ED Rounds – Ortho Clinic Pathway

ED Rounds – Ortho Clinic Pathway

ED Rounds Presentation by Dr Paul Keyes



A personal perspective on system review and pathway re-engineering…


Rationalization of Process

  • —Every consult is entered by ERP into I3 and printed to accompany copy or ED chart and is placed in clinic book, with a patient sticker placed on clinic appointment sheet.
  • —Non-urgent consults are faxed to orthopedic surgeons offices for triage and cue placement with all other primary care referrals
  • —If subspecialty specific consult requested, then this is faxed to the orthopod of choice’s office. If urgent, then the orthopod on call will sort/laterally refer consult in clinic that week


  • —Collaborative approach ED and ortho
  • —Single process for all orthopedic referrals
  • —Identical sorting of: In ED, Clinic, Ortho office/subspecialty referrals
  • —Legible, billable consults
  • —Timely and appropriate consultations/assessments
  • —Orthopod flexibility as to site of consultation/clinic
  • —Appropriate chain of responsibility from Consult to consultant evaluation


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EM Reflections – March 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…


Consider dissection in vertigo patients even without history of significant or mild trauma.

Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.

Diagnosis – CT Angiography

Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)

Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS

Vertebral Artery Dissection: Natural History, Clinical Features and Therapeutic Considerations – (full text)

Rounds Presentation by Dr Kavish Chandra (R2 iFMEM)

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Limping Kids – inability to weight bear is always significant…

Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.

Don’t miss – Septic Arthritis or SCFE

From – Orthobullets.com – Hip Septic Arthritis – Pediatric – Author:

See this SJRHEM ED Rounds on Limping Kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring (and a high CRP mandates further Ix to rule out septic arthritis)
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg



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DEM Rounds – October 14th 2014

A big welcome to our nursing / nurse practitioner colleagues at todays rounds. Recent attendance at m&m’s and rounds has been increasing significantly, and a larger venue may soon be required! Just a reminder that ALL (Students, Residents, Physicians, Nurses, NPs, etc) are invited to these CPD (continuous professional development) events.

Dr Chris Vaillancourt  presented the recent update in Food Allergies

We were remind that we are frequently faced with patients and their parents requiring advice on the hot topic of food allergies and especially ‘prevention’ of food allergies

Notes from rounds:

If one parent with a food allergy the child has 30% chance of developing Atopy (atopic dermatitis, childhood Asthma, food allergy, allergic rhinitis) in that order – allergic march – developed over childhood in this order
If two parents  with food allergy = child risk = 70%

Allergen exposure in early infancy is good if its via the gut, bad if its via the skin (especially if atopic via atopic skin rash)
Due to activation of T-Helper Cells – TH1 vs TH2 = less allergies if TH1 activated via gut than TH2 vis skin

Current Strategies  – debunked
Maternal hypoallergenic food eating – false
No cat in house – false – in fact a cat in the house with new infant may be protective

Most kids are getting sensitised via ‘broken skin’ in first year life
Via T-Helper 2 system
Getting exposed via gut stims TH1 system  – reduced risk of allergy

Window of opportunity
For kids at risk
4-6 months window for oral sensitisation – may reduce risk of later food allergy

Other Recommendations
No evidence for using soy milk to prevent food allergy

Breast feed until 4-6months then feed them what you want

Wait fro LEAP study – big RCT looking at food allergies and due to present results in next 2 months



Dr Peter Ross  presented on Ebola. An extremely stimulating review of the current situation and state of preparedness of own own system. Much discussion was had both during and after the presentation.

It was noted that there is a Provincial plan for managing patient with suspected Ebola. This can be accessed via the Horizon Intranet (Skyline Homepage) This is updated regularly. SJRHEM has printed copies of the plan in accessible areas of the department. These should be accessed and read by all. We have already completed an in-situ simulation for a ‘potential’ ebola case this month. The report for this can be accessed in the Simulation Files  – InSitu Sessions – Oct 3rd.

