ED Muskoka Physicians - Living the Dream

A. Fib Management

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PPH sim recap

For the ED in situ simulations this month we ran through a case of a woman arriving in labour with EMS, imminently delivering.

Learning Point 1: This patient should come to the ER, NOT be sent upstairs in an elevator.

Call for OB nurses to come down to US with FHR monitor, PANDA warmer, delivery kit etc.

After delivery, she beings bleeding. How do we approach a post-partum hemorrhage in the ER? 

  • Address the 4 T’s (and start with Tone!)

Learning Point 2: Oxytocin – Always give Oxytocin 10units IM or 3units IV with delivery of the anterior shoulder for prevention of PPH. Once PPH identified, can put 40units in 1L NS and run at 250cc/hr (10units/hr)

Learning Point 3: Physical maneuvers first – bimanual compression of the uterus, place a Foley Catheter to empty the bladder.

Learning Point 4: Secondary medications – 

  • TXA 1g IV
  • Misoprostol 200mcg (New SOGC guidelines recommend SL/PO – NOT PR)
  • Ergotamine 0.25mg IM
  • Carboprost (Hemabate) 0.25mg IM or IMM

*These are all available in the ADU but must be drawn out individually

OR can be found in the PPH kit on the floor

  • Resuscitate the patient – all our usual principles apply. 
  • Consider DIC screen/empiric fibrinogen (RiaSTAP)
  • Call for Help (Remember CODE OB gets you OR staff/surgery mobilized)

Learning Point 5: Bakri Balloon – 

If required for packing the uterus, this is found in the PPH kit on the floor, or in the OR 

In Dr. Branigan’s eloquent words: 

The goals of this simulation involve the principles of patient safety – the right care (skill sets, equipment and drugs) in the right place (in this case the ED due to imminent delivery).  It is a process to look at clinical knowledge (imminent delivery, PPH 4 Ts and treatment strategies) and organizational knowledge (who is your team and how do you call them, where is your equipment and your drugs)

I will attach the case we used in a group reply to this email, along with the new SOGC guideline if you are motivated to review it.  If you have a quiet shift and want to verbally review this case with the nurses on shift to make sure everyone knows where to find the medications and equipment etc feel free to refer to this! Hopefully little tidbits of education like this can help with group morale 🙂


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Staffing shortage labour day weekend

Hi everyone, just passing along a message from Roxy – she wanted us to know that both sites are extremely short on staffing this coming weekend, in both EDs and ICU. Apparently all efforts to replace nursing shifts have been made, without success. Sorry for the bad news.
Thank you all for the hard work as we near the end of summer. Almost there…

Call To Efficiency

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Low Risk Chest Pain

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Treatment of Corneal Abrasions

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January Virtual Journal Club

I’ll post a more “official” article and review later in the month but I came across this article about abscesses and thought it was interesting. Skin abscesses are not the sexiest topic but we treat them frequently so it would be worth considering a practice change if it improved patient comfort and/or outcome.

The SGEM post and podcast (link below) summarizes the article and does a critical appraisal. Original article is posted here: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14106

Essentially they looked at treatment failure as a primary outcome after treatment of skin abscesses with the loop technique versus standard packing with ribbon gauze. Secondary outcomes were ease of procedure, pain at the time of treatment, ease of care at 36 hours, and pain at 36 hours.

Study conclusion was:

“The LOOP and packing techniques had similar failure rates for treatment of subcutaneous abscesses in adults, but the LOOP technique had significantly fewer failures in children. Overall, pain and patient satisfaction were significantly better in patients treated using the LOOP technique.”

A few thoughts/questions:

What is everyone’s usual practice? Packing vs. no packing vs. leaving a small wick? Has anyone tried this loop technique?

Do we even stock vessel ties in the ER?

Given the questionable evidence regarding packing, wouldn’t it be easier to just not pack at all (ie. no loop or standard packing)?

Aerosol Generating Procedures


Journal of anesthesia 

Purpose of the Study  – Quantify the amount of aerosolization during aerosol generating procedures to inform risk assessment

Study Design

-They monitored aerosolization with continuous sampling with an optical particle sizer, which allowed characterisation of aerosol generation within the zone between the patient and anaesthetist

-The extent to which COVID is transmitted as airborne is controversial 

Problems with the study

-Small sample size – used 4 ORs in the UK

-Only 19 intubations and 14 extubations 

-During intubation they use BVM and not RSI


– Tracheal intubation including facemask ventilation produced very low quantities of aerosolized particles – 500x less than a cough (actually state that “this study does not support the designation of elective tracheal intubation as aerosol generating”.

-Extubation, particularly when the patient coughed, produced a detectable aerosol, 15 folds greater than intubation but 35 folds less than a volatile cough .

Questions– They just say “facemask ventilation” – I think they need to be more specific.  What type of facemask did they use, what was the flow rate?

Take away –

(1)If a break in PPE then chance of acquiring COVID is probably minimal during intubation.

(2) patients coughing on us is more risk than intubation, therefore patient’s properly wearing masks can reduce this.