Emergency Medicine Cases

I caught up with Dr. Anand Swaminathan, otherwise known as EM Swami, at The Teaching Course in NYC where he told his Best Case Ever from Janus General of his heroic and collaborative attempts at saving the life of a gentleman who presented to the ED with a classic story for a ruptured AAA. As William Olser famously said, "There is no disease more conducive to clinical humility than aneurysm of the...

While knowledge acquisition is vital to developing your clinical skills as an EM provider, using that knowledge effectively for decision making in EM requires a whole other set of skills. In this EM Cases episode on Decision Making in EM Part 2 - Cognitive Debiasing, Situational Awareness & Preferred Error, we explore some of the concepts introduced in Episode 11 on Cognitive Decision Making like...

Traditionally we've run at least 2 troponins 6 or 8 hours apart to help rule out MI and recently in algorithms like the HEART score we've combined clinical data with a 2 or 3 hour delta troponin to help rule out MI. The paper we'll be discussing here is a multicentre/multinantional study from the Canadian Medical Association Journal from this year out of Switzerland entitled "Prospective validatio...

Pain leads to suffering. Opioid misuse leads to suffering. We strive to avoid both for our patients. On the one hand, treating pain is one of the most important things we do in emergency medicine to help our patients and we need to be aggressive in getting our patients' pain under control in a timely, effective, sustained and safe fashion. This was the emphasis 10-20 years ago after studies showed...

Pediatric seizures are common. So common that about 5% of all children will have a seizure by the time they’re 16 years old. If any of you have been parents of a child who suddenly starts seizing, you’ll know intimately how terrifying it can be. While most of the kids who present to the ED with a seizure will end up being diagnosed with a benign simple febrile seizure, some kids will suffer from c...

When was the last time you saw ventricular fibrillation in a 4 month old? Dr. Simard tells his Best Case Ever of a Pediatric Cardiac Arrest in which meticulous preparation, sticking to his guns, early activation of the transportation service, and clever use of point of care ultrasound helped save the life of a child. He explains the importance of debriefing your team after an emotionally charged c...

Once we've achieved ROSC our job is not over. Good post-arrest care involves maintaining blood pressure and cerebral perfusion, adequate sedation, cooling and preventing hyperthermia, considering antiarrhythmic medications, optimization of tissue oxygen delivery while avoiding hyperoxia, getting patients to PCI who need it, and looking for and treating the underlying cause. Dr. Lin and Dr. Morriso...

A lot has changed over the years when it comes to managing the adult in cardiac arrest. As a result, survival rates after cardiac arrest have risen steadily over the last decade. With the release of the 2015 American Heart Association ACLS Guidelines 2015 online on Oct 16th, while there aren’t a lot a big changes, there are many small but important changes we need to be aware of, and there still r...

Opiate misuse is everywhere. Approximately 15-20% of ED patients in the US are prescribed outpatient opiates upon discharge. In Ontario, about 10 people die accidentally from prescription opiates every week. Between 1990 and 2010, drug overdose deaths in the US increased by almost four fold, eclipsing the rate of death from motor vehicle collisions in 2009. This was driven by deaths related to pre...

Most of us in North America live in cultures that almost never talk about death and dying. And medical progress has led the way to a shift in the culture of dying, in which death has been medicalized. While most people wish to die at home, every decade has seen an increase in the proportion of deaths that occur in hospital. Death is often seen as a failure to keep people alive rather than a natura...

Current estimates of the prevalence of obesity are that a quarter of adult Canadians and one third of Americans are considered obese with approximately 3% being morbidly obese. With the proportion of patients with a BMI>30 growing every year, you’re likely to manage at least one obese patient on every ED shift. Obese patients are at high risk of developing a host of medical complications including...

I caught up with airway educator, innovator and self-described enthusiast Dr. Richard Levitan at SMACC in Chicago this past June. In this Best Case Ever on Airway Strategy and Mental Preparedness in EM Procedures, Dr. Levitan uses a great save of his in a penetrating trauma case as a basis for discussion on mental preparedness and how we've been thinking about our general approach to emergency pro...

