EMSimCases.com | A not-so-boring take on Simulation

In the spirit of true FOAM-y collaboration, we are taking some time to feature a recent #FOAMed initiative that has been lead by two Canadian PGY4 residents.  As depicted in Eve Purdy’s post earlier this week, however, these two actually collaborated at a distance to bring this initiative to life.  Kyla Caners is a co-Chief Resident at McMaster University (Hamilton, ON, Canada) and Martin Kuuskne is a senior resident at McGill University (Montreal, QC, Canada).

Funny enough, I have known both of them separately for quite some time (Martin was once-upon-a-time a medical student who helped me on a paper; and Kyla is only a few years behind me in residency here at Mac), and only just realized that they were working on this project together. :D

We caught up recently to chat about their EMSimCases.com project:

 

TC:  So, Kyla & Martin, could you explain the inspiration/need for an online sim case repository? Who is the intended audience?

MK: Generally speaking, simulation is a resource heavy teaching method. It requires a high instructor-to-learner ratio, a dedicated space, specialized equipment, and time for running the simulations. Planning for and creating quality cases that run smoothly also takes a significant amount of time. Every site needs their own instructors, but not all sites need to have unique cases. If we learn from similar resources and complete common exams across Canada, why can’t we collaborate to create shared simulation resources?

KC: We’ve talked to a lot of different simulation educators along the way and we each took a look online to see if there was anything like this. We weren’t very impressed by the databases we did find. Simulation educators want something that is searchable and has a variety of cases in a wide range of topic areas and skill levels. Further, educators want to be able to modify a case so it can suit their specific educational needs. Some cases are specifically designed for a certain type of mannequin. The trick isn’t programming your mannequin. It’s ensuring that the case progression is logical and anticipates most likely learner actions. Mannequin sellers also sell pre-made cases…but that’s expensive! Clearly, EM simulation educators are keen to find easier ways to create and use new high-quality cases!

MK: The blog is intended for simulation educators in the field of EM. However, many of the cases would also be relevant to other critical care specialties (trauma, ICU, anesthesia). Similarly, we feel that EM residents and medical students could learn a lot by reviewing the case content. Finally, we will be featuring a biweekly segment on medical education & simulation theory, tips, and tricks. This could apply to anyone involved in simulation or medical education.

TC:  It says on your website that your resources are peer reviewed.  What is your peer review process?

MK: All submitted cases are first vetted by Kyla and I for face validity. They are then reviewed and initially edited by a senior emergency medicine resident member of our associate editor team. They are then reviewed by two members of our advisory board. The board member’s job is to ensure that the medical content is accurate, that the case has clear learning objectives, and that the learning objectives align with the case and its progression. Lastly, Kyla and I incorporate any improvements derived from the peer review process before it is published.

KC: Our advisory board consists of leaders in simulation and medical education who are spread across the country. The goal was to ensure a wide and expert perspective on the cases.

TC: So, that’s great that the content is vetted and reviewed a prioi.  But with simulation cases, reviewing them on paper is one thing…. But, tell me, are your cases tested before they are posted? If so, how?

KC: Absolutely! It’s incredibly important that cases work in real time with real learners. Some cases look great on paper or in theory, but fall flat when used in real life. So we make sure all cases are tried before publication by either Martin, myself, or one of our advisory board members in a simulated environment. We incorporate the cases into our simulation curriculum that we provide to our own residents.

TC: I’ll be honest with you, there are a LOT of other repositories for educational resources.  How is your site different than the other simulation repositories online? (e.g. MedEdPORTAL, SAEM case library)?

MK: We worked really hard to ensure that all the cases are formatted in the same way for consistency and ease of use. We created the EMSimCases template for this reason. Many existing sites have unstructured requirements for case publication; cases are presented in different and sometimes confusing formats. We thought we could improve on this and also create a platform for posts on simulation medical education – or simeducation as we call it – and to highlight innovative efforts in simulation happening across the country.

KC: We also wanted to ensure that all cases had gone through a peer review process. The sites you mentioned have a peer review process, but for some sites, it’s not explicit or hasn’t been completed for every case before they are published for use. Our goal was to front load that process, like a journal does, to ensure quality content.

