Date: January 28th, 2019

Reference:  Chu DK et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet 2018.

Guest Skeptic: Dr. Robert Edmonds is an emergency physician in the US Air Force in Virginia. This is Bob’s ninth visit to the SGEM.

DISCLAIMER: THE VIEWS AND OPINIONS OF THIS PODCAST DO NOT REPRESENT THE UNITED STATES GOVERNMENT OR THE US AIR FORCE.

Case: You’re working a shift in a rural emergency department when a 68-year-old man presents with a two-day course of worsening cough, shortness of breath, and fever. Their workup reveals a multifocal pneumonia with signs of sepsis.  The patient has an oxygen saturation of 98% on room air and your nurses ask if you want the patient to receive supplemental oxygen.

Background: The liberal use of supplemental oxygen therapy in acutely ill adults has a long history in the hospital, but high-quality therapy supporting its practice is unclear.

Recently, the role of oxygen therapy in non-hypoxic patients has been challenged in myocardial infarction patients, as seen in a number of trials including DETO2X-AMI

We covered the DETO2X-AMI trial on SGEM#192. The SGEM Bottom Line was that the routine administration of supplemental oxygen in patients with suspected or confirmed acute myocardial infarction who are not hypoxic does not appear to provide a patient-oriented benefit.

In the 2015 AVOID study there was some suggestion of increased MI size in the group of STEMI patients that received oxygen at 8 L/min compared to a room air control group. This study expands upon that investigation to patients with other conditions as well.

While supplemental oxygen is undoubtedly beneficial for patients acutely desaturating, in respiratory distress, or suffering from carbon monoxide poisoning just to name a few, there is widespread “indication creep” for this therapy.

In neonatal resuscitation oxygen is treated like a drug that should be appropriately dosed, with careful attention to limit its use to the minimum required amount out of a fear of harm from its excess use.

In acutely ill adults, this same concept is not yet as widespread and liberal administration is still common place.

Clinical Question: Is liberal oxygen therapy vs. conservative oxygen therapy for acutely ill adults effective and safe?

Reference: Chu DK et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. The Lancet 2018.

* Population: Acutely ill adults (>18 years old) with any condition requiring non-elective hospital admission and the potential to be exposed to supplemental oxygen

* Exclusions: Studies with patients who are younger than 18, pregnant, limited to patients with chronic respiratory disease, on extracorporeal life support, treated with hyperbaric oxygen or undergoing elective surgery

* Intervention: A higher oxygen target (liberal group). This was measured by FiO2, PaO2, arterial oxygen saturation measured by blood analysis or peripheral oxygen saturation measured by pulse oximeter.

* Comparison: The lower oxygen target (conservative group)

* Outcomes: The authors do not report any one outcome as a primary outcomes, but instead listed morbidity and mortality.

* Mortality: In-hospital, 30 days, and at the longest follow-up

* Morbidity: Disability measured by the modified Rankin Scale, risk of hospital-acquired pneumonia, risk of any hospital-acquired infection or hospital length of stay.

Authors’ Conclusions: “In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mo...

Date: January 30th, 2019

This is the third annual Canadian EM Wellness Week from CAEP. Emergency Medicine Ottawa is posting new episodes each day focusing on the humanity in emergency medicine.

* Day 1: Finessing your Finances in Residency

* Day 2: You’ve Got A Friend in Me – The Importance of Social Wellness and Being a New Parent

* Day 3: The Sandwich Generation – An Interview with Ken Milne and Nutritional Advice

* Day 4: A Letter to my Younger Self

* Day 5: Closing Thoughts

Dr. Bill Hettler, a family physician, originally developed the Wellness Wheel concept in 1976. He also co-founded the National Wellness Institute (NWI). Dr. Hettler identified six dimensions of wellness (occupational, physical, social, intellectual, spiritual and emotional). The NWI defines wellness as an active process through which people become aware of, and make choices toward, a more successful existence.

Definition of Wellness: the quality of state of being in good health especially as an actively sought goal. Merriam-Webster Dictionary

I was honoured to be asked to represent the “sandwich” generation of emergency physicians. Dr. Lisa Fischer interviewed me about taking care of parents and children while still working full time. We discussed how my father’s recent illness and death impacted me and things that helped me cope. You can read the blog by Dr. Fischer on nutritional advice at EMOttawa and you can listen to the podcast as an SGEM Xtra.

I learned five things as a result of being on the edge of burnout:

* It’s ok not to be ok

* Vulnerability is a sign of strength not weakness

* Take care of yourself

* Don’t be afraid or ashamed to ask for help

* Don’t panic, this too shall pass

You can watch my presentation on burnout at ACEM18, read the SGEM blog, download the slides, or listen to the SGEM Xtra podcast to find out more about burnout.

More resources on wellness can be found at these links (ACEM Member Wellbeing, ACEP Wellness Section, CAEP Resident Wellness and 

Date: January 22nd , 2019

Reference:  Frey et al Effect of Intranasal Ketamine vs Fentanyl on Pain Reduction for Extremity Injuries in Children: The PRIME Randomized Clinical Trial. JAMA Pediatrics December 2018

Guest Skeptic: Dr. Samina Ali is a pediatric emergency physician, clinician-scientist, and Professor of Pediatrics & Emergency Medicine at the University of Alberta…

Date: January 17th , 2019

Reference:  Clemency et al. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. AEM December 2018

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the excellent #FOAMed project called First10EM.com

Case: A 33-year-old man arrives via emergency medical services (EMS)…

Date: January 10th , 2019

Reference:  Busse JW et al. Opioids for Chronic Noncancer Pain A Systematic Review and Meta-analysis. JAMA December 2018

Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on…

Date: December 30th, 2018

Happy New Years to all the SGEMers out there in the #FOAMed world.  It is time to reflect upon 2018 and look forward to 2019. Last year we named 2017 the year of FeminEM and celebrated 15 amazing women in emergency medicine. This year I am going to highlight five of…

Date: December 21st, 2018

Happy holidays to all the SGEMers.  For everyone in the Northern hemisphere, let it snow, let it snow, let it snow. For those in the Southern hemisphere, I suggest you listen to the Tim Minchin song about having white wine in the sun. Regardless of where you are, I hope everyone…

Date: December 13th , 2018

Reference: Murata et al. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018

Guest Skeptic: Dr. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Associate Professor for the University of Leicester’s SAPPHIRE group. He specialises in Paediatric Emergency Medicine and is…

Date: December 4th, 2018

Guest Skeptic: Dr. Steven Novella is a Yale Neurologist, host and producer of the popular science podcast called the Skeptics Guide to the Universe and executive editor of Science Based Medicine blog.

This is an SGEM Xtra book review. I had the privilege of interviewing Dr. Novella about the new book…

Date: December 6th , 2018

Reference: Perkins et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. NEJM 2018.

Guest Skeptics: Jay Loosley is the Superintendent of Education at Middlesex-London Paramedic Service. Jenn Doyle is a paramedic educator at Middlesex-London Paramedic Service.

Case: A 51-year-old man experiences a cardiac arrest on the street. You…