The Skeptics Guide to Emergency Medicine

Dr. Rachel Hatcliffe, a pediatric emergency medicine attending at Children's National Hospital, and Dr. Kate Remick, an Assistant Professor at Dell Medical School, delve into the pediatric readiness of U.S. emergency departments. They discuss the impact of staffing challenges revealed during the COVID-19 pandemic and the critical need for pediatric emergency care coordinators. Highlighting a significant decline in pediatric inpatient units, they advocate for policy changes and enhanced resource allocation to improve care quality for children in emergencies.

Join Dr. Chris Carpenter, Vice Chair of Emergency Medicine at Mayo Clinic, as he delves into compelling topics surrounding emergency care. They discuss the critical implications of overnight stays for elderly patients, highlighting alarming mortality rates. The conversation sheds light on systemic issues like overcrowding and the urgent need for enhanced patient care strategies. They also explore the challenges of prioritizing geriatric needs while ensuring equitable care across all demographics in emergency settings.

Date: December 12, 2023 Reference: OCFP News. More Than Four Million Ontarians Will Be Without a Family Doctor by 2026. Nov 7, 2023 Guest Skeptic: Dr. Mahaleh Mekalai Kumanan attended Dalhousie University for her undergraduate studies, Master of Health Administration degree and medical school before completing her residency at the University of Western Ontario. She is currently the President of the Ontario College of Family Medicine (OCFP). This is an SGEM Xtra. I had the opportunity to interview the President of the OCFP about the current state of family medicine and some possible solutions. Please consider listening to the SGEM Podcast and hear what Dr. Kumanan has to say. It has been an interesting couple of months. The College of Family Physicians of Canada (CFPC) in September widely communicated they were going to implement an additional year of training for family medicine residents. There was an outcry from individuals and organizations (SRPC, CFMC, RDC, OMA & Ministers of Health) asking the CFPC to pause and reconsider. This included a statement from the OCFP. To its credit the CFPC listened, reflected, and responded in a very appropriate way. The CFPC President (Dr. Mike Green) apologized and announced they are not implementing an additional year of training. This took a great deal of insight and humility. Well done CFPC. Now it is time to address some immediate issues with Family Practice. Some listeners may be wondering why we are discussing this on an emergency medicine podcast. Well, it is because we are all on Team Patient. Family Medicine is the foundation of healthcare. Without strong primary care patients will eventually end up in the ED. I suspect Ontario is not the only province and Canada is not the only country struggling with these problems. As of September 2022, data by INSPIRE-PHC posted on the Ontario Community Health Profiles Partnership (OCHPP) shows nearly 2.3 million Ontarians are without a family doctor – that’s up from 1.8 million in March 2020, or up from 1.6 million in 2018. INSPIRE-PHC research, led by Dr. Kamila Premji, also shows 1.74 million Ontarian's have a doctor who is nearing retirement. In addition, the number of medical school graduates choosing to pursue family medicine is the lowest it’s been in 15 years. Using updated research, the OCFP now predicts that Ontario will exceed its previous forecast as the crisis in family medicine intensifies. Approximately 1 in 4 Ontarian's – or 4.4 million – will be without a family doctor by 2026. OCFP: Three Solutions to the Crisis Ensure Ontarians have a family doctor working alongside a team, so patients can get the help they need faster. Improve the accessibility of care by increasing the time that family doctors can spend providing direct patient care. Ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province. Research shows that patients with access to comprehensive team-based primary care, led by a family doctor, have better health outcomes, fewer visits to the hospital/emergency department/specialty care, and overall are more satisfied with their care. The Ontario government needs to commit to ensuring every family doctor and their patients have access to a team. Ontarians who have family doctors working in teams have far greater access to the care they need because their physicians are supported by nurses, pharmacists, dietitians, social workers and more. Having easy access to a team of health care providers led by a family physician means patients can get the right care from the right provider – and frees up time for family doctors to focus on patients that most need their expertise. Right now, 70 per cent of family doctors and their patients do not have access to team-based support. The second solution the OCFP suggests is to improve the accessibility of care by increasing the time that family doctors can ...

