The Skeptics Guide to Emergency Medicine

Date: October 21st, 2020 This is an SGEM Xtra episode. I had the honour of presenting at the Department of Family Medicine's Grand Rounds at the Schulich School of Medicine and Dentistry. The title of the talk was: How to think, not what to think. The presentation is available to watch on YouTube, listen to on iTunes and all the slides can be downloaded from this LINK. Five Objectives: Discuss what is science Talk about who has the burden of proof Discuss Evidence-based medicine (EBM), limitations and alternatives Provide a five step approach to critical appraisal Briefly talk about COVID19 and the importance of EBM What is Science? It is the most reliable method for exploring the natural world. There are a number of qualities of science: Iterative, falsifiable, self-correcting and proportional. What science isn’t is “certain”. We can have confidence around a point estimate of an observed effect size and our confidence should be in part proportional to the strength of the evidence. Science also does not make “truth” claims. Scientists do make mistakes, are flawed and susceptible to cognitive biases. Physicians took on the image of a scientist by co-opting the white coat. Traditionally, scientists wore beige and physicians wore black to signify the somber nature of their work (like the clergy). Then came along the germ theory of disease and other scientific knowledge. It was the Flexner Report in 1910 that fundamentally changed medical education and improved standards. You could get a medical degree in only one year before the Flexner Report. The white coat was now a symbol of scientific rigour separating physicians from “snake oil salesman”.  Many medical schools still have white coat ceremonies. However, only 1 in 8 physicians still report wearing a white lab coat today (Globe and Mail). Science is Usually Iterative: Sometimes science takes giants leaps forward, but usually it takes baby steps. You probably have heard the phrase "standing on the shoulders of giants"? In Greek mythology, the blind giant Orion carried his servant Cedalion on his shoulders to act as the giant's eyes. The more familiar expression is attributed to Sir Isaac Newton, "If I have seen further it is by standing on the shoulders of Giants.” It has been suggested that Newton may have been throwing shade at Robert Hooke. Hooke was the first head of the Royal Society in England. Hooke was described as being a small man and not very attractive. The rivalry between Newton and Hooke is well documented. The comments about seeing farther because of being on the shoulders of giants was thought to be a dig at Hooke's short stature. However, this seems to be gossip and has not been proven. Science is Falsifiable:  If it is not falsifiable it is outside the realm/dominion of science. This philosophy of science was put forth by Karl Popper in 1934. A great example of falsifiability was the claim that all swans are white. All it takes is one black swan to falsify the claim.  Science and Proportionality: The evidence required to accept a claim should be in part proportional to the claim itself. The classic example was given by the famous scientist Carl Sagan (astronomer, astrophysicist and science communicator). Did the TV series Cosmos and wrote a number of popular science books (The Dragons of Eden). Sagan made the claim that there was a “fire-breathing dragon that lives in his garage”. How much evidence would it take for you to accept the claim about the dragon? His word, pictures, videos, bones, other biological evidence, how about knowing any other dragons or dragons that breathe fire? Compare that to if I said we just got a new puppy and it’s in the garage. You would probably take my word for it. There is nothing extraordinary about the claim. Most of you should be familiar and have had experience with a puppy at some point in your life.