MK: And it was most important to us that this would serve as a free, open access, collaborative project. We want contributions from across the country! And we want it to be clear who wrote the cases. We want the cases to be clearly organized by content area. Ultimately, our blog will be searchable and will serve as a great way to look for a new version of a case you may have already run or to look for ideas for new cases.

TC: Can tell us a bit of the origin story for EMsimcases?

KC: I’ve spent the past year doing a fellowship in medical education and simulation. As a large part of my fellowship project, I’ve been designing a simulation component for our curriculum at the Royal College EM program at McMaster. Throughout the process, I’ve written a full curriculum of simulation cases for our residents. Writing cases is time-intensive. In fact, simulation is a very time-intensive way to teach. I kept thinking that if we couldn’t offload the amount of instructor time required for quality simulation, there should be a way that educators across the country could offload the case writing process. And hence, the idea of case repository was born.

MK: I had gone through a similar process at McGill; I developed and was leading the EM residency simulation curriculum with a resident colleague of mine, Wayne Choi. During my fellowship year in medical education and simulation, I thought about how incredible it would be for simulation educators to share their work to enhance the variety of cases that could be incorporated into their respective programs. I knew Jonathan Sherbino from my medical school training at McMaster and was aware of his expertise as a clinician educator. I contacted him regarding ideas about simulation based learning objectives and brought up the idea of creating a national repository of cases; he put me in contact with Kyla and the rest is history!

TC:  You two are at different universities and hundreds of kilometres away… How did you find it working on creating this project together?

KC: Right after we were put in contact by our mutual mentor, we both happened to be at the 2014 Simulation Summit in Toronto. It was so helpful to meet each other in person. The more we talked, the bigger and better the idea became. Our goal transformed from a small case book to a collaborative, FOAMed inspired blog! Having had that initial brainstorming session in person was such a great way to get things started.

MK: It’s surprisingly easy to collaborate via skype, email and even texting! Also, the fact that we both have access to editing the blog and have predetermined roles in terms of taking charge on selected blog posts is really helpful. Lastly, I think that being transparent and honest with our goals and opinions has made the process both successful and fulfilling.

KC: We also made a point of having regular meetings. We record minutes and action items after each meeting. And we always set the date for our next meeting before we end our current meeting. Setting clear timelines and goals also made our expectations of each other really clear.

TC:  What are your tips to med students doing sim for the first time?

MK: My advice would be to dive into the simulated environment as much as you can, regardless of the level of fidelity or realism! Treat the mannequin like a real patient. Talk to it; ask it questions. If you have to start compressions, give it your all and don’t be afraid to work up a sweat. Go through the motions of listening for breath sounds or putting in an IV. The more realistic learners treat the scenario, the more realistic the scenario becomes and the more it can mimic learning from a real patient encounter. Also, I think if you make the experience memorable, it will be easier to remember the learning points that you took away from the case.

KC: Remember that simulation is, above all else, a teaching modality. Just like a lecture is designed to deliver content, simulation is designed to teach a specific objective. Sometimes it feels like simulation is set up to make you fail. Particularly because any gaps in your knowledge feel like they are on display. But it’s actually the exact opposite. Why not jump in and make use of an excellent opportunity to realize what concepts you don’t fully understand? The point of simulation education is to help you learn content without needing to compromise patient care. The process of not knowing an answer is always uncomfortable. But in simulation, you should be happy to fail. And I bet you $10 that you’ll remember exactly what to do the next time you’re faced with a similar situation!

MK: I can vouch for that: I will NEVER forget about giving stress dose steroids for suspected adrenal insufficiency to a septic patient not responding to fluids or vasopressors after missing it in a simulated scenario during the CAEP Simulation Olympics 2 years ago!!

TC:  Okay, one last What’s your favourite flavour of ice cream?

KC: Mint chocolate chip. No question.

MK: I know its boring… but vanilla all the way!

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post EMSimCases.com | A not-so-boring take on Simulation appeared first on BoringEM and was written by Teresa Chan.

