Episode 9: Bacterial Peritonitis – Tap that Belly !

Episode 9: Bacterial Peritonitis – Tap that Belly !

In this episode, Dr. Thavanathan interviews Dr. Chirag Bhat, an R5 and chief resident of the Ottawa Emergency Medicine program (at the time of this podcast), on select complications of cirrhosis.

Note that he’s previously written a Grand Rounds Summary of the topic linked here.


For an even deeper dive, we recommend reviewing the 2018 EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.


Patient Case:

Dr. Bhatt highlights a challenging cirrhotic case that identified knowledge gaps. The patient presented with fever, tachycardia, abdominal pain, and had ascites on clinical examination. He suspected spontaneous bacterial peritonitis (SBP) and performed a paracentesis, and the patient met diagnostic criteria for SBP. He prescribed appropriate antibiotics and consulted internal medicine. But while reviewing the chart the following day he learned that despite this, the patient had decompensated. He was later diagnosed with secondary bacterial peritonitis and required emergent surgery.


Biggest Takeaway from the EASL Guidelines:

Cirrhotic patients can have extensive complications from their liver disease. In the emergency department, we often focus on variceal bleeding and less on SBP.  However, SBP has an extremely high mortality and is common. Clinicians should start considering it as the meningitis of the abdomen; in fact, meningitis has a lower mortality rate than SBP. For every four patients that you diagnose with SBP and treat with antibiotics, one will still die in hospital. Of cirrhotic patients, one in four will have at least one episode of SBP during their lifetime. It is both common and deadly.


Diagnosing SBP:

To diagnose SBP, we must do a diagnostic paracentesis and look at the absolute neutrophil count. The paracentesis findings are an ascitic absolute neutrophil count (ANC) of greater than 250 cells/mm.


Is peritonitis needed to diagnose SBP?

No, and in fact this is a common misconception within the name. While we look for fever and abdominal pain, only ½ of patients with SBP present with these symptoms. In fact, fever occurs in only 42% of patients. This is because cirrhotic patients are relatively immunocompromised.


Patients with SBP can present with any of the following:

  • Isolated hepatic encephalopathy
  • Renal failure
  • GI bleeding
  • Any abnormal vital signs
  • Vomiting
  • Metabolic acidosis
  • Leukocytosis


One study, which included paracentesis done in outpatient clinics, even found up to 13% of SBP patients were asymptomatic. The fact that something with a mortality of 25% can be that indolent should terrify you.


If you miss this diagnosis and discharge the patient home, their mortality approaches 90%. That’s why it’s a critical diagnosis. Every hour that you delay a diagnostic paracentesis in a patient with SBP increases their mortality by 3.3%. That’s why this is an ED diagnosis, and why you shouldn’t defer doing the paracentesis to the inpatient team. 


SBP Treatment:

Antibiotics remain a key component of treatment, specifically, a 3rd generation cephalosporin for community acquired SBP in low antibiotic resistance areas. Without antibiotics, SBP has a mortality of 90%. With antibiotics, the mortality is still 25%.


However, there is another extremely important intervention, that can decrease patient mortality from 25% down to 10%. That treatment is albumin.


The EASL guidelines of 2018 recommend that we give albumin at diagnosis at a dose of 1.5 g/kg. This is a grade I recommendation.


It’s based on the theory that albumin would increase intravascular volume but also binds endotoxins in patients with SBP and ultimately prevent hepatorenal syndrome and subsequent death.


This is based on a meta-analysis of four RCT studies done with a total of 288 patients with SBP.

It suggests that albumin has an NNT of 6 to prevent one death, and it has an NNT of 4 to prevent renal failure. So, this is a second critical action you can take on your next shift. Order albumin at 1.5 g/kg within 6 hours of diagnosis for your patients with SBP and help lower the mortality of this dangerous disease.


What is secondary bacterial peritonitis?
About 1 in 20 cases thought to be spontaneous peritonitis are secondary to another source. In contrast to SBP, secondary bacterial peritonitis is when ascites fluid is infected but it’s due to another intraabdominal infection. It’s secondary to another source, like appendicitis, or cholecystitis, or perforation.


