EM Reflections – April 2016

Thanks to Dr Joanna Middleton for this summary

Top tips from this month:

1)  The removal of chest tubes for simple pneumothorax was discussed.  Most physicians send the patient home for 24-48 hours, then reassess with an x-ray.  If the lung is inflated, most physicians clamp the tube for a certain period of time +/- check for air leak (placing end of tube in basin of water) then re-xray and pull the tube if the lung is still expanded.  If it is not expanded, some physicians will send the patient home with a recheck in 24-48hrs, other physicians attach to wall suction and consult surgery.

2)  When checking for lung expansion, consider ordering a single view of the chest.  Often times a patient with a PTX will have numerous X-rays and the lateral is not needed in most cases – this saves on radiation exposure.

3)  Ensure the Heimlich valve is attached correctly by looking for the “flow” arrow that is engraved on the side.  The arrow should be pointed away from the body.

4)  Pericarditis may not always present with the classic EKG findings of diffuse ST elevation.  There should always be a low threshold to exclude a STEMI and consult cardiology if there is any symptoms suggestive of ischemia.

5)  We see lots of people with falls/MSK injuries – be sure to ask WHY the patient fell.  Did they simply trip on the coffee table, or did they trip because they have a visual field deficit from a stroke and couldn’t see the coffee table?

6)  Management of severe asymptomatic hypertension in the ED – most physicians in our department do not treat the asymptomatic patient, although some will start a medication if the patient has no family doctor/uncertain follow-up.  Everyone agreed that the rapid lowering of BP is potentially harmful and should not be done.  This is in keeping with the ACEP guidelines.

EMCRIT link on this:  http://emcrit.org/practicalevidence/2013-acep-management-of-asymptomatic-htn/

I have also attached the 2013 ACEP guideline on this topic.

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New NICE Guidelines for the whole Trauma System!

Not content with producing evidence-based clinical guidelines for trauma management e.g. Head Injury Management, NICE are taking on the whole Trauma System. NICE have recently published new guidelines for fractures, complex fractures, spinal injury assessment, major trauma and major trauma service delivery. Yes, there is now a NICE guideline that covers the organisation and provision of major trauma services in pre-hospital and hospital settings, including ambulance services, emergency departments, major trauma centres and trauma units. 

It aims to reduce deaths and disabilities in people with serious injuries by providing a systematic approach to the delivery of major trauma care.





The full list of recommendations can be seen here and include:

1.1 Pre‑hospital triage
1.2 Transferring patients with major trauma
1.3 Pre‑alert procedures
1.4 Procedures for receiving patients in trauma units and major trauma centres
1.5 Transfer between emergency departments
1.6 Organisation of hospital major trauma services
1.7 Documentation
1.8 Monitoring and audit
1.9 Information and support for patients, family members and carers
1.10 Training and skills
1.11 Access to major trauma services


This well-researched document delivers quality evidence and recommendations and should be considered essential reading for all those involved in organising regional Trauma Services.


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Academic Emergency Physician – Knowledge Translation, Dalhousie University, Saint John, NB

Join the team in the Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada. An exciting opportunity to combine a 0.25 FTE role as lead for Knowledge Translation, with 0.75 FTE clinical time, at this teaching hospital and Level 1 trauma centre. See below for job details and explore sjrhem.ca for program details.


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EM Reflections – December 2015

Thanks to Dr Natasha DeSousa for her M&Ms presentation today.

Thanks to those who attended M&Ms. For those of you who missed it, here are the top tips:

1. When burring or curetting a corneal FB from an eye, remember there is always a risk of a scar and too much or too deep anteriorly means a scar in the visual field. Be careful.

Watch this video on corneal FB removal:

2. Transferring unstable patients within a hospital (e.g ED to CT, ED to Cath Lab etc) is associated with risk and requires careful consideration. 

See this article on Medscape (Crit Care. 2015;19(214) ) that discusses the risks involved during intrahospital transfers and proposes a checklist that can be used to ensure preparedness.  See the form proposed below (or here : http://www.ncbi.nlm.nih.gov/pubmed/25947327 )

Checklist_for_Intra-Hospital_Transport_of_Critically_Ill Checklist_for_Intra-Hospital_Transport_of_Critically_Ill 2

3. Personality traits can impact on the clinical interview. When considering a differential diagnosis, ask yourself: “If this were a different patient with the same presenting symptoms and signs, what diagnoses would I be considering?” Some physicians endorse having a list of at least three possibly life-threatening conditions on one’s radar for each presentation. Try it – this is a great way to mitigate the potentially life-threatening impact of fundamental attribution error.