Dr. Chris Bond, an emergency medicine physician and assistant professor at the University of Calgary, discusses the impact of microaggressions in the emergency department. He addresses how subtle discrimination affects patient care outcomes, focusing on a case study of a Chinese woman with chest pain. The conversation highlights how language barriers exacerbate these issues and the role of implementation science in improving healthcare interactions. Bond also emphasizes the need for training to foster better communication and understanding in diverse patient populations.

Date: November 20, 2023 Reference: Jones et al. Time to reflect on open-label placebos and their value for clinical practice. PAIN October 2023 Caitlin Jones PhD Guest Skeptic: Dr. Caitlin Jones is a Postdoctoral Research Associate at Sydney University’s institute for Musculoskeletal Health. Her research evaluates the benefits and harms of treatments for musculoskeletal conditions with a particular interest in high-risk treatment options such as opioid medicines and spinal cord stimulators for pain. She has a goal to improve patient outcomes and reduce harm from inappropriate treatments. We have an interesting back story on how we met. Dr. Sergey Motov and I did a structured critical appraisal of the OPAL trial (SGEM#419). You were the lead author on that study. You pointed out we missed some details in our review and provided some additional information. We were happy to hear from you and updated the SGEM episode based upon your comments. Not everyone has been so receptive to your study and your feedback. Thanks for appraising OPAL and for engaging with me about it. There were lots of varied responses to OPAL. Most were positive and interested. Some had opinions that the trial doesn’t reflect their practice or their patients, so it’s not relevant to them (reasonable position). Some are furious that we would even suggest that opioids don't work and they are certain this is part of a corrupt evil agenda (I don’t engage with this stance because nothing I can say will change their minds). I do engage when it’s just a genuine misunderstanding, or someone has missed some details.Everyone is free to make up their own mind about how they will or won’t apply these findings into their clinical practice, but I do feel an obligation to correct misunderstandings when I see them. After our exchange I looked up some of your other publications. One of them caught my eye as being very thought-provoking. It looked at open label placebo being used in clinical trials. The title of the paper was Time to reflect on open-label placebos and their value for clinical practice [1]. What got you interested in that topic? A lot of my research compares treatments for MSK pain to placebo to establish efficacy (how well it works). In my field we often find, sadly, that some of the treatments used for decades in clinical practice don’t show effects above that of the placebo when someone finally tests them properly. There’s been increasing chatter about OLPs with a few editorials written in big journals, and an increase in publications on the topic, so it is clearly gaining traction in the clinical and research community. A lot of my work so far has been about testing treatments that have been used for decades without proper testing, and then when we finally test them, we discover we were doing more harm than good all this time. Open label placebos as a clinical treatment are new enough that there is time to intervene and advocate for some thorough testing before they become common place in clinical care. I don’t want this to be another thing where we realize in 50 years’ time that we were harming not helping. SGEM listeners are probably familiar with the placebo effect, but can you give us a brief definition or description? The placebo effect is the positive effect on outcomes stemming from positive expectations around receiving a treatment, but not the treatment itself. Placebo in a research context is the gold standard comparison in efficacy trials that can provide an estimate of the treatment effect, filtering out all the biases and contextual effects that aren’t directly caused by the treatment of interest, so we are left with an estimate of the direct effects of the treatment itself. Then along came some research which caused some excitement. They reported that you could elicit a placebo effect without deceiving the patients (ie telling them it is a placebo) [2]. Yes,

Dr. Alasdair Munro, a clinical research fellow in pediatric infectious disease, joins to dissect the nuances of pediatric sinusitis. They analyze a case of a 4-year-old with yellow nasal discharge and fever, questioning if antibiotics are warranted. The conversation highlights the challenges of differentiating between viral and bacterial infections, discusses recent guidelines, and challenges assumptions about nasal discharge color. They also delve into the importance of evidence-based treatment while promoting shared decision-making in pediatric care.