Date: October 14th, 2020 Guest Skeptic: Dr.Salim Rezaie is a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education.  Salim is probably better known as the creator and founder of the wonderful knowledge translation project called REBEL EM. It is a free, critical appraisal blog and podcast that try to cut down knowledge translation gaps of research to bedside clinical practice. Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020.  Case: A 42-year-old helmeted bicycle rider is involved in an accident where he hits his head on the ground.  At the time of emergency medical services (EMS) arrival, the patient is alert but seems a bit confused.  The accident was within one hour of injury and his Glasgow Coma Scale (GSC) score was 12. Vital signs show a slight tachycardia but otherwise normal. Pupils were both equal and reactive and he doesn’t appear to have any other traumatic injuries, or focal neurologic deficits. Other injuries appear minimal with some abrasions from the fall. Background: The CRASH-2 trial, published in 2010, showed a 1.5% mortality benefit (NNT 67) for patients with traumatic hemorrhage who received tranexamic acid (TXA) compared to placebo. Dr. Anand Swaminathan and I covered that classic paper on SGEM#80. TXA has become standard practice in many settings as a result of this data.  However, patients with significant head injury were excluded in this study and it was unclear of the effect of TXA in this group. CRASH-3 Fast forward to October 2019, when CRASH-3 was published. This large, very well-done randomized placebo-controlled trial examined the use of TXA in patients with traumatic brain injuries (TBIs) with GCS score of 12 or lower or any intracranial bleed on CT scan and no extracranial bleeding treated within 3 hours of injury. The authors reported no statistical superiority of TXA compared to placebo for the primary outcome of head injury-related deaths within 28 days. We reviewed that article published in the Lancet in SGEM#270. Subgroup analysis did demonstrate that certain patients (GCS 9 to 15 and ICH on baseline CT) showed a mortality benefit with TXA. While very interesting and potentially clinically significant, we need to be careful not to over-interpret this subgroup analysis. We did express concern over the possibility that this subgroup would be highlighted and “spun”. Unfortunately, that did happen with a subsequent media blitz and a misleading infographic. Further data is clearly needed to elucidate the role of TXA in patients with TBI. Clinical Question: Does pre-hospital administration of TXA to patients with moderate or severe traumatic brain injury improve neurologic outcomes at 6 months? Reference: Rowell et al. Effect of Out-of-Hospital Tranexamic Acid vs Placebo on 6-Month Functional Neurologic Outcomes in Patients With Moderate or Severe Traumatic Brain Injury. JAMA 2020. Population: Patients 15 years of age or older with moderate or severe blunt or penetrating TBI. Moderate to severe TBI was defined as a GCS 3 to 12, at least one reactive pupil, systolic blood pressure ≥90mmHg prior to randomization, able to receive intervention or placebo within two hours from injury, and destination to a participating trauma center. Exclusions: Prehospital GCS=3 with no reactive pupil, start of study drug bolus dose greater than two hours from injury, unknown time of injury, clinical suspicion by EMS of seizure activity, acute MI or stroke, or known history, of seizures, thromboembolic disorders or renal dialysis, CPR by EMS prior to randomization, burns > 20% total body surface area, suspected or known prisoners, suspected or known pregnancy), prehospital TXA or other pro-coagulant drug given prior to randomization or subjects who hav...

Date: October 9th, 2020 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department, specifically the use of ketamine. His twitter handle is @PainFreeED. Reference: Friedman et al. Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study. AEM 2020. Case: A 41-year-old man without a significant past medical history presents to the emergency department (ED) with a chief complaint of lower back pain that started 48 hours prior to the ED visits after attempting to move a couch in his house. He describes the pain as sharp, constant, non-radiating, and 6/10 in intensity. Pain gets worse with movement and minimal bending. The pain is limiting his usual activities included his ability to go to work. He denies weakness or numbness of the legs as well as bowel or bladder dysfunctions. You perform a physical exam and note prominent tender area to palpation at the right lumbar region. You explain to the patient the most likely diagnosis is a muscle strain. Your usual approach is to treat this type of case scenario with Ibuprofen. The patient asked you if Ibuprofen alone will be strong enough to control his pain. Background: Pain is one of the most frequent reasons to attend an ED. Low back pain (LBP) is responsible for 2.3% of all ED visits resulting in 2.6 million visits each year in the USA (Friedman et al Spine 2010). We have covered back pain a number of times on the SGEM. SGEM#87: Let Your Back Bone Slide (Paracetamol for Low-Back Pain) SGEM#173: Diazepam Won’t Get Back Pain Down SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain The SGEM bottom line from SGEM#240 was: There appears to be no long-term analgesics benefits from prescribing opioids for chronic non-cancer pain (nociceptive and neuropathic). However, their use is associated with increased adverse events. The American College of Emergency