PPE Training is ongoing

Dr Howlett will be posting an update to this website in the next week

Video: here

Full presentation here : 

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Dr David Lewis presented on limping kids

Take home pearls:

  • A limping/NWB child that can crawl is likely to have pathology below the knee
  • Examine least likely source of symptoms first.
  • Flex, Adduct and Int Rot hip most likely manoeuvre to elicit pain in hip pathology
  • Children >8yrs – X-ray hip first
  • If fever (>38°) or > 24hrs then bloods (incl CRP)
  • CRP < 12 is very reassuring
  • Positive ultrasound is most likely to be irritable hip
  • Negative ultrasound – X-ray leg

Full presentation here: 

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DEM Rounds – June 10th 2014

Impressive attendance at today’s Rounds. This must be reflective of the quality of the presentations, which were both informative and entertaining.

Dr Todd Way kicked us off with a timely reminder on the importance of quality ED Charting. Remember, “if its not written in the chart – it didn’t happen” – Your best defence in any legal issue or complaint are high quality, contemporaneous and legible notes in the ED chart.

We were reminded of the importance of addressing inconsistencies between other related records (triage/EMS) and our own notes “historic alternans”

More and more physicians are now subject to the “Atlantic Colleges Medical Peer Review” process – which includes a thorough review of charting practice. So, now is a good time to reflect on your ED Charting by asking yourselves the following questions:

  • The best part of my chart is_________
  • The first thing I would change about the way I chart is _______.
  • The main reason I don’t do a better job of charting is ________.
  • My ED department could better support my charting by ________.
  • If I could choose 1 thing to change in my colleagues chart it would be _________.
  • The ideal type of charting for me is _______. (Ie. EMR, T-chart, form chart, dictation, scribed, etc.)

Full presentation here:  ER Charting-Way-June 2014


Dr Paul Page chose the beginning of summer to remind us that, with the close proximity of the Bay of Fundy, accidental hypothermia can occur at any time of the year here in Atlantic Canada!

Accidental hypothermia is defined as a drop in core body temperature to less than 35 degrees Celsius. Measurement of core temperature is dependent on properly calibrated low reading thermometers. In an intubated patient use a thermistor transducer inserted into lower 1/3 esophagus.

Rewarming with high volumes of warm (38-42 degrees Celsius) i.v fluids. Active external and minimally invasive internal rewarming.

Consider ECMO if not responding to medical therapy or when signs of life absent.

Up to 3 defibrillations but withhold epinephrine until temp > 30 degrees Celsius

Potassium  10-12 mmol per litre is the cut-off for futility.

Immersion has a better outcome than submersion.


Full presentation here : Accidental Hypothermia – Page – June 2014


Dr Paul Keyes gave us the benefit of his many years in practice with his talk “the orthopaedic things I wish I knew in 1998…”


Posterior dislocation of the gleno-humeral joint is commonly missed. Patients with poor ability to communicate suffer this injury disproportionately – Epilepsy, ETOH, Electrocution.


Knowledge of the shoulder radiographic views and ability to interpret the axillary Y view is imperative.


Whatever reduction technique is used the elbow must be able to cross the midline freely to confirm the shoulder is in joint.

If you cant prove its in joint then it’s out of joint…


Joint aspiration  delays arthroplasty by 3-6 months, due to perceived increased risk of infection by the orthopaedic surgeon. It may be appropriate if concerned about a possible diagnosis of septic arthritis, but do consider the implications and definitely don’t stick a needle through an infected bursitis in to a sterile joint.


Don’t aspirate a joint post-arthroplasty until you have discussed the case with the operative surgeon/surgeon on call.


Hip arthroplasty can be either Total or Hemi. Total hip arthroplasty (THA) includes an acetabular component which can result in an obstruction to straightforward reduction.  THAs are more likely to be damaged by vigorous reduction attempts. Therefore discuss with operative surgeon/surgeon on call prior to any heroics.


Flouroscopic guided reduction will save time and face. It should be considered for all major joint reductions but in particular the elbow joint.


Always document vascular/nerve integrity pre and post reduction.


Full presentation here: ED rounds Ortho – Keyes – June 2014

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