When you do the paracentesis, you’ll still have an absolute neutrophil count > 250 cells/mm3, and you will be tempted to call this spontaneous, when in fact, it is secondary from another source. The reason this matters is that secondary peritonitis is a surgical pathology. Without surgery, their mortality is around 100%. Because we wouldn’t be treating the source


How do you differentiate between SBP and Secondary Bacterial Peritonitis?
Unfortunately, this remains a challenge. There’s not much on history that will differentiate between the two. However, on physical exam, secondary bacterial peritonitis patients tend to have more severe and focal abdominal pain.


Is there a clinical tool that can help distinguish between the two?

The Runyon criteria

When you do the paracentesis, you’re looking for 2 of 3 findings in the ascitic fluid:

  1. Protein > 10 g/L
  2. Glucose < 2.8 mmol/L
  3. LDH > ULN of the serum.


These criteria have a specificity of 90%, but a sensitivity of 66% for secondary bacterial peritonitis. So, as emergency physicians, we can’t use Runyon criteria to rule out secondary peritonitis. However, applying the Runyon criteria can push you to do a CT when you weren’t going for other reasons.


Advanced Imaging

Dr. Bhatt highlights a few reasons you should strongly consider performing a CT scan on a patient with cirrhosis and ascites.

  1. Severe abdominal pain
  2. Focal abdominal pain
  3. Positive Runyon criteria
  4. Not responding to typical SBP treatment, including antibiotics and albumin
  5. Also consider a very high ANC as a clue.


Take-home Points:

  • Adopt an extremely low threshold to perform a diagnostic paracentesis in cirrhotic patients. It has an extremely high mortality with a very subtle presentation.

  • The paracentesis findings are an ascitic absolute neutrophil count (ANC) of greater than 250 cells/mm.
  • Only half of SBP patients present with fever and abdominal pain. SBP can present with isolated hepatic encephalopathy, renal failure, GI bleeding, any abnormal vital sign, vomiting, metabolic acidosis or leukocytosis.
  • For SBP treatment, in addition to antibiotics, prescribe albumin at a dose of 1.5 mg/kg as per the latest 2018 EASL guidelines. This is a grade I recommendation.
  • When diagnosing SBP also consider secondary bacterial peritonitis, which occurs in 1 in 20 patients. This is a surgical emergency of the abdomen. Have a low threshold for advanced imaging, particularly in patients with severe or focal abdominal pain, those with meeting Runyon criteria, and patients not responding to treatment as expected.


Episode 8: Patient Complaints

Episode 8: Patient Complaints

On this episode of the EM Ottawa Podcast, Dr. Rajiv Thavanathan talks to  Dr. Nicholas Schouela to discuss the patient complaints process, approaches and mitigation strategies. 


Why do they matter?

They’re common. They’re associated with shame and distress. We’re generally high achieving people who take perceived failures poorly. Importantly, many are based on legitimate patient safety issues. By addressing this, we can work towards improving patient safety.


What has changed recently in the patient safety landscape?

In Canada, between 2016-2020, there was a 20% increase in college complaints across all specialties. The ED sees the 3rd highest rate of college complaints across all specialties; for reference, the highest being obstetrics & gynecology, and the second being general surgery.


How did Covid-19 influence patient complaints?

Despite decreased patient volumes during the initial phases of the pandemic, complaints continued to rise increasing locally in Ottawa by 22%.


What guidelines or legislation exist for hospitals in managing the complaint process?

All provinces have essentially mandated that patient complaints are taken seriously and in a structured way.

Ontario has the Excellent Care for All Act. This is a piece of legislation that was developed to increase the focus and accountability for delivering high-quality care through the initiation of multiple hospital and government level committees.


What is the CMPA, and what is its role in patient complaints?  

The CMPA is a not-for-profit defense association, they provide medical legal advice and assistance, patient compensation, resource for risk management, and they write medical-legal opinions for public policy. For patient complaints, they are there to advise, and if needed provide legal counsel.

What are the steps involved after receiving a patient complaint at the college level?

One of the first steps should involve contacting the CMPA. You should not attempt to access or edit the patient’s chart. Following this, you respond to the complaint with the CMPA’s help. Following your response, the CPSO begins the investigative process; this can take between 3 to 10 months. It then takes 2 to 3 months to formulate a decision; essentially a year-long process.