See last month’s report for a full list of clinical decision making biases

4. What is fundamental attribution error?  This is the tendency for people to place an undue emphasis on personality to explain someone else’s behavior in a given situation rather than considering other potential factors.  For instance, “he is wailing out in pain because he has an opiate addiction problem” rather than “he is wailing out in pain because his bowel has just perforated.”

5. Management of Acute pain in the Emergency Department is a priority. See the SJRHEM pain control resource page.


6. The management of spontaneous pneumothorax remains controversial. There are a number of international guidelines e.g British Thoracic SocietyConsider consulting Thoracic surgery when a lung has failed to fully re-inflate after 72 hours of standard treatment.

7. Flexor tendon injuries need to see plastic surgery within 48 hours. Delaying the repair beyond this can result in poorer outcomes. See this article for a further information on flexor tendon injuries in the hand.


Open Orthop J. 2012; 6: 28–35.

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EM Reflections – November 2015

Thanks to Dr Joanna Middleton for her M&Ms presentation today.

Here are the top tips from M and M’s this month.  Thanks to everyone who participated.

1.  Anchoring bias was present in a few of the cases this month.  Try to keep an open mind and look for alternate diagnoses when seeing patients with recurrent visits for similar complaints. Get a list of decision making errors here. Also a nice blog post on this subject from the short coatand finally for the last word on clinical decision making in Emergency Medicine, watch these free lectures by Pat Crosskerry and see his full list of biases below.

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2.  Elderly patients often have multiple complaints and issues when they are admitted to hospital.  When discussing with the admitting physician, please try to communicate the significant/potentially life-threatening abnormal findings that are present during your work-up. See the current guidelines from the CFPC – GUIDE TO ENHANCING REFERRALS AND CONSULTATIONS BETWEEN PHYSICIANS  

3.  Below-knee DVT’s – 10-20% risk of extension/embolization. See UpToDate article. Management options are repeat/serial ultrasounds in low risk patients, vs anti-coagulation in higher risk patients (high clot load, pregnancy, cancer patients etc).  A recent article published in Blood, by Gualtiero Palareti gives an excellent evidence-based insight, with case examples, into this issue. A proposed management algorithm was included.



4.  Undiagnosed diabetics can present with really vague complaints  (see this patient point of view) – have a low threshold for getting an accu-check.

5.  If you have a DKA patient, use the DKA protocol! (Adult DKA, Pediatric DKA) That is why we have a PROTOCOL.  If potassium is low (<3.3) remember to replace prior to starting insulin infusion.  The insulin causes intracellular shift of potassium and resulting arrhythmias/death.

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EM Reflections – October 2015

Thanks to Dr Natasha DeSousa for her M&Ms presentation today.

Top tips from October 2015 M&Ms

1.  Consider a ‘road test’ before sending a patient home, especially if s/he has received multiple doses of narcotics. Ensure that the success or failure of the ‘road test’ is documented in the chart.

2.  If home is the disposition, ensure patients have someone to accompany them if s/he has received multiple doses of narcotics.

3.  Renal stones are painful; remember, we have a Renal Colic protocol that facilitates pain relief before a patient is even seen by a physician.

4.  Beware fundamental attribution bias – intoxicated patients can still have painful fractures that require expedient analgesia.

5.  Documentation facilitates communication between ourselves and other colleagues, and serves as an important medicolegal record of a patient encounter.

6. Newly confused patients or patients with new objective limb weakness should receive an emergent head CT before admission to the hospitalist service. 

7. Avoid administering ASA to newly confused or weak patients before a head CT confirms absence of a SDH/SAH.

8. Consider documenting conversations with Radiology when discussions about CTs occur.




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Uncertainty and the Diagnostic Leviathan

“She had a normal CT yesterday. Why another?” I asked the physician.

“That scan was enhanced. Contrast obscures small kidney stones. We need an unenhanced CT to rule out a stone,” he reasoned.

“A small kidney stone is unlikely to explain her pain. There was no hydronephrosis or perinephric stranding. You will advise ‘avoid dehydration.’ This is good advice regardless of the presence of a 2-mm nonobstructing calculus,” I explained…

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Walk sign is on

The recent controversy surrounding the provision of school buses for children in suburban southern New Brunswick highlights some issues of public health and safety that are relevant for all municipalities and regions of the country.