A recent needs assessment completed in Toronto found that Emergency providers are undereducated when it comes to the Emergency Management of Sickle Cell Disease. This became brutally apparent to me personally, while I was researching this topic. It turns out that we’re not so great at managing these patients. Why does this matter? These are high risk patients. In fact, Sickle Cell patients are at...

Sickle Cell Acute Chest Syndrome remains the leading cause of death in patients suffering from Sickle Cell Disease. In his Best Case Ever, Dr. Richard Ward, a hematologist with a special interest in Sickle Cell Disease, describes a case of a Sickle Cell Disease patient who presents with what appears to be a simple pain crisis, but turns out to be a devastating Acute Chest Syndrome. He gives us the...

You’d think ketamine was in the ED drinking water! Not only has this NMDA receptor antagonist been used effectively for procedural sedation and rapid sequence intubation, but also, for delayed sequence intubation to buy time for pre-oxygenation, for life-threatening asthma as it has bronchodilatory and anxiolytic effects, for severely agitated psychiatric patients and excited delirium syndrome to...

Pain is the most common reason for seeking health care. It accounts for 80% of ED visits. The WHO has declared that “optimal pain treatment is a human right”. As has been shown in multiple ED-based Pediatric pain management studies, Pediatric pain is all too often under-estimated and under-treated. Why does this matter? Under-estimating and under-treating pediatric pain may have not only short ter...

On this EM Cases Best Case Ever Dr. Anthony Crocco, the Head and the Division Head of Pediatric EM at McMaster University and Medical Director of Pediatric Emergency Medicine at Hamilton Health Sciences Hosptial, discusses an approach to the neonatal lazy feeder and why we should abandon the use of codeine in pediatrics as well as in breastfeeding mothers. The approach to the neonatal lazy feeder...

In the first of our series on Highlights from North York General's Emergency Medicine Update Conference, Dr. Kylie Boothdiscusses Backboard and Collar Nightmares. The idea that backboards and c-spine collars prevent spinal cord injuries came from level 3 evidence in the 1960's and there has never been an RCT to prove this theory. In fact a Cochrane review on the topic in 2007 concluded that "the e...

In this Best Case Ever with Dr. Scott Weingart, the brains behind EMcrit.org, we hear the devastating story of a tracheostomy gone bad. Dr. Weingart shares with us what he has learned about how to manage massive hemoptysis in tracheostomy patients, and in particlar, a step-wise approach to managing a tracheo-innominate fistula. We discuss the balance between providing maximal aggrressive critical...

For years we’ve been transfusing red cells in the ED to patients who don’t actually need them. A study looking at trends in transfusion practice in the ED found that about 1/3 of transfusions given were deemed totally inappropriate. As we explained in previous EM Cases episodes, there have been a whole slew of articles in the literature over the years that have shown that morbidity and mortality o...

In this Journal Jam we have Dr. Michelle Lin from Academic Life in EM interviewing two authors, Dr. Rebecca Smith‑Bindman, a radiologist, and Dr. Ralph Wang an EM physician both from USCF on their article “Ultrasonography versus Computed Tomography for suspected Nephrolithiasis” published in the New England Journal of Medicine in 2014. There is currently a wide practice variation in the imaging wo...

In this Part 2 of EM Cases' Highlights from Whistler's Update in EM Conference 2015 Dr. David Carr gives you his top 5 pearls and pitfalls on ED antibiotic use including when patients with sinusitis really require antibiotics, when oral antibiotics can replace IV antibiotics, how we should be dosing Vancomycin in the ED, the newest antibiotic regimens for gonorrhea and the mortality benefit associ...

Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering - why was DKA singled out in t...

This is Part 1 of EM Cases' series on Diagnostic Decision Making with Walter Himmel, Chris Hicks and David Dushenski discussing the intersection of evidence-based medicine, cognitive bias and systems issues to effect our diagnostic decision making in Emergency Medicine. In this episode we first discuss 5 strategies to help you master evidence-based diagnostic decision making to minimize diagnostic...

In anticipation of our series of podcasts on Diagnostic Decision Making with Dr. Walter Himmel, Dr. Chris Hicks and Dr. David Dushenski we have Dr. Hicks presenting his Best Case Ever. Taking action in Emergency Medicine requires not only careful consideration of the best evidence, the experience of the clinician, the patient's values and the system that you work in, but also the will to act. Dr....