Physicians (ACEP) has updated their clinical policy on prescribing opioids for adult ED patients. There are no Level A recommendations, one Level B recommendation and multiple Level C recommendations (ACEP June 2020) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? Level B Recommendations: When possible, treat opioid withdrawal in the emergency department with buprenorphine or methadone as a more effective option compared with nonopioid-based management strategies such as the combination of α2-adrenergic agonists and antiemetics Many other pharmaceutical treatments besides opioids have been tried to address acute LBP pain with limited success. These include: acetaminophen (Williams et al Lancet 2014), muscle relaxants (Friedman et al JAMA 2015), NSAIDs (Machado et al Ann Rheum Dis 2017), steroids (Balakrishnamoorthy et al Emerg Med J 2014) and benzodiazepines (Friedman et al Ann Emerg Med 2017). Pain outcomes for patients with LBP are generally poor; One week after an ED visit in an unselected LBP population, 70% of patients report persistent back pain–related functional impairment and 69% report continued analgesic use (Friedman et al AEM 2012). There are a number of non-pharmaceutical treatment modalities that have also been tried to treat low back pain. They include: CBT and mindfulness (Cherkin et al JAMA 2016), chiropractic (Paige et al JAMA 2017), physical therapy (Paolucci et al J Pain Research 2018) and acupuncture (Colquhoun and Novella Anesthesia and Analgesia 2013). None of these other treatments has high-quality evidence supporting their use. Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line medication therapy for patients with acute...

Date: September 28th, 2020 Guest Skeptic: Dr.Michelle Cohen (@DocMCohen). She is a rural Family Physician, writer (CBC News, Toronto Star and McLean’s Magazine), Assistant Professor Queens University and the Co-Chair of the Advocacy Committee of Canadian Women in Medicine. Dr. Michell Cohen This is an SGEM Xtra episode based on an article by Dr. Cohen and Dr. Kiran published in the Canadian Medical Association Journal (CMAJ). The article was called Closing the gender pay gap in Canadian medicine. Please listen to the SGEM podcast to hear Dr. Cohen answer five questions and discuss the issue of gender pay inequity.   Five Questions about the Gender Pay Gap Is the gender pay gap real? Do women just work less (or less efficiently) than men? What are some of the root causes of the gender pay gap? What can we learn from other jurisdictions? What can be done to close the gender pay gap in Canadian medicine? The CMAJ article fits with the evidence presented at FIX19. It also is consistent with the study published a year ago that showed Ontario female surgeons made 24% less per hour than male surgeons. This pay gap persisted even after adjusting for various factors (Dossa et al JAMA 2019). The Ontario Medical Association (OMA) has published a report called Understanding Gender Pay Gaps Among Ontario Physicians from their Human Resources Committee. It found that male physicians on average bill 15.6% more than female physicians even after controlling for a number of variables. There was a recent study that looked at the 194 countries and the gender of the national leader (Garikipati and Kambhampati 2020). They found that countries led by women were associated with better COVID-outcomes. This is low quality evidence because it is an observational study that is pre-print (not peer reviewed) and we should not over-interpret the results. This association between women leaders and good COVID responses was discussed in a debate about masks back in the spring of this year (SGEM Xtra Masks4All). There was a stronger association between women leaders and good COVID responses than to mandatory universal masking policies. Conclusions to the CMAJ Article “Women continue to be paid less than men in medicine. The gender pay gap exists within every specialty and also between specialties, with physicians in male­dominated specialties receiving higher payments. The gap is not explained by women working less but, rather, relates more to systemic bias in medical school, hiring, pro­motion, clinical care arrangements, mechanisms used to pay physicians and societal structures more broadly. Progress in Canada will require a commitment from medical associations and governments to close the pay gap, starting with transparent reporting of physician payments stratified by gender. We need to go further as a professionto understand how gender, race, disability and other identi­ties intersect to affect gaps in pay and then take action to address these gaps to realize the vision of pay equity for all in medicine.” We need to ensure that everyone gets the emergency care they need, regardless of whether they identify as a man or woman. The emergency department is like a lighthouse. It is the one place in the house of medicine where the light is always on and will treat anyone at any time for anything. The gender inequity discussion does dichotomize things into men and women. This is a false dichotomy. There are people who do not identify as a man or women. Gender is complex and on a spectrum. There is how a person identifies, expresses themselves, the sex assigned at birth, who they are physically attracted to and who they are emotionally attracted to. I would suggest that FBM is just the starting point and we need to take it one step further to Gender-Based Medicine (GBM). The Gender Unicorn is a graphic representation demonstrating the complexity of gender and ...

