EM Cases Main Episodes are round table in-depth discussions with 2 or more EM Cases guest experts, inherently peer reviewed, and edited for a podcast.
In this EM Cases episode on Pediatric Procedural Sedation with Dr. Amy Drendel, a world leader in pediatric pain management and procedural sedation research, we discuss how best to manage pain and anxiety in three situations in the ED: the child with a painful fracture, the child who requires imaging in the radiology department and the child who requires a lumbar puncture. Without a solid understanding and knowledge of the various options available to you for high quality procedural sedation, you inevitably get left with a screaming suffering child, upset and angry parents and endless frustration doe you. It can make or break an ED shift. With finesse and expertise, Dr. Drendel answers such questions as: What are the risk factors for a failed Pediatric Procedural Sedation? Why is IV Ketamine preferred over IM Ketamine? In what situations is Nitrous Oxide an ideal sedative? How long does a child need to be observed in the ED after Procedural Sedation? Do children need to have fasted before procedural sedation? What is the anxiolytic of choice for children requiring a CT scan? and many more...
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While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like cognitive debiasing strategies, and some of the concepts introduced in Episode 62 Diagnostic Decision Making Part 1 like risk tolerance, with the goal of helping you gain insight into how we think and when to take action so you can ultimately take better care of your patients. Walter Himmel, Chris Hicks and David Dushenski answer questions such as: How do expert clinicians blend Type 1 and Type 2 thinking to make decisions? How do expert clinicians use their mistakes and reflect on their experience to improve their decision making skills? How can we mitigate the detrimental effects of affective bias, high decision density and decision fatigue that are so abundant in the ED? How can we use mental rehearsal to not only improve our procedural skills but also our team-based resuscitation skills? How can we improve our situational awareness to make our clinical assessments more robust? How can anticipatory guidance improve the care of your non-critical patients as well as the flow of a resuscitation? How can understanding the concept of preferred error help us make critical time-sensitive decisions? and many more important decision making in EM nuggets...
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Pain leads to suffering. Opioid misuse leads to suffering. We strive to avoid both for our patients. On the one hand, treating pain is one of the most important things we do in emergency medicine to help our patients and we need to be aggressive in getting our patients’ pain under control in a timely,
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Pediatric seizures are common. So common that about 5% of all children will have a seizure by the time they’re 16 years old. If any of you have been parents of a child who suddenly starts seizing, you’ll know intimately how terrifying it can be.
While most of the kids who present to the ED with a seizure will end up being diagnosed with a benign simple febrile seizure, some kids will suffer from complex febrile seizures, requiring some more thought, work-up and management, while others will have afebrile seizures which are a whole other kettle of fish. We need to know how to differentiate these entities, how to work-them up and how to manage them in the ED. At the other end of the spectrum of disease there is status epilepticus – a true emergency with a scary mortality rate - where you need to act fast and know your algorithms like the back of your hand. This topic was chosen based on a nation-wide needs assessment study conducted by TREKK (Translating Emergency Knowledge for Kids), a collaborator with EM Cases.
With the help of two of Canada’s Pediatric Emergency Medicine seizure experts hand picked by TREKK, Dr. Lawrence Richer and Dr. Angelo Mikrogianakis, we’ll give you the all the tools you need to approach the child who presents to the ED with seizure with the utmost confidence.
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Once we've achieved ROSC our job is not over. Good post-arrest care involves maintaining blood pressure and cerebral perfusion, adequate sedation, cooling and preventing hyperthermia, considering antiarrhythmic medications, optimization of tissue oxygen delivery while avoiding hyperoxia, getting patients to PCI who need it, and looking for and treating the underlying cause. Dr. Lin and Dr. Morrison offer us their opinion on the new simplified approach to diagnosing the underlying cause of PEA arrests. We'll also discuss when it's time to terminate resuscitation or 'call the code' as well as some fascinating research on gender differences in cardiac arrest care. These co-authors of the guidelines will give us their vision of the future of cardiac arrest care and we'll wrap up the episode with a third opinion, so to speak: Dr. Weingart's take on the whole thing....
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A lot has changed over the years when it comes to managing the adult in cardiac arrest. As a result, survival rates after cardiac arrest have risen steadily over the last decade. With the release of the 2015 American Heart Association ACLS Guidelines 2015 online on Oct 16th, while there aren’t a lot a big changes, there are many small but important changes we need to be aware of, and there still remains a lot of controversy. In light of knowing how to provide optimal cardio-cerebral resuscitation and improving patient outcomes, in this episode we’ll ask two Canadian co-authors of The Guidelines, Dr. Laurie Morrison and Dr. Steve Lin some of the most practice-changing and controversial questions.
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Most of us in North America live in cultures that almost never talk about death and dying. And medical progress has led the way to a shift in the culture of dying, in which death has been medicalized. While most people wish to die at home, every decade has seen an increase in the proportion of deaths that occur in hospital. Death is often seen as a failure to keep people alive rather than a natural dignified end to life. This is at odds with what a lot of people actually want at the end of their lives: 70% of hospitalized Canadian elderly say they prefer comfort measures as apposed to life-prolonging treatment, yet as many as ⅔ of these patients are admitted to ICUs.
