February 21, 2019

Background: Emergency Physicians and trainees spend the majority of their clinical day performing clerical tasks which are widely disliked(Füchtbauer LM, 2013). Core tasks such as obtaining information, cognitive synthesis and communication are punctuated with other tasks including hours of electronic hospital record data entry, relaying information to multiple colleagues, sending investigation requests, booking beds, coordinating patient movements and chasing investigations(Kee R, 2012).  In addition to reducing physician productivity and contributing to work place dissatisfaction, the clerical tasks performed by doctors are a waste of medical resources. Patients need physicians to be available to them, rather than spending 30-43% (Robert G. Hill Jr., 2013)of their shift on clerical data entry requiring multiple “mouse clicks” for even simple tasks. Many of these non-core tasks may be amenable to task substitution leaving Emergency Physicians free to focus on “doctoring”. Emergency Medicine scribes (“scribes”) may or may not be a partial solution (Bastani A, 2014)to Emergency Department (ED) workforce capacity building. Scribes function as a bedside clerical assistant to the physician. They are becoming more common in the US, but not elsewhere. Scribes cost money, which represents a health opportunity cost. There have been a number of emergency studies that have evaluated before and after scribe implementations (Hess JJ, 2015)(Arya R, 2010)and one single-centre study  that randomised scribes to pediatric and adult areas of their ED (Heaton HA, 2016). There have not been any independently-funded, level II evidence studies about the effect of the scribe on emergency department metrics, nor any published information regarding patient safety. An Australian collaboration (philanthropically funded) recently undertook a prospective, multicentre randomised trial of scribes in the Emergency Department and their results were published in the BMJ in January 2019.

February 14, 2019

Background: The 2014 AHA guidelines for the management of NSTEMI, recommend unfractionated heparin with an initial loading dose of 60IU/KG (maximum 4,000 IU) with an initial infusion of 12 IU/kg/hr (maximum 1,000 IU/hr) adjusted per active partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed (Level of Evidence B) [2]. With even a higher level of evidence the 2014 AHA guidelines for the management of NSTEMI, also recommend enoxaparin 1mg/kg subcutaneously every 12 hours with reduced dosing to 1mg/kg subcutaneously in patients with a creatinine clearance <30mL/min) (Level of Evidence A) [2].  The studies supporting this therapy were performed primarily on patients with a diagnosis of unstable angina and in the era before dual anti platelet therapy and early catheterization/revascularization. Therefore, the authors of this paper looked to evaluate the clinical outcomes associated with parenteral anticoagulation therapy (Heparin) in the era of dual anti-platelet therapy in patients with NSTEMI.

February 13, 2019

Online educational resources, social media, and asynchronous education increasingly dominate innovation and continuing medical education for practicing emergency physicians. The “Free Open-Access Medical Education” (FOAM) movement has utilized the power of global connectivity to drive narrowing of the knowledge translation window, however critics have urged caution and warned of error, as many of these resources lack peer review or quality control.REBEL EM is an online educational resource widely used throughout the FOAM community, garnering an average of 3,000 - 30,000 views/engagements per educational post, and satisfying all quality indicators that have been previously identified as markers of reliability and usability for digital scholarship.To this end, we at REBEL EM are conducting a survey looking at rates of certain medication usage in the treatment of renal colic.

February 7, 2019

Welcome back to REBELCast.  In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be a frustrating thing, but it doesn’t have to be.  Patients and providers are often frustrated for different reasons.  Patients for multiple IV attempts and providers because of the time it can take to perform the procedure, delays in care, or lack of success. If you want to get better at this all-important procedure, read/listen on.

January 23, 2019

When I was a kid, I used to play chess with my grandfather every day.  Each piece on the chess board had unique moves that could be made in order to help win and capture the other person’s king (i.e. checkmate).  I used to think the king was the most important piece when I was kid, but the truth is, the king, had some of the most limited moves. A more reasonable reality is that the strength of the king is enhanced by optimally orchestrating and enhancing each of the other piece’s abilities.  A team can either be successful or fail based on the management style of a leader. Recently, I also read a book called Multipliers, by Liz Wiseman who does an absolutely amazing job talking about the attributes of successful leaders.  I began to think about the ideas in this book and the analogies that could be made to the pieces on a chess board.  From this combination, I developed a talk on leadership : "Titles Don't Make Leaders."