Behind the Scenes: doing research at a distance

Editor’s note: In this article Eve Purdy discusses lessons learned while performing, writing and publishing research with a team spread across the country. The final product “The use of free educational  resources by Canadian emergency medicine residents and program directors” was published in CJEM in March 2015.  Of note, she (and some of here colleagues) will be available to answer questions via the new CJEM Facebook page in the coming weeks!  – TC

 

“Hi, I’m Eve Purdy,” I said as introduced myself to a physician at the CaRMS social in Winnipeg.

“Nice to meet you, I’m Joeseph Bednarcyzk,” the doc responded.

And then we both started laughing.

You see, Joe and I had been working together on a paper that was about to be published… Yet, we had never actually met.

Welcome to academic publishing in the 21st century!

***

Flashback to 2013 where Brent Thoma and I conceived a project over coffee  at CAEP 2013. We knew we shared an interest in how online and open access resources (#FOAMed) affect education and we were “nerding out”. We lamented that despite our gut feeling, there was little empiric support for our gestalt, and no one really knew if these resources were being used as ubiquitously amongst EM learners as we suspected. Being people of action, we decided to tackle the problem…

But first we needed to draft a dream team.

Drafting Your Dream Team

As we sat sipping our lattes, we thought up the best possible roster for our team. What did this project need for success and who could help. Like any team the research unit has multiple roles that need to be filled. The needs we saw and recruited for were:

  • Communicator: to make it a truly Canadian project we needed to include French-speaking physicians/programs and we needed someone who could translate the survey but who could also help to increase the response rate among residents.
  • Methodology Expert: If you are going to do a project, do it right. Neither of us felt perfectly comfortable with our desired methodology so we recognized that recruiting somebody with expertise in the area would be extremely helpful.
  • Passion generators/work horses: We figured that we had these roles covered.
  • Coach: We all need help seeing the bigger picture. We wanted someone who could help us turn a good project, into a great project.

Fortunately, everyone on our short list said yes! David Migneault (communicator), Joseph Bednarczyk (methods expert) and Jonathan Sherbino (coach) were drafted and the dream team was formed, but there was only one problem….none of us lived in the same city!

 

Collaborating at Distance

When working at a distance you are not going to run into each other in the hallway or in the department, so there might not be that immediate feeling of necessity to complete tasks. Learning to work in geographically disparate teams, however, is likely the future of academic success.  (NB: BoringEM managing editor, Teresa Chan, has recently written about this phenomenon for the ICE blog.)

Collaborating with people you are far from requires an extra bit of discipline. These strategies and use of technology allowed us to be efficient. The publishing date is 2015 which makes it seem like this was a 2 year project however, the actual time from idea conception to completion (acceptance to CJEM) was about 9 months…coincidence? ;)   I think not.

Team Management

  • Clear expectations: Every contributor knew what their role was. All had a job and everyone was aware at the outset that this project was going to maintain momentum. All involved bought into that approach.
  • Hard deadlines: Whether it be survey creation, data analysis, paper writing or editing deadlines for completion/feedback were set and respected (see clear expectations above). There were no cases of manuscripts sitting in inboxes for months just waiting to be “gotten to”.
  • Structure: We largely communicated by email with individuals responding in a very timely fashion. The few times (three maybe?) that we we met virtually as a group  it was with purpose and structured. We all came prepared and left with tasks. Follow up for tasks was performed by email.

Harnessing Technology

To employ these team management strategies we leveraged a number of technologies to improve communication to facilitate working at a distance.

  • Email: Our primary method of communication was email with a group thread. It was alright, but maybe not the best group messaging system (see next section).
  • Conferencing: we used Skype but again I think there are better options like Google Hangouts.
  • Google docs: We used this at the beginning for brain storming but found that once we were making more complex edits to surveys and manuscripts that the review functions on Word were better. I do believe the functionality of track changes has improved since we were using this google docs.
  • Shared dropbox folder: Here we stored pdf references, draft manuscript versions and images.

