March 4, 2019

Background: Over the past few years we have seen a surge in the use of oral Factor Xa inhibitors (apixaban, rivaroxaban etc) for anticoagulation.  The reason for this is the ease of use, standard dosing with no levels to check and no injections needed. Despite these advantages, the risk of bleeding remains a concern.  These agents unfortunately do not have any specific reversal agents.  In May of 2018, Andexanet alfa gained accelerated approval by the FDA for the reversal of these agents, but robust evidence in its support have been lacking.

February 28, 2019

Background: Standard management of septic shock has included, IV fluids until optimal intravascular volume is achieved, appropriate early antibiotics, and source control.  Typically, only after all these measures have been undertaken is vasopressor infusion initiated if a MAP of ≥65mmHg is not achieved. There have been some animal and human studies that have advocated for early norepinephrine administration in septic shock improving hemodynamics and mortality.  The issue, with these trials is that they were retrospective which means these studies suffer from the limitations of this type of methodology (i.e. convenience sampling, recall bias, confounding, and ultimately cannot determine causation, only association).

February 26, 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 [1]. 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 [2]. To this end, we at REBEL EM are conducting a survey looking at rates of certain medication usage in the treatment of renal colic.  This is the follow up survey after the publication of the LIDOKET trial.

February 25, 2019

Introduction: The production and release of new antibiotics is rare and should be celebrated by clinicians. As antibiotic resistance continues to mount, our options narrow and, in turn, our patients suffer. Recently, the NEJM published two articles on a new antibiotic that was recently FDA approved - omadacycline. The articles compared omadacycline to moxifloxacin in the treatment of community acquired pneumonia (CAP) and to linezolid in the treatment of skin and soft tissue infections. Both studies yielded promising results for the new drug which should be cause of excitement. However, significant biases, methodological flaws and poor selection of comparator treatments should temper our excitement.

Both studies tested the new antibiotic in a non-inferiority set up. Non-inferiority studies seem to be increasingly prevalent in the literature and because they serve an important purpose, it’s important for us to understand them and also to understand why this approach is used and why it may not be appropriate.

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.