Quality End of Life Care in Emergency Medicine is not widely taught. Most of us are not well prepared for death in our EDs – and we should be. There’s no second chance when it comes to a bad death like there is if you screw up a central line placement, so you need the skills to do it right the first time.
To recognize when comfort measures and compassion are what will be best for our patients, is just as important as knowing when to intervene and treat aggressively in a resuscitation. Emergency physicians should be able to recognize not only the symptoms and patterns that are common in the last hours to days of life, but also understand the various trajectories over months or years toward death, if they’re going to provide the high quality end of life care that patients deserve.
So, with the help of Dr. Howard Ovens, a veteran emergency physician with over 25 years of experience who speaks at national conferences on End of Life Care in Emergency Medicine, Dr. Paul Miller, an emergency physician who also runs a palliative care unit at McMaster University and Dr. Shona MacLachlan who led the palliative care stream at the CAEP conference in Edmonton this past June, we'll help you learn the skills you need to assess dying patients appropriately, communicate with their families effectively, manage end of life symptoms with confidence and much more...
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Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including diabetes, hypertension, coronary artery disease, peripheral vascular disease, biliary disease, sleep apnea, cardiomyopathy, pulmonary embolism and depression, and are less likely compared to non-obese adults to receive timely care in the ED.
Not only are these patients at higher risk for morbidity and mortality, but obesity emergency management is complicated by the patient’s altered cardiopulmonary physiology and drug metabolism. This can make their acute management much more challenging and dangerous. To help us gain a deeper understanding of the challenges of managing obese patients and elucidate a number of important differences as well as practical approaches to obesity emergency management, we welcome Dr. Andrew Sloas, the founder and creator of the fantastic pediatric EM podcast PEM ED, Dr. Richard Levitan, a world-famous airway management educator and innovator and Dr. David Barbic a prominent Canadian researcher in obesity in emergency medicine from University of British Columbia....
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A recent needs assessment completed in Toronto found that Emergency providers are undereducated when it comes to the Emergency Management of Sickle Cell Disease. This became brutally apparent to me personally, while I was researching this topic. It turns out that we’re not so great at managing these patients. Why does this matter?
These are high risk patients.
In fact, Sickle Cell patients are at increased risk for a whole slew of life threatening problems. One of the many reasons they are vulnerable is because people with Sickle Cell disease are functionally asplenic, so they’re more likely to suffer from serious bacterial infections like meningitis, osteomyelitis and septic arthritis. For a variety of reasons they’re also more likely than the general population to suffer from cholycystitis, priapism, leg ulcers, avascular necrosis of the hip, stroke, acute coronary syndromes, pulmonary embolism, acute renal failure, retinopathy, and even sudden exertional death. And often the presentations of some of these conditions are less typical than usual.
Those of you who have been practicing long enough, know that patients with Sickle Cell Disease can sometimes present a challenge when it comes to pain management, as it’s often difficult to discern whether they’re malingering or not. It turns out that we’ve probably been under-treating Sickle Cell pain crisis pain and over-diagnosing patients as malingerers.
Then there are the sometimes elusive Sickle Cell specific catastrophes that we need to be able to pick up in the ED to prevent morbidity, like Aplastic Crisis for example, where prompt recognition and swift treatment are paramount. A benign looking trivial traumatic eye injury can lead to vision threatening hyphema in Sickle Cell patients and can be easy to miss.
In this episode, with the help of Dr. Richard Ward, Toronto hematologist and Sickle Cell expert, and Dr. John Foote, the Residency Program Director for the CCFP(EM) program at the University of Toronto, we’ll deliver the key concepts, pearls and pitfalls in recognizing some important sickle cell emergencies, managing pain crises, the best fluid management, appropriate use of supplemental oxygen therapy, rational use of transfusions and more...
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Pain is the most common reason for seeking health care. It accounts for 80% of ED visits. The WHO has declared that “optimal pain treatment is a human right”. As has been shown in multiple ED-based Pediatric pain management studies, Pediatric pain is all too often under-estimated and under-treated. Why does this matter? Under-estimating and under-treating pediatric pain may have not only short term detrimental effects but life-long detrimental effects as well; not to mention, screaming miserable children disturbing other patients in your ED and complaints to the hospital from parents. Whether it’s venipuncture, laceration repair, belly pain or reduction of a fracture we need to have the skills and knowledge to optimize efficient and effective pain management in all the kids we see in the ED. What are the indications for intranasal fentanyl? intranasal ketamine? Why should codeine be contra-indicated in children? How do triage-initaited pain protocols improve pediatric pain management? Which are most effective skin analgesics for venipuncture? To help you make these important pediatric pain management decisions, in this podcast we have one of the most prominent North American researchers and experts in Emergency Pediatric pain management, Dr. Samina Ali and not only the chief of McMaster Children’s ED but also the head of the division of Pediatric EM at McMaster University, Dr. Anthony Crocco.
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