Date: October 2nd, 2020 Guest Skeptic: Dr.Barbra Backus is an emergency physician at the Emergency Department of the Erasmus University Medical Center in Rotterdam, the Netherlands. She is the creator of the HEART Score and an enthusiastic researcher. Reference: Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM July 2020 Case:  A 65-year-old man with a history of well controlled hypertension presents to the emergency department and is diagnosed with a mild stroke (NIHSS score 3). He is a non-smoker, not diabetic and has never had a stroke before. The only medicine he takes is an angiotensin converting enzyme inhibitor. You are wondering if he should be discharged on just aspirin or aspirin plus another antiplatelet agent like ticagrelor. Background: Acute ischemic strokes are the leading cause of disability in our society and the third most common cause of death. Aspirin has been used to prevent a subsequent stroke in patients who suffered an acute ischemic stroke (AIS) or transient ischemic attack (TIA), which occur in approximately 5-10% of patients in the first few months after their primary event. Trials have shown mixed results with the combination of aspirin with clopidogrel in this population. SGEM#24 reviewed a randomized controlled trial (RCT) of aspirin vs. aspirin + clopidogrel in patients with recent symptomatic lacunar infarcts identified by MRI (Benavente et al NEJM 2012). Adding clopidogrel to aspirin did not reduce recurrent strokes but did increase risk of bleed and death. The study was stopped early due to harm and lack of efficacy. An RCT done in China on patients with minor strokes or TIAs who were treated within 24 hours after the onset of symptoms showed that aspirin plus clopidogrel is superior to aspirin alone for reducing the risk of stroke in the first 90 days and does not increase the risk of hemorrhage (Wang et al NEJM 2013). A third RCT assigned patients with minor ischemic stroke or high-risk TIA to ASA alone or the combination of both aspirin and clopidogrel. This trial was also stopped early because of lower risk of major ischemic events but higher risk of major hemorrhage with the combination therapy compared to aspirin alone (Johnston et al NEJM 2018). As an antiplatelet agent that blocks the P2Y12 receptor, clopidogrel requires hepatic conversion to its active form through a pathway that is ineffective in 25% of white and 60% of Asian patients; efficacy is therefore uncertain in these patients (Pan et al Circulation 2017). Ticagrelor is a direct-acting antiplatelet agent that does not depend on metabolic activation. A trial of ticagrelor alone did not show a benefit over aspirin in preventing subsequent cardiovascular events (Johnston et al NEJM 2016). The effect of the combination of ticagrelor and aspirin on prevention of stroke has not been well studied. Clinical Question: Is the combination of ticagrelor and aspirin superior to aspirin alone in reducing the risk of subsequent stroke or death among patients with acute non-cardioembolic cerebral ischemia? Reference:Claiborne Johnston S et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. NEJM July 2020 Population: Patients 40 years and older who experience a mild-to-moderate acute noncardioembolic ischemic stroke (NIHSS score of 5 or less), or high-risk TIA (ABCD2>5) or symptomatic intracranial or extracranial arterial stenosis (>50% lumen narrowing accounting for the TIA) Excluded: Thrombolysis or EVT was planned <24 hours before randomization or if there was planned use of anticoagulation or specific anti-platelet therapy other than ASA. Patients were also not eligible if they had “hypersensitivity to ticagrelor or ASA, a history of atrial fibrillation or ventricular aneurysm or a suspicion of a cardioembolic cause of the TIA or stroke, planned carotid endarterectomy that required discontinuation of t...

