Delta variant will continue to weigh down our healthcare system. The pandemic shone a spotlight on our weaknesses, so we must now be strong advocates for change. Canadians are cautious, which has its place, but mere incrementalism is harmful in COVID.

As emergency physicians, we need to continue our work advocating for a better, more nimble system that works for all Canadians. COVID has flourished at the intersection of racism, ageism, and marginalization.

Similarly, we must lend our voices in the effort to appropriately train, pay, and staff the rest of our system. We are a business of people, after all, and “the conditions of work are the conditions of care.”

Here’s what else you need to know today:

Leadership and Flow / Leading and Flow: Using the Golden Lining of Covid-19 to Catalyze Change

Speakers: Tasleem Nimjee, Lisa Calder, Eddy Lang, Constance Leblanc

Emergency physicians have many skills that make good leaders, including being able to act in the face of uncertainty. Other key emergency physician skills that make good leaders include conflict management and knowledge of healthcare systems, and these skills are often not taught in traditional educational curricula. To increase your skills, look out for local workshops.

One pressing area that we need leadership is around mediums of healthcare delivery, specifically as virtual care emerges. There needs to be a national conversation around the type of healthcare delivery that optimizes patient safety, continuity of care, and the patient-physician relationship. Emergency physicians should play an active role in these discussions.

COVID / Canadian COVID-19 rapid response network

Speaker: Corinne Hohl

The Canadian COVID-19 rapid response network has harmonized data collection in patients with suspected COVID-19 across 50 Emergency Departments in 8 provinces in Canada. Currently there are over 20,000 COVID positive patients enrolled in the network. There are multiple projects that will be published soon, including clinical decision rules on which patients will test positive for COVID, who can be safely discharged from the ED, and who will die from COVID. Another study will compare how treatment patterns and resource utilization changed over the course of the pandemic and its effect on patient outcomes.

Setting up the network and starting data collection was a very challenging process that took months, involving multiple redundant applications to have individual institutions to approve ethics or to give institutional approval. Unlike the United Kingdom, Canada has not yet developed a robust system to harmonize approval of data collection on a provincial or national level. This is a challenge that will require continued advocacy to address for the management of future public health emergencies.

Recent EM Literature

Speaker: Ken Milne, Lauren Westafer, Samina Ali, Kirsty Challen

Dr Ken Milne assembled a supergroup of literature and knowledge translation experts  – Dr Lauren Westafer, Dr Samina Ali, and Dr Kirsty Challen, to discuss a topical selection of medical literature.

ULTRA – Early TXA after SAH: a randomized controlled trial 

  • This study does not show clear clinical benefit from TXA use in non-traumatic SAH.

Risk of Nonunion with Nonselective NSAIDs, COX-2 Inhibitors, and Opioids

  • There was no significant increase in non-union in NSAID users after fracture, though an association was shown with COX-2 inhibitors and new opioid prescriptions. Confounders abound.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care

  • The role of emotions in patient safety is an important and early topic of research. Future work should study the association of care-provider emotional regulation and mitigation of patient safety risks.

Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A network Meta-analysis  

  • Bronchiolitis will last about 14-28 days. Hypertonic saline alone or combined with nebulized epinephrine may reduce an infant’s stay in hospital. However, evidence is limited.

Short-course antimicrobial therapy for Pediatric community-acquired pneumonia (SAFER Trial)

  • Short course (5 days) amoxicillin is comparable to standard care (10 days) for treatment of outpatient community acquired pneumonia.

Intranasal ketamine for acute pain management in children: a systematic review and meta analysis

  • Intranasal ketamine may be considered as an alternative to intranasal opioid in acute pain management.

Parental assessment of disease severity in febrile children under 5 years of age: qualitative study

  • Parents used the normal behaviour and physical features of their child as a reference frame for judging how sick their child is. 
  • Consider asking parents how their child looks when their temperature comes down after receiving anti-pyretics. Looking and acting well can be a reassuring finding.

The Use of Tranexamic Acid to Reduce the Need for Nasal Packing in Epistaxis (NoPAC): Randomized Controlled Trial

  • In patients who fail initial measures (pressure, vasoconstrictors), TXA is unlikely to help control epistaxis, even if the patient is on anticoagulation. 

Antacid Monotherapy Is More Effective in Relieving Epigastric Pain Than in Combination With Lidocaine: A Randomized Double-blind Clinical Trial

  • In a comparison of 20cc antacid versus 10cc antacid + lidocaine versus 10cc antacid + viscous lidocaine, antacid alone both worked better and was more acceptable to patients

A Randomized Controlled Trial of Novel Loop Drainage Technique Versus Standard Incision and Drainage in the Treatment of Skin Abscesses

  • Loop drainage technique compared to Incision and Drainage with packing had significantly lower treatment failure (zero!).

Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis

  • The odds of treatment failure was higher (OR 2.02) in the Incision and Drainage group compared to the loop drainage group.

Further reading:

This post was copyedited and uploaded by Sam Wilson MD (@samwilson_95)

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Hans Rosenberg

Hans Rosenberg

Hans Rosenberg is the Director of Digital Scholarship and Knowledge Dissemination Program and Assistant Professor at the University of Ottawa
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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.
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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.
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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).
Daniel Ting
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