What are common pitfalls made in responding to patient complaints?

  • Opening the patient’s chart without permission. You need permission from your local hospital to do so as the information does not belong to you.
  • Trying to edit the note or the encounter. If you alter the patient encounter, your credibility is instantly lost.
  • Responding too emotionally or defensively. You want to remain factual and even-toned.


What are the outcomes of complaint decisions?

Split into favorable or unfavorable outcomes. Favorable essentially meaning you were in the right. Unfavorable outcomes include cases that were dismissed with concern, suspensions, restrictions placed on a license, revoking of a license, or voluntary resignation or resignment.


Why do patients complain?

Multiple reasons, although most commonly due to a perceived injustice. A 2018 ED study by the CMPA showed that approximately half of all patient complaints involved scenarios that resulted in patient harm. Of these harm-scenarios, 90% of medical experts were critical of the initial care provided. 

Complaints can be divided into three different categories: Clinical care, situational awareness, or a communication breakdown.


What deficiencies were identified by the CMPA as leading to complaints?

The vast majority pertain to inadequate patient assessments. A good proportion also include failure to refer to appropriate consulting services, and inadequate or incomplete investigations.


What are situational awareness complaints?

On average, 1 out of every 5 complaints are based on situational awareness. These include monitoring issues, such as a patient that should have been on a monitor but was placed in an unmonitored area and harm resulted. This further includes tests that were sent off and not followed up on, patients discharged prior to abnormal lab values resulting, or the physician performing an incomplete review of the medical chart leading to suboptimal care.


What is communication breakdown from the CMPA standpoint?

On average, 1 out of every 4 complaints relate to communication breakdown. These can be divided into four broad categories: physician to patient communication, inter-physician, physician to other allied health providers, and documentation.

Is communication modifiable in reducing patient complaints?

Absolutely. Improving communication can also improve your decision making and situational awareness.


What aspects of handover may reduce patient complaints?

Handover is a high-risk time of physician-to-physician communication breakdown. Poor handover increases the risk of patient harm, time in the department, and investigations.

Dr. Ed Kwok, in a 2020 study identified that ¼ of patients were inadequately handed over, with up to ½ of patients consulted inadequately handed over.

Ultimately, the risks associated with missing key information in handover can be minimized by using a standardized framework, such as ED VITALS.


Beyond a standardized handover framework, how can we further improve communication?

Disclosing non-clinically relevant abnormal results. Particularly if patients have access to reviewing their own labs or electronic charts, as this can be distressing to patients. Addressing all incidental findings on imaging, even if it simply means following up with their primary care provider in 6-months to repeat the test.


Tips for disclosing errors

Firstly, certain situations mandate the disclosure of error. This includes any incident that leads directly to patient-harm, or that reached the patient and had the potential for harm, even if it didn’t cause any harm. Generally, it’s a good idea to disclose any incident that reaches the patient even if it didn’t have the potential for harm.


Any pearls or pitfalls for apologizing to patients?

An apology in the form of a statement of regret is both a good idea and can help with emotional healing. This is protected across Canada in different provincial acts as not being considered an admission of fault. For reference, in Ontario, this act is called the Apology Act. 


What are the critical elements of discharge instructions that can minimize patient complaints?

This is the final impression you give to a patient and relays critical information. You should include advise specific to their condition, a follow-up plan, the signs and symptoms in which you would want them to seek care again and make it clear that they are always welcome to return. This should be done verbally at a minimum; however, written handouts can be a nice compliment to this.


Where do we go wrong with obtaining and documenting consent in the ED?

Two different categories. The first is forgetting to obtain consent entirely, which can lead to allegations of battery. The second is a consent process that fails to adequately inform them. Recall that consent includes multiple components: it needs to be voluntary, the patient needs to have capacity, they need to be properly informed about the risks, benefits, alternatives, and consequences of declining the procedure.


In the age of electronic charting, what are the medicolegal risks of using pre-filled templates or dot-phrases?

While largely beneficial, they can lead you to documenting things you didn’t do, which can of course harm you medicolegally. There hasn’t been a specific CMPA judgement on this that the authors are aware of.