Date: September 22nd, 2020 Guest Skeptic: Dr. Chris Bond is an emergency medicine physician in Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM. Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020. Case: A 34-year-old male presents to the emergency department with burning epigastric pain after eating two hours ago. He says he gets this from time to time but this is the worst it has ever been. He denies chest pain, shortness of breath, fever and vomiting. His vital signs are within normal limits and his abdominal exam reveals mild epigastric and left upper quadrant tenderness with no peritonitis. Pink Lady Cocktail Background: Patients presenting to emergency departments (EDs) with epigastric pain are typically treated with an antacid, either alone or combined with other medications. Such medications include viscous lidocaine, an antihistamine, a proton pump inhibitor, or an anticholinergic (1,2). In Canada we often use an antacid plus viscous lidocaine referred to as a “Pink Lady”. This is different than the alcoholic cocktail called a Pink Lady. In the US, combination treatment is often called a “GI Cocktail”. There are mixed results from studies with varying methodological quality looking at acute dyspepsia management in the ED. One single-blind study comparing 30 mL of antacid with or without 15 mL of viscous lidocaine found the addition of lidocaine significantly increased pain relief, decreasing patient pain score by 40 mm compared to 9 mm with antacid monotherapy (3). Another single-blind RCT comparing antacid plus either benzocaine solution or viscous lidocaine found no statistical difference between the two interventions, however, there was no antacid monotherapy group (4). A larger, double-blind RCT of 113 patients compared 30 mL of antacid monotherapy, antacid with 10 mL of an anticholinergic, and antacid with anticholinergic and 10 mL of 2% viscous lidocaine. This study found all treatments had clinical efficacy and there was no statistical difference in pain relief between the three treatment groups. The conclusion from Berman et al was to recommend antacid monotherapy (5). Clinical Question: Is antacid monotherapy more effective in relieving epigastric pain than in combination with lidocaine? Reference: Warren et al. Antacid monotherapy is more effective in relieving epigastric pain than in combination with lidocaine. A randomized double-blind clinical trial. AEM Sept 2020. Population: Adult patients with epigastric pain or dyspepsia presenting to the emergency department. Excluded: Patients unable to consent or under 18 years of age. Intervention:  Arm 1 (Viscous): Received 10 mL oral lidocaine 2% viscous gel plus 10 mL antacid (traditional antacid/lidocaine mixture) Comparison: Arm 2 (Solution): Received 10 mL lidocaine 2% solution plus 10 mL antacid Arm 3 (Antacid): Received 20 mL antacid alone Outcome: Primary Outcome: Change in pain scores on 100mm visual analog scale (VAS) at 30 minutes after treatment. Secondary Outcomes: Medication palatability (taste, bitterness, texture, and overall acceptability) using a VAS, change in pain score 60 minutes post administration and adverse events. Dr. Jamie Warren This is an SGEMHOP episode which means we have the lead author on the show, Dr. Jaimee Warren. She is a first-year doctor at the Royal Melbourne Hospital and an aspiring emergency and retrieval physician. She hopes to one day work in rural and extreme environments. Authors’ Conclusions: “A 20 mL dose of antacid alone is no different in analgesic efficacy than a 20 mL mixture of antacid and lidocaine (viscous or solution). Antacid monotherapy was more palatable and acceptable to patients.