How should we resolve the tension between encouraging families to get more exercise (walking to and from school would seem to provide an ideal opportunity), and the need to prevent injuries on our streets?

Without entering into the debate surrounding what might be a reasonable distance to walk to school for young children, it is clear that we must act to prevent both illness and injury, by providing safe routes for non-vehicular transportation (walking, cycling) in our communities. There is little point in increasing exercise to reduce your long-term risk of illness, if that process entails a significant risk of injury.

It is important for government agencies to co-ordinate their regulations. If a particular district requires its children to walk to school, then it must ensure that it provides a safe corridor for that walk, on EVERY DAY that school is open.


I highlighted the issue of unsafe pedestrian crosswalks in the media two years ago, and will do so again now, along with some other observations on road safety, based on recent engineering and medical research.

In Canada, over 15,000 people are hospitalized due to major traumatic injuries each year, of these cases over 10% will die in hospital. Nationally, injury accounts for over 900 potential years of life lost per 100,000 residents. In New Brunswick, nearly half of individuals admitted to a major trauma centre due to injury have been involved in a transportation-related event.

The modern approach to injury control involves three facets: prevention, acute care and rehabilitation. Prior to the 1950’s, human error was believed to be the principal factor of unintentional injury. At that time interventions were primarily based around public education on safety. Injury prevention has now evolved to include epidemiology, public policy, law enforcement and engineering.

The components of injury can be broken down into three sets of factors; human factors, vehicle and equipment factors, and environmental factors; as well as three phases; before, during and after the incident. Society has historically focused on the vehicle and equipment factors along with rescue facilities and trauma care in hospitals. This has led to major improvements in lowering the numbers of injuries and deaths. However, much more can be done by municipalities and provincial government to improve the pre-incident environmental factors; i.e. improve road design and layout, speed limits, and pedestrian facilities.

In 1907, the first traffic island in North America was built in San Francisco. In 1911, the state of Michigan painted the first centre dividing line. A year later, Salt Lake City mounted a handmade wooden box with coloured red and green lights on a pole using electricity from overhead trolley wires to power the first traffic light.


The recent addition of centre road islands in Rothesay is a good example of the use of engineering to change traffic behaviour. While initially unpopular with motorists, the zone of Hampton Road involved now has more pedestrian crosswalks, cycle lanes and slower traffic.

Sometimes we fail to see the poor logic in our design because it has been around for so long. Two examples of poor logic in traffic design are the colour of lights used at crosswalks, and the design of arterial roads.

As previously highlighted in the media, the inconsistent use of both red and yellow lights at regional crosswalks send a mixed message to pedestrians and drivers. The audible warning played at crosswalks stating that “drivers may not stop,” while true, also highlights the inadequacy of the crosswalk design. Psychologically, motorists are conditioned to STOP at RED lights, whereas YELLOW lights indicate only caution. As a pedestrian crossing a road, you would much prefer the motorist to stop! It is time to change all pedestrian crosswalk lights to RED.


On the issue of arterial roads and divided highways, while it may not seem illogical to drive at high speed towards vehicles coming in the opposite direction, separated only by a narrow yellow painted line, and trusting that all the drivers coming towards you (often at combined speeds of over 200 km/h) are not impaired or distracted; perhaps if we had just invented the car and were thinking of laying down roads, we might not design such a system! While separation of lanes by islands in low speed zones in towns has been shown to improve safety, that effect pales in comparison to the benefits of physically separating high-speed traffic lanes.


New Brunswick has great examples of both single and twinned limited access highways (where on and off ramps minimize traffic crossing the road at intersections). In the current economic climate, it is unlikely that the province can afford further twinning of major highways. However, addition of safe passing lanes and replacing the yellow centre line with a physical median barrier, may be an affordable improvement, which has been shown to reduce road collisions in the order of 70%.

single lane divided highway

These examples of engineering, alongside continued improvements in legislation and public awareness campaigns to prevent speeding, distracted and impaired driving, provision of protected corridors for cyclists and pedestrians, as well as ongoing improvements in trauma care would help to provide a healthier, safer environment for all New Brunswickers, of all ages, whether they are driving, cycling, or walking, to school or work, or just for the betterment of their health.


Dr. Paul Atkinson MB MA FRCEM

Professor and Research Program Director

Emergency Medicine

Dalhousie University

Saint John Regional Hospital

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Emergency Physician Speed: How Fast is Fast Enough?