Any advice to be more empathetic or caring for patients in the emergency department?

Remember that patients present to the ED because they have a worry or concern. Even if they don’t have underlying emergent pathology, they don’t feel well. Using empathy to address these concerns remains paramount. Additionally, use a patient-centered approach with culturally appropriate care. 


What practical advice do you have for physicians dealing with patient complaints?

Recognize that these aren’t easy. We will all receive at least one during our career no matter how careful we are. We know that complaints can cause significant emotional distress, anxiety, depression, substance abuse, social withdrawal, work disruptions, insomnia, loss of trust in patients, and feelings of helplessness. Self-care is important: exercise, mindfulness, and seeking out supportive people in your network or professional support. There are provincial medical associations physician help programs. If you work out of a university, there are also university affiliated faculty wellness programs. The CMPA itself also has several resources and guides.


Any practical strategies that can be exercised independently?

Cognitive strategies, such as the best-friend strategy, which involves treating yourself how you would treat your best friend if they came to you in the same scenario. Reflect on maintaining a growth mindsight and consider reviewing your knowledge base if there were any identified areas of deficit. Most importantly, practicing self-care as emphasized above.



Episode 6: Tick Borne Illness Part 2 – Anaplasmosis

Episode 6: Tick Borne Illness Part 2 – Anaplasmosis

EMOttawa Podcast Episode 6
Tick Borne Illness Part 2 – Anaplasmosis

Click here for Part 1, focusing on Lyme disease.

In part 2 of our 2-part series on tick-borne diseases, Dr. Rajiv Thavanathan interviews Dr. Mikkey McGuinty, an infectious disease clinician-scientist on the topic of anaplasmosis. For a basic review of the disease and pathophysiology, we suggest our previous posts on lyme disease, vector borne illnesses part I and part II. 


Anaplasmosis is the broad name for diseases cause by the Gram-negative bacterium Anaplasma phagocytophilumIt is a tick-borne illness, carried by the same Ixodes Scapularis tick that can cause Lyme disease. In humans, it’s called HumanGranulocytic Anaplasmosis (HGA). 

Why are we hearing about Anaplasmosis only recently?

Increased prevalence of ticks with climate change and the evolution of their habitat.

Up until 2020, many physicians had never seen HGA in Ottawa. There were 2 documented cases in Ontario over the last 5-years, both of which were in the Toronto region, which made sense given it’s proximity to the southernmost part of Ontario. Until recently clinicians were not routinely testing for it, and it’s likely that this represents an underestimation of the true prevalence. To date in 2021, there have been 5 documented hospital cases in the Ottawa region 


  • In Ontario and most of Canada, the same as Lyme disease. That is, tick endemic regions.
    • Ticks in these regions are often found in areas with long grass and low brush. 
    • HGA is more common in Europe. It infects a different tick species (not Ixodes Scapularis), hence the difference in prevalence. 

Classic Presentation

  • Febrile, summer illness.
  • No erythema migrans.
  • Delayed presentation. On-average, illness occurs 1-2 weeks from exposure.
  • Symptoms are general and can include fever, fatigue, myalgias, headache, and less commonly, GI symptoms of nausea, vomiting or diarrhea.

Populations at Risk

  • Elderly (age >60), advanced HIV disease, or impaired T-cell immunity such as organ transplant recipients.
  • Unlike Lyme disease, most people will have a self-limited illness. It doesn’t have as delayed a presentation.
    • However, It can cause severe illness, including syndromes that look like septic shock because of cytokine response to the infection. You can have multi-organ system failure as a result, including brain disease, myocardial involvement, respiratory failure, severe hepatitis, renal failure.
  • 3-5% morbidity, with a case fatality rate of ~1%.

Diagnostic Clues

  • Cytopenia – particularly thrombocytopenia and leukopenia (less commonly anemia)
  • Mild biochemical hepatitis

 Advanced Testing

Bottom line: A challenging diagnosis to make in the ED. Needs to be a clinical diagnosis and confirmatory tests take a while to come back. 

