cognitive decision making, diagnostic decision making, medical ethics

Rapid Reviews Videos on Hyperkalemia

Our new EM Cases feature Rapid Reviews Videos is growing! The latest release covers the main episode on hyperkalemia with Melanie Baimel and Ed Etchells. In the first video Nick Clarridge reviews a general approach to hyperkalemia, the ECG changes and mimics and determining the cause. In the second video he reviews the 3 core principles of hyperkalemia management, the indications for calcium, insulin and bicarb in hyperkalemia and the options in management of hyperkalemia associated with cardiac arrest....

By | 2017-04-25T10:44:02+00:00 April 25th, 2017|Categories: Clinical Practice, News, Rapid Reviews Videos|Tags: , |0 Comments

WTBS 11 – Keeping Score: Providing Physician Feedback

What does the evidence say about the true utility of physician performance feedback and scorecards? Do they meet a real need for information to guide self-improvement or just scratch our competitive itches? What do we know about the best way to provide feedback? In this month’s guest blog Dr. Amy Cheng, the Emergency Department Director of Quality Improvement at St. Michael’s Hospital in Toronto with an interest in physician performance feedback, reviews what’s known and comments on her own experiences...

WTBS 10 – EM Quality Assurance Part 2: Individual Responsibilities

Last month in introducing part one of our guest blog on quality assurance I told a story about a missed opportunity with follow-up care. This month I’d like to share a story with a happier ending. Recently, a patient presented at our emergency department (ED) with a non-specific fever. After discharge the patient’s blood cultures were reported positive, but attempts to reach this person over the ensuing 36 hours at the contact numbers provided were unsuccessful. An enterprising colleague googled the patient and found contact information online that eventually led to a call to the patient in a hotel room in another city, but when reached the patient was ill and confused...

Best Case Ever 45 – Mike Winters on Cardiac Arrest

I had the great pleasure of meeting Dr. Mike Winters on his first ever visit to Canada at North York General's Emergency Medicine Update Conference, where he gave two fantastic presentations. His credentials are impressive: He is the Medical Director of the Emergency Department, Associate Professor in both EM and IM, EM-IM-Critical Care Program co-director and Residency Program Director of EM-IM at the University of Maryland in Baltimore. Sometimes we are so caught up with the job we need to get done during cardiac arrest that we forget about the important and profound effect that this event has on patients' families. On this Best Case Ever Dr. Winters tells the story of witnessing his grandfather's cardiac arrest, being present in the ED during the resuscitation attempts, and how that experience has coloured his practice. We discuss some pearls on communication with patients' families after death, colour-coded cardiac arrest teams and how to integrate POCUS into cardiac arrest care while minimizing chest compressions.

WTBS 8 – Succeeding With the Dirty Task of Hand Hygiene Promotion

Succeeding with the dirty task of hand hygiene promotion How many psychiatrists does it take to change a light bulb? The punch line to that old joke is, of course, “One—but the light bulb has to want to change.” But just as it’s tough to get patients to modify their behaviour (quit bad habits, take up good ones, comply with their meds, etc.), it’s also difficult for ED leaders to get their staff to alter their practices for the better. One example I find many EDs struggle with is improving hand hygiene. Despite what research has shown, some staff may believe they wash their hands plenty, thank you very much. Others may accept the evidence but struggle to remember to comply with hand hygiene guidelines, or competing priorities in a busy shift may get in the way of even the best of intentions. Access to a sink or supplies may be a problem when we provide care in hallways or waiting rooms; on the other hand, we may encounter patients stealing and drinking unsecured hand sanitizer. (Practice tip: If a patient becomes more intoxicated or less responsive after arrival in the ED, they may have consumed sanitizer.) In this month’s guest post, Dr. Mike Wansbrough, a colleague of mine at Mount Sinai Hospital in Toronto, Ontario, talks about his journey as our department’s “hand hygiene champion” (which means I was smart enough to delegate this thankless task to someone else—thanks, Mike!). Mike is a creative guy, so when he faced frustrations in trying to change the “light bulbs” that are my medical staff, he thought an online movie in this era of YouTube sensations might help. A link to the short film is provided below; the content has been researched and vetted by infection control experts and is only four minutes long. You are welcome to use it if it helps with your own hand hygiene efforts. I plan to make it mandatory viewing for our staff. Do you have other tips, suggestions, or resources on this issue to share? Please share them in our comments section so we can all learn from each other!