Date: September 16th, 2020 Guest Skeptics: Dr. Robert Goulden and Dr. Audrey Marcotte are Chief Residents from the Royal College of Emergency Medicine Program at McGill University. Robert’s academic interests include research and evidence-based medicine. Alongside his EM residency, he is doing a PhD in epidemiology. Audrey’s academic interests include trauma and resuscitation. Outside of medicine, Audrey likes to play rugby and run. Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 This was an SGEM Journal Club episode recorded live at McGill University Grand Rounds. This was the third time coming to McGill University Department of Emergency Medicine to give Grand Rounds. The first visit was back in 2013 for SGEM#50: Under Pressure - Vasopressin, Steroids and Epinephrine in Cardiac Arrest. The bottom line was this was interesting, but VSE protocol was not ready for routine use. The second visit was SGEM#176: Somebody’s Watching Me – Cardiac Monitoring for Chest Pain. We were trying to answer the question: Do all patients presenting to the emergency department with chest pain need to be placed on cardiac monitoring or could some be safely removed? The SGEM Bottom Line was that for some patients presenting with chest pain who are chest pain free and have normal/non-specific ECG findings could potentially be safely removed from cardiac monitoring using the Ottawa CPCM Rule. Five Rules of SGEM-JC Case:A 58-year-old man presents with hypotension, tachycardia, and pallor. He vomits a large amount of bloody emesis and has epigastric discomfort. He is not taking any anti-coagulants. He remains hemodynamically unstable despite initial resuscitation and has another episode of hematemesis in front of you. While waiting for your consultant to answer the phone, you consider treating him with tranexamic acid (TXA), but wonder if it will prevent death from gastrointestinal (GI) bleeding. Background: We have covered the use of TXA a number of times on the SGEM. TXA is an anti-fibrinolytic agent that inhibits clot breakdown and has demonstrated mixed results in different clinical settings. The CRASH-2 trial showed a 1.5% absolute mortality benefit with TXA in adult trauma patients compared to placebo (SGEM#80). TXA also seems to improve patient-oriented outcomes in epistaxis (SGEM#53 and SGEM#210). However, TXA did not show a statistically significant difference for the primary outcome in post-partum hemorrhage (SGEM#214) WOMAN Trial, hemorrhagic stroke (SGEM#236) or traumatic intracranial hemorrhage (SGEM#270) CRASH-3. A Cochrane systematic review and meta-analysis of eight smaller trials (n=1,701) using TXA in gastrointestinal bleeding suggested a large (40%) risk reduction in all-cause mortality (Bennett et al 2014). However, even a meta-analysis is prone to bias and is only as good as the quality of the included trials. When all participants in the intervention group with missing outcome data were included as treatment failures, or when the analysis was limited to trials with low risk of attrition bias the mortality benefit of TXA disappeared. Clinical Question: Does treatment with TXA reduce the mortality of patients with upper or lower GI bleeds? Reference: Roberts et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet 2020 Population: Adult patients (16 years of age or 18 years of age and older depending on country) with significant upper or lower GI bleed. Significant bleed was defined clinically (judged at risk of bleeding to death, hypotension <90 mmHg systolic, tachycardia,

Date: September 11th, 2020 This is an SGEM Xtra episode. I was invited by the College of Physicians and Surgeons of Ontario (CPSO) to give a talk at their council meeting on burnout. It was an opportunity to share my journey and give an important message about kindness. I have discussed burnout and wellness a number of times on the SGEM: SGEM#289: I Want a Dog to Relieve My Stress in the Emergency Department SGEM Xtra: CAEP Wellness Week 2019 SGEM Xtra: On the Edge of Burnout SGEM Xtra: Don’t Give Up – The Power of Kindness SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust SGEM Xtra: Five Tips to Avoid Emergency Medicine Burnout Burnout vs. Moral Injury The word burnout was coined by Herbert Freudenberger in 1974. He defined it as “a state of fatigue or frustration that resulted from professional relationships that failed to produce the expected rewards”. A distinction between burnout and moral injury was made during the presentation. Moral injury has been defined as: “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations". This was originally described in soldiers’ responses to their actions during war. Journalist Diane Silver described moral injury in her State News article as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” The moral injury of physicians is being unable to provide high-quality care they want to provide