Racing legend Mario Andretti famously said, “If everything seems under control, you’re just not going fast enough.” He was talking about cars, but to many beleaguered emergency physicians trying to keep up with the patient queue, emergency medicine often seems this way.

Read more from Dal’s own Dr. David Petrie here…


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Sustainable Working Conditions for Emergency Physicians

This program, proposed by the International Federation for Emergency Medicine is supported by this recent publication by Dr Michael Howlett et al.

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The leadership of the International Federation for Emergency Medicine is greatly concerned about the sustainability of professional practice for emergency physicians worldwide.  Accordingly, in 2013 a Taskforce was established to review the best working practices and agree on a set of core principles that would provide guidance and support for a sustainable, fulfilling career in Emergency Medicine.   The Group, led by Dr Taj Hassan (RCEM), included representatives from the UK, USA, Canada, South America, Australia, Singapore, HK and South Africa.

A Position Statement has now been developed and is attached.  It can also be accessed via the IFEM Website


We hope it will provide guidance in this key area and can be the foundation of a set of materials that can be used by Emergency Physicians to help provide better structure to their clinical careers.

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Delays to initial reduction attempt are associated with higher failure rates in anterior shoulder dislocation: a retrospective analysis of factors affecting reduction failure

Delays to initial reduction attempt are associated with higher failure rates in anterior shoulder dislocation: a retrospective analysis of factors affecting reduction failure

  1. Avinash Kanji1,2,
  2. Paul Atkinson2,3,4,5,
  3. Jacqueline Fraser3,4,
  4. David Lewis2,3,
  5. Susan Benjamin2,5

+Author Affiliations

  1. 1Faculty of MedicineUniversity College CorkCork, Ireland

  2. 2Department of Emergency MedicineHorizon Health NetworkSaint John, New Brunswick, Canada

  3. 3Department of Emergency MedicineDalhousie UniversitySaint John, New Brunswick, Canada

  4. 4Discipline of Emergency MedicineMemorial UniversitySaint John, New Brunswick, Canada

  5. 5New Brunswick Trauma ProgramSaint John Regional HospitalSaint John, New Brunswick, Canada
  1. Correspondence toDr Paul Atkinson, Professor, Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, 400 University Avenue, Saint John, New Brunswick, Canada E2L 4L4; paul.atkinson@dal.ca
  • Received 17 February 2015
  • Revised 8 June 2015
  • Accepted 9 June 2015
  • Published Online First 25 June 2015


Introduction Little is understood about the relationship between delay to treatment and initial reduction success for anterior shoulder dislocation. Our study examines whether delays to initial treatment, from injury and hospital presentation, are associated with higher reduction failure rates for anterior shoulder dislocation.

Methods A retrospective database and chart review was performed for patients undergoing intravenous sedation for attempted reduction of anterior shoulder dislocation in the emergency department (ED). Stepwise regression analysis was performed to identify predictors of reduction failure. Key variables analysed were the duration of the wait in the ED, the interval between the time of injury and first intervention and the interval from time of injury to arrival at the ED. Possible confounding variables analysed included age, gender, dose of sedative agent, qualifications of the reducing physician and whether the dislocated shoulder was recurrent.

Results The duration of the intervals from injury to first reduction attempt and from arrival at the ED to first reduction attempt were both independent predictors of a higher reduction failure rate (OR=1.07, 95% CI 1.02 to 1.13; OR=1.19, 95% CI 1.05 to 1.34). Every interval of 10 min increased the odds of a failed reduction attempt by 7% and 19%, respectively. Overall, shoulder reduction was successful during the initial sedation event in 97 cases (92%) and unsuccessful in nine cases (8%).

Conclusions Delays to first reduction attempt either from the time of injury or within the ED are associated with a lower reduction success rate for anterior shoulder dislocations.

Key messages

What is already known on this subject?

  • Anterior shoulder dislocations are a common joint dislocation seen in the emergency department (ED). The failure rate for closed reduction in the ED is low. Although these injuries are triaged as urgent, there is little published evidence describing the impact of timely reduction on success rates for closed reduction.

What might this study add?

  • This retrospective study of patients undergoing procedural sedation for anterior shoulder dislocation found an association between treatment delays and initial reduction failure rates. The results of this study support the established ‘truism’ that these injuries should be treated as quickly as possible after arrival to the ED.

Full Article:

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