WTBS 6 Measuring Quality – The Value of Health Care Metrics

A New York Times article titled “How Measurement Fails Doctors and Teachers” went viral on social media in January and caused a lot of chatter in medical circles. Its author, a professor of medicine at the University of California, gave voice to a wide sense of frustration, and while I understand that feeling and think it’s justified, I don’t agree with labelling measurement as the culprit. As I expressed in my first WTBS blog post, “Why Recording Time to Initial Assessment is Worthwhile,” I believe my job as an administrator is to make the job of my staff easier, and measurements can help us maintain standards of care and understand where gaps in the system may exist—when such data are collected and used appropriately. In this guest blog, Dr. Lucas Chartier, an emergency physician in Toronto with a background in quality improvement, expands on the subject of how we’ve gone off course in our zeal for measurement and helps us try to find the path back to our intended goals.

Episode 75 Decision Making in EM – Cognitive Debiasing, Situational Awareness & Preferred Error

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...

Episode 74 Opioid Misuse in Emergency Medicine

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, effective, sustained and safe fashion. This was the emphasis 10-20 years ago after studies showed that we were poor at managing pain and our patients were suffering. On the other hand, opioid dependence, addiction, abuse and misuse are an enormous public health issue. Opioid misuse in Emergency Medicine has become a major problem in North America over the past 10 years at least partly as a reaction to the years that we were being told that we were failing at pain management. As Dr. Reuben Strayer said in his SMACC talk on the topic: “Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.” So how do we strike a balance between managing [...]

WTBS 5 Emergency Physician Speed Part 2 – Solutions to Physician Productivity

In Emergency Physician Speed How Fast is Fast Enough – Part I, Dr. David Petrie addressed the issue of physician productivity (patients per hour, or PPH), the many factors that influence how quickly emergency physicians can process patients, and some of the tradeoffs between speed and quality. He also discussed the processing rate of the entire ED and introduced the concepts of surge capacity and the effect of crowding on safety if the ED can’t keep up. In this follow-up blog, Dr. Petrie expands on the departmental aspects of throughput and safety, and calls on policy-makers to recognize the need to include surge capacity in planning efforts. He also makes some powerful arguments about the related issues of so-called 'inappropriate visits' and the changing role of the ED. In this post - Emergency Physician Speed Part 2 - Solutions to Physician Productivity , he also brilliantly dismantles some common myths about ED visits — and drivers of costs.

Best Case Ever 41 Opiate Misuse and Physician Compassion

Opiate misuse is everywhere. Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to prescription opiates, which now kill more people than heroin and cocaine combined. Opiates are the most prescribed class of medication in the US. In 2010, one out of every eight deaths among persons aged 25 to 34 years was opiate-related. Four out of 5 new heroin users report that their initial drug was a prescription opiate. In Ontario, three times the people died from opiate overdose than from HIV in 2011. Yet, we are expected to treat pain aggressively in the ED. Dr. Reuben Strayer, the brains behind the fantastic blog EM Updates tells his Best Case Ever, in which he realizes the importance of physician compassion in approaching the challenging drug seekers and malingerers that we manage in the ED on a regular basis. This Best Case Ever is in anticipation of an upcoming main episode in which Dr. Strayer and toxicologist Dr. David Juurlink discuss how to strike a balance between managing pain effectively and providing the seed for perpetuating a drug addiction or feeding a pre-existing drug addiction, and how we best take care of our patients who we suspect might have a drug misuse problem.