to their patients. My struggle with Burnout My struggle with burnout included the death of my father (Dr. Ken Milne Sr.) in November of 2018, the sudden death of my "little" brother Scottie (The Moose) in February 2020 and the unexpected death our family dog Moxy (best dog every) this summer. Much of this taking place in the context of the COVID19 global pandemic. All the slides from this CPSO presentation can be downloaded and shared from this link. The CPSO video recorded the presentation and it should be available soon. There are also a number of references for further information on burnout. Shanafelt et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015 Shanafelt et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc 2016 West et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016  Dr. Goldman & BatDoc One of the big lessons I have learned over the last two years is to be kinder. This was taught to me by my kindness mentor Dr. Brian Goldman from CBC show White Coat Black Art. He has published a book called The Power of Kindness: Why Empathy Is Essential in Everyday Life. I had the honour of interviewing Dr. Goldman on an SGEM Xtra. We need to try to be kinder to ourselves, kinder to each other and kinder to each other. In a world where you can be anything, be kind.   College of Physicians and Surgeons of Ontario The CPSO has recognized that our health care system is facing pressures and the COVID19 pandemic has made things even worse. The June 2020 eDialogue highlighted five things the college is doing to mitigate this increase in stress. Introduced Alternative Dispute Resolution mech as an option for the handling of low-risk matters Decreased the time to complete a complaint by 47% in 2019, compared to 2018 Promoted connectedness through the quality improvement’s (QI) emphasis on peer interactions Encouraged professionalism to flourish by developing a QI framework that allows physicians to self-direct their learning Redesigned policies that allow physicians to immediately understand and access College expectations

Date: August 27th, 2020 Guest Skeptic: Dr. Malthaner is the Chair/Chief of the Division of Thoracic Surgery, Director of Thoracic Surgery Research and Simulation, and Professor in the Departments of Surgery, Oncology, and Epidemiology and Biostatistics at the Schulich School of Medicine and Dentistry and Western University. Rick is also the founder of Western University’s Department of Surgery Journal Club and runs The Skeptik Thoracik Journal Club. Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Case: A 49-year-old healthy male electrician presents to the emergency room with right chest pain and dyspnea. The work-up reveals a diagnosis of a right pneumothorax confirmed by chest x-ray (CXR). What do you do? Background: A patient with a pneumothorax is a common presentation to the emergency department. Pneumothoraxes can be broken down into either primary or secondary. Primary pneumothorax occurs in healthy people. Secondary pneumothoraxes are associated with underlying lung disease. There is considerable heterogeneity in the management of primary spontaneous pneumothoraxes, but the most common treatment is interventional drainage, sometimes progressing to surgical intervention. However, the insertion of a chest tube is often painful and can cause organ injury, bleeding, and infection. An alternative approach is conservative management, with intervention reserved for patients for whom the pneumothorax becomes physiologically significant. I covered in the Skeptik Thoracik Journal Club which can be viewed on YouTube. Clinical Question: Does everyone with a large first-time spontaneous pneumothorax need a chest tube? Reference: Brown et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. NEJM 2020 Population: Patients 14 to 50 years of age with a unilateral primary spontaneous pneumothorax of 32% or more on chest radiography according to the Collins method. Exclusion: Previous primary spontaneous pneumothorax on the same side Secondary pneumothorax (defined as occurring in the setting of acute trauma or underlying lung disease including asthma with preventive medications or symptoms in the preceding two years) Coexistent hemothorax Bilateral pneumothorax “Tension’ pneumothorax” (systolic BP <90 mmHg, mean arterial pressure <65 mmHg, or shock index HR/SBP ≥1) Pregnancy at time of enrolment Social circumstances (inadequate support after discharge to re-attend hospital if required or unlikely to present for study follow up) Planned air travel within the following 12 weeks Intervention: A small chest tube (≤12 French) was inserted and attached to an underwater seal, without suction and a CXR was obtained one hour later. If the lung had re-expanded and the underwater drain no longer bubbled, the drain was closed with the use of a three-way stopcock. Four hours later, if the patient’s