The Skeptics Guide to Emergency Medicine

Dr. Neil Dasgupta discusses using POCUS for rapid diagnosis of acute aortic dissections in a 59-year-old man with chest pain. The study named after 'Speed' emphasizes high sensitivity for diagnosing aortic dissections. Challenges in diagnosing dissections are explored, highlighting biases and limitations in implementing ultrasound techniques. The role of POCUS in diagnosis is emphasized, along with upcoming movie-themed parties for audience engagement.

Ethan Milne, a Marketing PhD student at Ivey Business School, dives into the relationship between consumer behavior and mental health treatments. He discusses a case of a young man with major depressive disorder who worries about authenticity in using synthetic medication. The conversation explores preferences for natural over synthetic treatments, transparency in research, and the appeal to nature fallacy. Milne emphasizes informed decision-making in healthcare while shedding light on how social media influences consumer support for treatments.

In this engaging discussion, Nirdosh Ashok Kumar, an Emergency Medicine Specialist from Aga Khan University Hospital in Karachi, dives into the complexities of diagnosing Acute Aortic Syndrome (AAS). He highlights the high misdiagnosis rates and the importance of timely intervention. The conversation sheds light on various biases in AAS research and the challenges of clinical decision-making amid limited resources. Kumar emphasizes the need for better communication with patients to enhance understanding of symptoms, ultimately aiming to improve outcomes in emergency settings.

Dr. Alexandra (Ali) Espinel, an Associate professor of pediatrics and otolaryngology, dives into the complexities of pediatric oropharyngeal trauma. She discusses a real case of a young boy injured by a toothbrush, highlighting the risks of oral injuries in active children. The conversation touches on the challenges of using CT angiography, revealing that its routine use may not be warranted. Additionally, they explore the contentious role of antibiotics in treatment and stress the importance of personalized care and family involvement in clinical decision-making.

Dr. Rupinder Sahsi, an emergency physician and EBM enthusiast with academic ties to McMaster and Wright State universities, joins to discuss the safety of nitroglycerin use in right ventricular myocardial infarctions (RVMI). The conversation delves into the historical doubts surrounding nitrates and highlights a recent meta-analysis that suggests reassessing prior clinical guidelines. Dr. Sahsi critiques existing studies and calls for a more evidence-based approach, balancing clinical insights with anecdotes that keep the discussion lively.

Dr. Ellie Hill, a pediatric emergency medicine physician at Children’s National Hospital, dives into the complexities of treating urinary tract infections (UTIs) in children. She explores the possibility of shorter antibiotic courses, addressing parental concerns and presenting research findings that suggest 5-day courses may be just as effective as longer ones. The discussion highlights the challenges in UTI diagnosis and the importance of shared decision-making with families, all while emphasizing the need for antibiotic stewardship to combat resistance.

Dr. Chris Root, an EMS fellow and flight physician with extensive experience, discusses the debate surrounding small bag ventilation masks during out-of-hospital cardiac arrests. He examines a study questioning traditional airway management priorities, emphasizing the importance of high-quality CPR and defibrillation. The conversation dives into research comparing ventilation mask effectiveness, with intriguing findings suggesting smaller bags might not yield the best outcomes. Root calls for a careful evaluation of these practices to enhance emergency medical service protocols.

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 spend providing direct patient care. This has got to be about the mountain of paperwork. Family doctors say they can spend up to 25% of their week on administrative work. This is time that could be spent providing direct patient care. We need to give family doctors more time to spend on direct patient care. There are several policy solutions including EMRs, centralized referrals and minimizing forms. On average, family doctors spend 19 hours a week on administrative tasks such as writing sick notes and filling out lengthy insurance forms. Simple measures such as eliminating sick note requirements and standardizing insurance forms, would mean more time treating patients. The third solution brought forward by the OCFP is to ensure every Ontarian has a family doctor by recruiting and retaining more family doctors within the province.  There is an incredible amount of institutional knowledge out there considering walking away from primary care. We need to keep them engaged. 1.3 million Ontarians live without a doctor. And 1-in-5 family physicians plan on retiring within the next five years. We need to recruit and retain more family physicians. Our conversation reminded me of a quote by the famous Canadian and father of socialized medicine, Tommy Douglas. The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.