  • Typically, morulae are found in the 1st 3-5 days of the infection, as opposed to later in the course.
  • Serology can be ordered but is only diagnostic when paired. You need an acute sample while sick, and a paired convalescent sample to determine the antigen titre delta.
  • PCR is the gold standard test, and the test of choice in regions with high prevalence.
    • In the ED, this could be helpful for high-suspicion presentations that will be treated empirically or referred to infectious disease.
      • A convincing clinical history, including tick exposure within the last 2-weeks now presenting with fever, myalgias and headache, with thrombocytopenia and biochemical hepatitis.

Prophylaxis & Treatment

  • Does doxycycline prophylaxis change the likelihood of developing HGA?
    • No, at least we don’t have data for it.
    • However, if they have risk factors (RF) for HGA, they have RF for Lyme disease, so if they meet tick criteria for doxycycline prophylaxis this should be given.
  • Treatment is Doxycycline 100mg PO BID x 10-14 days.
    • HGA is incredibly doxycycline sensitive, and the duration could be as short as 7-days, but we’re also concerned about treating Lyme disease.
  • The ID physician’s joke: No one should die without a trial of doxycycline.

Ottawa Specific Testing


  • Epic doesn’t have HGA set up as a specific test for blood films
  • If you’re planning to order microscopy and asking to look for morulae, call the hematopathology team to inform them that HGA is on your differential.
    • Simply commenting on this in the EPIC comment section if often missed.

Take-Home Points

  • Anaplasmosis, also known as HGA, is a tick-borne illness carried by the same tick that can cause Lyme disease.
  • The classic presentation is a febrile summer illness, typically 7-days post tick exposure. Symptoms include fever, myalgias, headache, and less commonly, GI symptoms.
  • While typically self-limited, populations at risk of complications are the elderly (age >60), advanced HIV disease, or those with impaired T-cell immunity such as organ transplant recipients.
  • Suggestive lab abnormalities include thrombocytopenia, leukopenia, and mild biochemical hepatitis.
  • Testing in the ED can include ordering microscopy by hematopathology to look for morulae, which are intraneutrophilic bacterial bodies, with peak sensitivity on days 3-5.
  • PCR is the gold-standard test. For patients being treated empirically or referred to infectious disease, this can be considered.
  • Treatment: Doxycycline 100mg PO BID 10-14 days.
  • It’s never the wrong time to offer preventative care for tick-bites.



Episode 5: Tick Borne Illness Part 1 – Lyme Disease

Episode 5: Tick Borne Illness Part 1 – Lyme Disease

EMOttawa Podcast Episode 5
Tick Borne Illness Part I – Lyme Disease

In part 1 of our 2-part series on Tick-borne diseases, Dr. Rajiv Thavanathan interviews Dr. Mikki McGuinty, an infectious disease clinician-scientist. This episode covers nuances of lyme disease with relevance to the front line provider. For a basic review of the disease and pathophysiology, we suggest our previous posts on lyme disease, vector borne illnesses part I and part II. 

Local Prevalence of Lyme Disease 

Common. Five years ago, it would be incredibly rare to see a case of locally acquired Lyme disease in Ottawa. They were seen in Kingston often, but now we’re seeing more and more cases in Ottawa. In the province of Ontario in 2017, we documented over 1000 cases, and numbers have been rising since. However, four years prior, we were roughly seeing 300-cases per year. This isn’t just due to under recognition, there’s more Lyme carrying ticks. Reasons for this include complex dynamics of climate change, as well as habitat change for typical reservoir animals of these diseases. Overall, the IDSA threshold for an endemic area is 20% or more of ticks infected with Borrelia Burgdorferi.

Do we need to identify the tick?

The bottom line: no. In Dr. McGuinty’s experience, a patient bringing in a suspected tick in Ottawa hasn’t helped. Most tick-borne illnesses diagnosed do not have a tick identified. Physicians are generally not any more skilled than the public in comparing the identified tick to those found in a textbook or on the internet.

However, if you live in a region that has multiple infectious ticks (i.e. lone star ticks or dog ticks) that can carry different diseases than in our local Ontario region, there’s more value to identification to target treatment. In Ontario, we assume it’s an Ixodes tick.