Date: November 22, 2023 Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine. Case: A 72-year-old man with a history of high blood pressure and diabetes calls emergency medical services (EMS) for chest pressure and dyspnea that started 1 hour ago. Upon EMS arrival, they find the patient is sweaty with normal vital signs. A 12-lead electrocardiogram (ECG) demonstrates ST elevations in leads II, III, and aVF with ST depressions in leads I and aVL and the team begins transport to the nearest percutaneous coronary intervention (PCI) capable hospital. Background: We have covered the issue of heart attacks several times on the SGEM. These include looking at the HEART score, troponin testing and cardiovascular disease in women. One aspect we have not addressed is rural. SGEM#151: Groove is in the HEART Pathway SGEM#160: Oh Baby, You’re Too Sensitive – High Sensitivity Troponin SGEM#280: This Old Heart of Mine and Troponin Testing SGEM#370: Listen to your HEART (Score) SGEM#400: A Little Bit of Heart and Sport and Sports Related Sudden Cardiac Arrest in Women SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease Current guidelines target a time between first medical contact (FMC) like EMS on-scene and stent or balloon deployment (PCI) of 90 minutes or less. If time from FMC to PCI is anticipated to be greater than 120 minutes, the guidelines recommend systemic thrombolysis rather than PCI [1]. I’ve published on this issue with a project we called “barn door-to-needle time” [2]. We looked at 101 STEMI patients from two rural EDs. The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes. Regional systems of care have been designed to rapidly recognize patients with STEMI and direct STEMI patients to timely reperfusion. Many hospitals do not provide PCI, prolonging transportation times, which disproportionately affects rural patients. There are several distinct time intervals in the care of patients with STEMI and it is unclear which steps in pre-PCI care of patients contribute to avoidable delays. Clinical Question: Is there an association between in-hospital mortality and time between first medical contact and primary percutaneous coronary intervention in rural patients who present with a STEMI? Reference: Stopyra et al. Delayed First Medical Contact to Reperfusion Time Increases Mortality in Rural EMS Patients with STEMI. AEM November 2023. Population: Patients ≥ 18 years of age who were transported to one of three tertiary care hospitals by a rural EMS agency and received primary percutaneous coronary intervention (PCI) for STEMI. Rural agency was defined by US census codes (2014) Excluded: Patients <18, those who had prehospital cardiac arrest, and those who were transferred between hospitals Exposure: 90-minute first medical contact to PCI goal (defined as time between the time recorded as EMS personnel arrival on scene and the time the angioplasty or stent was deployed Comparison: Greater than 90 minute first medical contact to PCI Outcome: Primary Outcome: All-cause in-hospital mortality during the index hospitalization Secondary Outcomes: Prehospital time intervals stratified by index hospitalization mortality. Type of Study: A retrospective cohort study from eight rural North Carolina EMS agencies between January 2016 to March 2020. Dr. Michael Supples

Dr. Matt Schmitz, an Orthopaedic Surgeon transitioning from a 20-year Air Force career to Clinical Professor at UC San Diego, tackles the tricky world of scaphoid fractures. He sheds light on the flaws of X-rays in diagnosis, discussions about the significance of clinical exams, and the implications of misdiagnosis. The conversation extends to surgical techniques, patient communication, and even a quirky contest. Packed with insights, this episode explores how to improve outcomes while navigating the complexities of wrist injuries.

Dr. Damian Roland, a Consultant in Paediatric Emergency Medicine at the University of Leicester NHS Trust, shares his expertise in managing pediatric sepsis. He discusses the critical need for early detection and effective interventions. The conversation dives into the complexities of diagnosing sepsis, questioning the effectiveness of current screening methods and lab tests. Roland critiques the misuse of 'sepsis screening' terminology, arguing it's more about clinical judgment and timing than standard tests. He highlights the challenges of pediatric fever assessments in emergency settings.

Dr. Sergey Motov, an Emergency Physician and leading pain management researcher, shares insights on back pain management. He discusses a recent clinical case of severe back pain and the complexities of patient treatment choices. The conversation highlights the limited efficacy of opioids compared to placebo, emphasizing non-opioid alternatives for safer management. Dr. Motov critiques treatment guidelines versus real-world prescribing, shedding light on the importance of evidence-based approaches in emergency medicine.