For Next Time

When considering working on a project at a distance again, there are many things that I would do exactly the same. The team structure and function was gold but some aspects of our workflow could be improved. I would:

  • Consider using Slack for communication. This app allows teams to communicate efficiently and if you are managing multiple projects with multiple teams the advantage becomes having all of those centralized in one place!
  • Use Google Hangouts instead of Skype. It has easily accessible features that allow sharing of a desktop view to multiple people, which could have allowed us to review the manuscript/images in real time. If we had used Hangouts I also probably would have recognized Joeseph at the CaRMS social because it allows videoconferencing with multiple users, instead of the voice-only functionality of Skype when in a group.

I would also suggest that budding academicians consider the publishing time of the journal to which you submit. Our project was completed within six months of starting, accepted within nine months but not published until about two years after we began. Given the nature of the subject matter we studied, this delay compromises the validity of our findings.  We are hopeful, however, that given CJEM’s recent transition to online publication this lag time will be reduced!

I really look forward to sharing a beer with these awesome team members at CAEP 2015 to celebrate our completed work! We hope that this post might clarify what working with a geographically distanced team looks like. So go out, find your dream team and keep progressing the field!

Have questions please ask below!  You can also reach me via the CJEM Facebook page (www.facebook.com/cjemonline) where I will be answering questions about this article in the coming weeks.

 

NB: The project described in this blog post has been recently published in the Canadian Journal of Emergency Medicine.  

The citation is:  

Purdy E, Thoma B, Bednarcyzk J, et al. The use of free online educational resources by Canadian emergency medicine residents and program directors. 2015 CJEM 17(2):101-106.

Read the article here.

View the official CJEM infographic for this paper below!

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Behind the Scenes: doing research at a distance appeared first on BoringEM and was written by Eve Purdy.

KT Evidence Bite: Fibrinolysis in Intermediate PE

Editor’s note: This is a series based on work done by three physicians (Patrick ArchambaultTim Chaplin, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism

Citation: 

Meyer, G., Vicaut, E., Danays, T., Agnelli, G., Becattini, C., Beyer-Westendorf, J., … & Konstantinides, S. V. (2014). Fibrinolysis for patients with intermediate-risk pulmonary embolism. New England Journal of Medicine370(15), 1402-1411. PMID: 24716681

Nickname of study: 

PLEITHO Trial

Summarized by: Patrick Archambault
Reviewed by: Teresa Chan & Tim Chaplin

Clinical Question

In patients with intermediate-risk PE (signs of RV dysfunction and cardiac injury) does fibrinolysis improve clinical outcomes?

PopulationNormotensive adult patients with intermediate-risk pulmonary embolism: (1) right ventricular dysfunction on echocardiography (see footnote) or computed tomography AND (2) positive troponin I or T
Interventiontenecteplase (full bolus dose over 5-10 seconds based on weight: >60kg=30 mg; >90kg=50mg) plus heparin started immediately after randomization
Controlplacebo plus heparin
OutcomePrimary: death or hemodynamic decompensation (or collapse) within 7 days

Secondary: 1) death < 7 days after randomization, (2) hemodynamic decompensation < 7 days, (3) confirmed symptomatic recurrence of PE < 7 days, (4) death < 30 days, (5) major adverse events < 30 days

Methods

This was a randomized, double-blind trial, with intention-to-treat analysis

Results

Primary outcome (benefit)

  • Death OR hemodynamic decompensation was 2.6% (TNK) vs 5.6% (placebo)
  • OR=0.44 (95% CI 0.23-0.87, p=0.02)
  • This results in an NNT of 33

Secondary outcome (harms)

  • Extracranial bleed: 6.3% (TNK) vs 1.2% (placebo) p<0.001
  • Stroke: 2.4% (TNK) vs 0.2% (placebo)  p<0.003
  • This results in a NNH of 45

Conclusions

Normotensive patients with intermediate-risk pulmonary embolism benefit from treatment with a single intravenous bolus of tenecteplase, but at a higher risk of ICH.

Take Home Point

Normotensive patients with intermediate-risk pulmonary embolism benefit from treatment with a single intravenous bolus of tenecteplase (but effect driven by decrease in hemodynamic collapse not the death outcome) and with a higher risk of ICH. More studies are ongoing about the use of reduced doses of TNK. In June 2014, a meta-analysis was published in JAMA.