Exposure Duration 

In determining prophylaxis treatment, does the duration of tick attachment matter? There’s a good science answer for this, and a practical real-life answer for this:

There are lots of good studies showing that borrelia burgdorferi is NOT transmitted during the first 24-hours of attachment. However, the vast majority of those who have a tic-borne illness don’t recall having a Tic attached. And just because you’re seeing a patient with a tick attached doesn’t mean that same patient didn’t have three ticks on them earlier and this is the only one left. Therefore, our local practice is treating regardless of the presumed attachment duration.

Tick engorgement is also notoriously unreliable to the untrained eye. Albeit if you’re an ER or family physician living in New York State, you might have more experience with this.

Erythema Migrans 

A common clinical miss for Lyme disease is failing to recognize disseminated (or secondary) Lyme. Often called about a patient febrile with a weird rash. And at this point it’s disseminated with different stages of bullseye rashes. It’s not just a simple or single lesion.

Regarding the timing of erythema migrans, its variable, with some lesions showing within 2-3 days of exposure, and some as late as 30-days after. The appearance can also vary amongst patients significantly. While many patients get the classic targetoid lesion with the central bite, some get erythema throughout. Therefore, if a patient has a tick exposure, and you think it’s a possibility the rash could be migrans, it’s best to err on the side of caution.

Clinical pearl: it should never be painful. (It should also never be pruritic, but Dr. Mcguinty has seen a few cases with associated pruritus).


IDSA Guidelines: 200mg of doxycycline x 1 dose (or 4.4mg/kg in pediatrics), beginning within 72-hours of tick removal, for an Ixodes tick, in an edemic area, where the Tick was on for 36-hours or more.

However, regarding the timing, you should use your clinical judgement.

I.e., a patient presenting at the 84-hour mark post-tick removal might still benefit from prophylaxis, whereas a patient with a tick removed one week ago will not. There’s good evidence that delayed prophylaxis doesn’t mitigate the presence of Lyme disease.

Lyme Serology 

In acute Lyme disease with erythema migrans, there’s typically no utility in sending serology for Lyme. It takes at least 3-weeks, and up to 6-weeks, to develop antibodies to Borrelia. And depending on your institution’s lab, it takes an average of 1-week for serology to come back.

ID Referrals  

Should you refer every patient treated for Lyme disease to ID?

Bottom line: No. Unless you feel uncomfortable or have questions regarding the case. Almost everyone with acute Lyme disease will improve, with outpatient wait times to see an ID specialist are typically ≥ 2-months.

Facial Nerve Palsy 

Steroids in the setting of a facial nerve palsy with suspected Lyme disease:

  • If you’re confident it’s Lyme, and you’re treating a Bell’s palsy, it’s an appropriate indication for an earlier resolution of symptoms.
  • IDSA says there’s no added benefit from adjunctive steroids in the general for Lyme neuropathy, but it’s worth starting early in the <72-hour window for cranial neuropathies.
  • There’s neither good evidence for benefit or harm.

Duration of Doxycycline 

  • 10-days? 14-days? 21-days?
  • It’s not black and white. In Dr. McGuinty’s practice, generally will give 14-day courses.
  • More likely to give 21-days if there’s features that suggest dissemination, if it’s been at least 2-3 weeks since possible exposure, presenting with delayed onset of rash or recurrence of fever. As it’s hard to say whether it’s primary or early secondary disease.


  • A common symptom of Lyme disease, and Dr. McGuinty notes clinician’s often inappropriately treat these patients for meningitis with IV antibiotics.
  • If they have no physical exam findings of meningitis, it’s likely not meningitis.
  • Headache, even severe headache, is quite common in the early stages of these diseases. i.e., Covid patients get bad headaches, but it’s often not meningitis, rather it’s related to the underlying infectious process with a significant cytokine release.