condition was stable and a repeat CXR showed that the pneumothorax had not recurred, the drain was removed, and the patient was discharged. If the initial drain insertion did not result in resolution on CXR or if the pneumothorax recurred under observation, the stopcock was opened, the underwater seal drainage was recommenced, and the patient was admitted. Subsequent interventions were at the discretion of the attending clinician. Comparison: Patients were observed for a minimum of four hours before a repeat CXR was obtained.After observation, if patients did not receive supplementary oxygen and were walking comfortably, they were discharged with analgesia and written instructions. Interventions were allowed in the conservative-management protocol under five conditions: Clinically significant symptoms persisted despite adequate analgesia; Chest pain or dyspnea prevented mobilization; Patient was unwilling to continue with conservative treatment;

Date: September 3rd, 2020 It has been a tough year for all of us with the global pandemic of COVID19. I hope everyone is safe and taking care of themselves both physically and mentally. It is more important than ever during these difficult times to stay socially connected to those we love and care about. You are all leaders in your own way and can set the tone for your community. Lead by example: wash your hands well, practice physical distancing (not social distancing) and be smart about wearing a mask. More than anything else, try to be kinder to each other as we get through this challenging time. We have just finished Season#8 of the SGEM with an episode on the diagnostic accuracy of clinical findings, lab tests and imaging studies for COVID19 (SGEM#299). This was an SGEM Hot off the Press episode in partnership with Academic Emergency Medicine (AEM). We track these special shows and this one got close 2.6 million twitter impressions in one week. It is also now in the top 50 papers every published by AEM according to Altmetrics. This represents some excellent knowledge translation (KT) by addressing awareness. The SGEM continues to grow and has approximately 43,000 subscribers. It has been successful because of people like you who listen every week. I would also like to thank the SGEMHOP Team (Drs. Bond, Heitz and Morgenstern), PaperinaPic producer (Dr. Challen), all the guest skeptics and my best friend Chris Carpenter. The SGEM continues to try and cut KT window down from over ten years to less than one year. It does this by doing a structured critical review of a recent publication and then shares the information using social media. Our ultimate goal is for patients to get the best care based on the best evidence. Scottie (The Moose) Milne As many of you know, 2020 has been additionally difficult for the Milne family with the unexpected death of my little brother Scottie in February. I'm still processing the grief and appreciate all the love and support everyone has provided. We all deal with death in our own way and on our own time schedule. Part of my grieving process was to plant an oak tree for Scott this spring. I know it will grow as big and strong as he did. If you have a sibling, friend, or anyone you care deeply about, I would encourage you to reach out to them today. Let them know how much you love them and appreciate them being part of your life. It may be your last opportunity. It is also ok not to be ok. You do not need to be a super hero. Asking for help is a sign of strength not weakness. I asked for and received help from many of you and it got me through this very painful time. You know who you are and thank you so much. I would like to take this opportunity to thank you SGEMers for everything you do in providing excellent patient care. As a gift, please accept this PDF book of SGEM Season#6. You will find links to all your favourite episodes, PaperinaPic infographics, and Twitter polls. Don't Panic! Dr. Chris Carpenter's chapter on evidence based medicine, Dr. Justin Morgenstern's (First10EM) simplified guide to approaching the literature and Dr. Anthony Crocco's SketchyEBM chapter are all still part of the book. Please feel free to share SGEM Season#6 book via your social media networks (email, Facebook, Twitter, Instagram, etc). If you are looking for the amazing theme music that helps with the KT for each SGEM episode, you can find them on Spotify. Most of the music comes from the 1980's because it is clearly the best musical era. This KT project continues to be part of the free open access to medical education movement (FOAMed). I continue to strongly believe we should share our intellectual capital and efforts with everyone around the world with no paywalls. This information should be for anyone, anywhere and at anytime. The SGEM Season#6 was put together with the help of my niece Rhiannon Milne who just finished her degree in Global Busine...