EBM Considerations

  • Co-intervention: Were the hemorragic complications due to previous LMWH or fondaparinux given before randomization?
  • Compound outcomes: the efficacy of thrombolysis was mainly driven by the prevention of hemodynamic decompensation more than its effect on mortality. Hemodynamic collapse was defined as:
    • need for CPR or
    • systolic BP <90mmHg for >15 minutes or
    • drop of systolic BP by at least 40mmHg for at least 15 min with signs of endorgan hypoperfusion (cold extremities or low urinary output < 30 mL/h or mental confusion or
    • need for catecholamine administration to maintain adequate organ perfusion and a systolic blood pressure of > 90 mm Hg (including dopamine at the rate of > 5 micrograms/ kg per minute)
  • Chosen Dose: To reduce risk of ICH in patients over 75 years, should we adopt a policy to reduce dose by 50%? (NB. In a recently published prehospital trial of TNK in STEMI, there were no cases of intracranial hemorrhage when the dose was reduced by 50% in patients 75 years of age or older. (PMID: 23473396 Full text click here). A reduced dose strategy also has merit: see MOPETT trial.

NRC – BoringEM – Fibrinolysis PE

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bite: Fibrinolysis in Intermediate PE appeared first on BoringEM and was written by Eve Purdy.

Life Beyond Medicine | Why I Write

I recently wrote a piece for our Life Beyond Medicine series explaining why running specifically, and physical activity more generally, is such a central part of my mental well-being as a resident. On writing it, however, I realised that something big was missing: Running is an important process for me, but I hadn’t spoken at all about writing, which is another essential part of how I make sense of the world and stay sane during my medical training.

When something scary, overwhelming, or exciting happens at work, the gears in my head start to turn, and I get the itch to sit in front of my computer and write. I may submit my story to a publication or publish it on my personal blog, This Liminal Space (sluckettg.wordpress.com), but just as often the story sits on my computer unread. I may open it once or twice, adding detail or editing, but more often the story remains unchanged on my hard drive after initial edits, a record of a difficult, joyous, sad, or angry time during my training.

The process of writing matters to me more than the content.  Here’s why:

  1. Writing helps me understand my own feelings.

After a public reading of a piece I had written, a friend paid me one of the highest compliments I had ever received. She said that I somehow knew how to put into words the feelings she didn’t know she had. I thanked her, but didn’t share something that was equally true: I often put into words feelings I don’t know I have. I find that process of writing that liberates my emotional experience. Sitting in front of a computer, picking and choosing words and phrases, lets me tap into an emotional experience I’m often not aware of. Understanding how I feel about something that has happened to me (or someone else) lets me deal with it productively, instead of letting it fester under the surface.

 

  1. Writing helps me understand the feelings of others.

If I’ve ever been in the thick of something emotional with you, you had better believe you’ve become a character in one of my stories. I may have been angry with you at the outset, but by the time I’ve finished writing, I’ve likely come to a better understanding of your actions. To write someone as a character means to try to find a way to understand his or her motivations and thought processes,. I like to write characters from the inside out, and that can involve some serious emotional work. Usually I come out with a better understanding of the players in my story, and consequently greater compassion and empathy than I had had before.

 

  1. Putting an experience down on paper takes the experience out of my head.

Have you ever heard the advice that you should write your worries on a piece of paper before you go to bed? It’s supposed to help you get to sleep. Something about writing out your worries takes away your need to think about them as you lay in bed. I don’t really understand how this works, but writing, more generally, seems to do the same for me. I may turn an experience over in my mind for hours, days, or weeks before I feel ready to write my thoughts down. Then, having written out the experience, I’ll stop thinking about it as intensely. That can be a huge relief! I’m not sure whether it’s because I’ve processed the experience, or because I’ve acknowledged my emotions, but there’s something magically stress-relieving about writing.