Take-Home Points 

  • Lyme disease is becoming increasingly prevalent in Ontario and across Canada, and this isn’t just due to increased disease recognition.
  • Tick identification seldom changes clinical management, and most tick-borne illnesses diagnosed never have a tick identified.
  • IDSA Prophylaxis recommendations: 200mg of doxycycline x 1 dose (or 4.4mg/kg pediatrics), within 72-hours of tick removal, for an Ixodes tick, in an endemic area, where the tick was attached for >36-hours.
  • In clinical practice, the duration of tick-attachment is notoriously unreliable, and this should not be used to preclude prophylaxis.
  • Erythema migrans has a variable appearance. However, it should never be painful.
  • Lyme serology lacks utility in the ED and should not typically be sent. In addition to the results taking 1+ weeks to result, it takes an average of 3-6 weeks to develop antibodies to borrelia burgdorferi
  • A headache with Lyme disease is common and does not typically indicate meningitis.




  1. Ottawa Prevalence. https://med.uottawa.ca/en/news/tiny-predators-park-1-out-3-ticks-tested-new-ottawa-study-carry-lyme-disease
  2. IDSA Guidelines. https://www.idsociety.org/practice-guideline/lyme-disease/



EMOttawa Podcast Episode 4: Reflections with Ian Stiell

EMOttawa Podcast Episode 4: Reflections with Ian Stiell

Podcast Episode #4 – Dr. Tiffany Lam & Dr. Ian Stiell

(Click here to access Podcast Main menu)

For our fourth episode of the Ottawa EM Podcast, Dr. Tiffany Lam makes her much anticipated Podcast debut! She sits down to talk to Dr. Ian Stiell, a world-renowned clinician and researcher best known for his development of the Ottawa EM decision rules.

How did you get involved in research?

It was ultimately unexpected, as I was not involved in research as a medical student or clinician. It began with leading journal club as a junior staff, learning how studies should be designed, and then going on to pursue a master’s in epidemiology.

Sometimes you need to go with your gut and follow any opportunities that arise, you can’t pre-ordain what’s going to happen.

Who were your mentors growing up?

My father was a forestry researcher, and although not a clinical researcher, I suppose this rubbed off. There was not a lot of emergency medicine research happening early-on in my career, so I relied on a multidisciplinary team of other clinicians early-on.

Advice for students or residents interested in emergency medicine research?

Reach out to known researchers as early as you can. If you’re a medical student, ask for opportunities in your 1st or 2ndyear volunteering or potentially working as a summer student. In Ottawa, there are multiple new EM projects happening each year, including opportunities to get involved helping with the resident research projects.

How does your clinical work influence your research?

After working in the ED for 40-years, it’s really a never-ending opportunity of ideas. Residents are always asking “why do you do it that way?” and you’re expected to know the answer. If you don’t, potentially there’s a new research idea. EM is unique in that we see the early stages of the undifferentiated patient. Whether in identification of disease, risk stratification or prognostication, there are always new opportunities for research in the ED.

What is the most meaningful change you’ve seen regarding the use of evidence in EM?

The shift away from eminence-based medicine, that is, away from old professors telling you what’s right just because it’s always been that way. Now we look at the studies first, and trainees are being taught earlier-on to critically appraise the literature.

How do you maintain a balanced schedule?

Part of it comes with learning how to be more efficient. Working hard, but also being proficient with your time. As an editor-and-chief for CJEM, this includes appraising articles quickly.

How does Ian Stiell prevent burnout?

Right now, it’s through having lots of hobbies outside of medicine and exercising. My hobbies have included skiing, mountain biking, playing golf, tennis and travelling when it’s not a global pandemic. Currently, I’ve been spending a lot of time with my family and grandchildren.

What are some of the greatest life lessons you’ve learned during your career?

You can’t totally preplan your life. In medical school I wanted to be a neurologist, then surgeon, then family doctor, and all of that seemingly went by the wayside as I grew up. You need to be open to new opportunities. Allow yourself to change course if you find something you like better. And don’t be afraid to admit you don’t like the path you’re on and change course.

What’s next for Dr. Ian Stiell?

I’m still actively involved in research, but part of my role has shifted more towards mentoring residents and new researchers. I’m also involved in working as the editor-and-chief of the Canadian Journal of Emergency Medicine (CJEM).

Any final parting words of advice?

While it depends on your personality, emergency medicine is an amazing career to pursue, particularly if you have a short-attention span. It’s exciting, fast paced, a team sport, and there are countless opportunities for clinical research—whether in quality improvement, simulation, or point-of-care ultrasound (POCUS) to name a few.