Not everyone is a natural writer (I’m not!), just like not everyone is a natural runner (again, I’m not!), but if you want to try writing, my best advice is to grab pen and paper (or your laptop), set a time limit (10 minutes is a nice place to start), and write about something you know (there are lots of writing prompts available online if you need a place to start). Like your cardiovascular system or your leg muscles, writing ability is something that is developed with practice. And don’t forget that editing is a magical thing – most writing doesn’t turn out great on the first try, even for experienced authors. So give it a shot! It’s cheaper than therapy and safer than drugs for dealing with the stressors of a life in medicine.

Reviewed by staff (Dr. Heather Murray)

 

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Luckett is a resident at McMaster University. Newbie to the #FOAMed world. Interested in literacy, health advocacy, creative writing, and near-peer mentorship.

The post Life Beyond Medicine | Why I Write appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

Keep Emergency for Emergencies? Reframing the basic assumption

Emergency departments (ED) are open 24 hours a day, 365 days a year. Health conditions can develop or worsen at a moments’ notice, making the ED a necessary safety net for even the best healthcare systems. However, the very characteristic that makes the ED essential also leaves it open to abuse. When there is nowhere else to go it is an attractive location to bring the intoxicated, the homeless, the destitute – the people with nowhere else to go. Worse, occasionally it can seem like the ED is overwhelmed by seemingly healthy patients who are not patient at all.

These realities have led to the increasing prevalence of “patient-blaming.” A popular administrative response to ED overcrowding, especially in publicly funded healthcare systems, seems to be to tell patients to stay away unless they have a “true emergency.” Perhaps the best example is the Australian video “Keep Emergency for Emergencies” that recently went viral.

It implies that ED overcrowding is the result of low-acuity patients with “fake emergencies” – a conclusion that has been well-studied and found to be patently untrue [1,2,3] – rather than a systemic problem resulting from the health system’s inability to predict and meet demand. My own health region has not been immune from this line of thinking, having recently instructed patients on “proper use” of the ED.

The Canadian Association of Emergency Physicians (CAEP) frames ED overcrowding as a problem of ‘Access Block’:

“(Access block is) the inability of admitted patients to access in-patient beds from the ED.”

and asserts quite bluntly that:

“Contrary to popular perceptions, ED overcrowding is not caused by inappropriate use of ED’s, or by high numbers of lower acuity patients presenting to the ED”

While this does not make intuitive sense, it is true because low-acuity patients do not require a hospital bed and can generally be assessed and discharged quickly without contributing substantively to access block.

The problems with “fake” emergencies

It would be easy to conclude that having fewer patients in an overcrowded ED would be beneficial regardless of whether or not they created the problem. If that were the case this type of public service announcement would serve an important purpose. However, I think there are three problems with this conclusion.

First, sick patients often do not realize that they are sick. Over the past 6 months I can think of multiple stoic patients that I saw for general malaise (a condition that is not on any lists of “true emergencies”) that had serious pathology (e.g. myocardial infarction, hyperkalemia, diabetic ketoacidosis) requiring inpatient treatment. Our patients do not have the benefit of emergency health care training to help them determine what an emergency is and what it is not. In response to public campaigns inspired by the commercial above, these patients would have likely stayed at home because they “didn’t want to be a bother.” This decision would have been severely detrimental to both their health and the ultimate cost of their care.

Second, it puts the blame for overcrowding on our patients rather than our system. Beyond being unfair (and untrue!), this response has the potential to sour the attitude of already stressed healthcare providers towards low-acuity patients. Those that buy into this message could see patients as the problem, rather than our purpose, leading to dissatisfaction and poor care.

Third, it gets in the way of good care. In my (admittedly very short) emergency medicine career I have found that many of the patients who are perceived as abusing the system (and there certainly are some) do not think they are, do not want to be, or came in for another reason. Think of the patient with frostnip (who came in because he was worried that his ear was going to fall off), the recent immigrant with the flu (who did not know how to access primary healthcare), or the women with a headache (who was too scared to tell us that her spouse is beating her). In each case the assumption that these patients are “abusing the system” would result in worse outcomes due to missed opportunities for education and/or intervention.

New Concept: The Basic Assumption

Last year I attended the Comprehensive Instructor Workshop at the Institute for Medical Simulation, a course that puts substantial focus on the art of debriefing learners following simulation. One of the primary tenets of their course is instilling “The Basic Assumption” into attendees.

The Basic Assumption

“We believe that everyone participating in activities is intelligent, capable, cares about doing their best, and wants to improve.”

While at first glance this seems like a fairly standard motherhood statement, after conducting simulation debrief after debrief I have learned its value. Facilitators vary widely in their debrief style, but it is always clear that the best of them believe in the integrity of their learners. Their debriefs are more enlightening, honest, and educational as a result. Seeing this led me to make The Basic Assumption a central tenet of my educational philosophy.

Combining this with my observations of some of my most admired mentors led me to a striking realization: in the same way excellent facilitators assume the best about their learners, excellent emergency physicians assume the best about their patients. Noting this, I rewrote The Basic Assumption to change its focus from learners to emergency department patients.

The Basic Assumption about Emergency Department Patients

“We believe that every patient presenting to the ED is honest, cares about their health, and needs our assistance.”

In the same way that this leads to optimal educational interactions with learners, believing in the integrity of our ED patients will lead to better care for them and a longer and more satisfying career for me. Just as the Center for Medical Simulation embraces The Basic Assumption for their trainees, I would love to see ED’s embrace it for their patients.

Conclusion

Working in an emergency department is a difficult job. Even when the department is spilling into the nearby Tim Hortons we do not turn anyone away. After resuscitating a young trauma patient it can be difficult to have patience for a low-acuity patient requesting a prescription refill. However, a better understanding of the underlying causes of access block and ED overcrowding can help. I am encouraged to know that my health region will no longer ask the public to avoid the ED. Instead, we are working to find ways to connect patients with the resources they need – even if it means coming to the ED while we figure it out.

I hope backlash against the inaccurate and harmful “Keep Emergency for Emergencies” commercial and campaign will lead heath care leaders to a similar conclusion in Australia. After all, “these patients are honest, they care about their health and they need our assistance.” If we can find it in ourselves to greet each and every patient with this assumption, I believe we will be more satisfied with our jobs and provide better care to our patients.

Please share this post if you agree with its sentiments as BoringEM does not have the budget to make such a snazzy video in response!

Expert Peer Review: This post was reviewed by Drs. James Stempien (@docstemp) and Mark Wahba (@mywahbaMD).

Further Reading

  1. Affleck A, Parks P, Drummond D, Rowe BH & Ovens HJ. (2013). CAEP position statement: Emergency department overcrowding and access block. Canadian Journal of Emergency Medicine, 15(6), 359-370. DOI 10.2310/8000.CAEPPS [Link]
  2. Canadian Health Services Research Foundation. (2009). Myth: Emergency Room Overcrowding is caused by Non-urgent Cases. [Link]
  3. Picard A. (2015). What’s really to blame for ER congestion?  The Globe and Mail. [Link]

Author information

Brent Thoma
Editor in Chief at BoringEM
Emergency Medicine Resident at the University of Saskatchewan, wannabe Medical Educator, Blogging Geek. + Brent Thoma

The post Keep Emergency for Emergencies? Reframing the basic assumption appeared first on BoringEM and was written by Brent Thoma.

Boring Question | Does this pediatric patient require a hard cast ?

It is a typical day in Fast Track, and you have a 8 year old who fell off their skateboard with a distal radius fracture that is commonly referred to as a “Buckle fracture” (AKA torus fracture). The child is very upset and concerned about having their arm splinted / casted given that they plan on spending a lot of time in a swimming pool this summer. You wonder, does this patient require an unremovable splint in the ED?

Fortunately, for your patient, the literature is on their side. In one study of 87 patients (age 6 to 15 years) with distal radius and/or ulna buckle fractures treatment with a short arm cast for 3 weeks (45 patients) was compared with a removable splint (42 patients). Scoring via the Activities Scale for Kids [1] at days 14 and 20 suggested better physical functioning and less difficulty with activities in the removable splint group [2]. A second study on buckle fractures allocated 18 pediatric patients to a removable bandage [ie, an ACE wrap] and 21 to plaster cast. Results strongly favored the removable bandage with excellent range of motion in the first week and no reported adverse effects [3]. A third study evaluated 66 adult patients with minimally displaced distal radial fractures that were randomly assigned to either a plaster cast or removable splint. Cast satisfaction, cast problems and the functional assessment score at 6 weeks all favored the removable splint [4].

Many of you may be wondering about patient compliance and potential complications. Well, in a meta-analysis [5] encompassing 455 participants, there were no refractures reported during the healing period regardless of degree of immobilization, with improved function, patient acceptance, and caregiver satisfaction with the use of removable splints.

In fact, the same can be said for Salter Harris Class I & II ankle fractures. In a study of 54 children treated with a removable ankle brace vs 50 casted children, 81% of those in a removable ankle brace were back at baseline activities in 4 weeks compared to just 60% of those casted [6]. A second study of 40 patients with Lauge-Hansen supination-eversion, stage II ankle fractures compared a removable air stirrup splint to casting; this study demostrated a significant improvement in early patient comfort, post-fracture swelling, range of ankle motion at union, and time to full rehabilitation with the removable splint [7]. In a third study that looked at splinting vs casting of 62 pediatric sprained ankles, absenteeism and the parents’ absenteeism were higher in the casted group [8].

After explaining to the parents that non-displaced buckle fractures heal quite well on their own, that refractures are rare, and that functionality is regained sooner with a removable splint, you proceed to place a removable Velcro wrist splint, recommend rest, ice, elevation, NSAIDs, and primary care follow up in 1-2 weeks. The patient proceeds to do well without complications, and is swimming without sequelae in a matter of weeks.

References

  1. Activities Scale for Kids. Website. Available at: http://www.activitiesscaleforkids.com/
  2. Plint, A. C., Perry, J. J., Correll, R., Gaboury, I., & Lawton, L. (2006). A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.Pediatrics117(3), 691-697.
  3. West, S., Andrews, J., Bebbington, A., Ennis, O., & Alderman, P. (2005). Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. Journal of Pediatric Orthopaedics25(3), 322-325.
  4. O’connor, D., Mullett, H., Doyle, M., Mofidi, A., Kutty, S., & O’SULLIVAN, M. (2003). Minimally displaced Colles’ fractures: a prospective randomized trial of treatment with a wrist splint or a plaster castJournal of Hand Surgery (British and European Volume)28(1), 50-53.
  5. Kennedy, S. A., Slobogean, G. P., & Mulpuri, K. (2010). Does degree of immobilization influence refracture rate in the forearm buckle fracture?.Journal of Pediatric Orthopaedics B19(1), 77-81.
  6. Boutis, K., Willan, A. R., Babyn, P., Narayanan, U. G., Alman, B., & Schuh, S. (2007). A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fracturesPediatrics119(6), e1256-e1263.
  7. Stuart, P. R., Brumby, C., & Smith, S. R. (1989). Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fracturesInjury20(6), 323-326.
  8. Launay, F., Barrau, K., Simeoni, M. C., Jouve, J. L., Bollini, G., & Auquier, P. (2008). [Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]Archives de pediatrie: organe officiel de la Societe francaise de pediatrie15(12), 1749-1755.

Reviewing with the Staff | Damian Roland

In all aspects of medicine translating evidence into practice is a slow process. Paediatric Emergency Medicine is no exception. In this short review the evidence for using splints rather than casts is presented. A Cochrane review six years ago highlighted their potential benefit however only slowly are children’s emergency departments using this approach to improve the patient experience and reduce costs.

The challenge here, ignoring the inherent face validity, is the balance between  improved patient experience, for which there is good evidence, and potential negative outcomes. The authors don’t describe the quality of the papers that are reviewed: what were the biases, and were they sponsored by splint manufacturers for instance.

This conundrum is a persistent research challenge – but our hospital for one (Leicester Royal Infirmary, UK) has been using splints for buckle fractures for some time. :)

Author information

Patrick Bafuma
Patrick Bafuma

The post Boring Question | Does this pediatric patient require a hard cast ? appeared first on BoringEM and was written by Patrick Bafuma.