Contrast Allergy Powerplan
FYI there is a powerplan for premedication for contrast allergies. (Memo to be uploaded.)
Comprehensive Drug Screening
I've been told that some docs are ordering this test frequently. Please consider ordering the routine urine DOA instead if needed. The comprehensive screen is an added cost, does not come back during the ED visit, and as a result does not change management. Personally I only order it if there is a legal reason for doing so.
Hemodynamics Consults
FYI from Dr Nikoo:
Dear Colleagues,
As some of you may be aware, I did provide a pilot service for advanced HD assessment for a couple of weeks last year. Feedback provided to me was very positive and a request was made to provide this service more consistently if possible.
Now with the introduction of ICU C Service, I am able to provide this service on a daily basis during my ICU C weeks as well as during some of my "Off service weeks".
A consult of Advanced HD assessment combines full echocardiography assessment (as per ASE guidelines) with pulmonary and vascular ultrasound protocols (VexUs and DVT studies) to answer the clinical question asked.
For example, if there is a case of undifferentiated hypoxemia, Advanced HD assessment could help to tease apart potential underlying cardiac causes like valvular heart disease, heart failure (systolic or diastolic), pulmonary HTN (cardiac or non-cardiac), intracardiac shunts, and pericardial diseases, from other causes of hypoxemia (primary pulmonary disease, neuromuscular weakness, etc.).
This service does not intend to replace needs for formal 2D echo. On the other hand, it focuses more toward answering clinical questions asked, and not only providing a detailed read of cardiac structures like in a formal 2DEcho report.
Combining it with lung and vascular US, it could be a powerful and efficient way of narrowing down differential diagnosis and in some cases, providing recommendations regarding the next diagnostic and therapeutic decisions.
In ER settings, it can help with scenarios like undifferentiated shocks, diagnosis of septic cardiomyopathies, to determine if a patient's chronic cardiac condition is responsible for their symptoms and presentation, and in some cases, making diagnosis of DVT and potential PEs.
By providing this service, my main goal is to assist with timely diagnosis and management of patients with ambiguous or difficult-to-assess hemodynamics on their surface physical exams. The hope is that it will in turn lead to shorter hospital stays and increasing patient and family satisfaction among other patient care metrics.
Fentanyl / Medetomidine
FYI — street fentanyl is now often contaminated with medetomidine, which may trigger profound bradycardia and prolonged sedation among other symptoms. Narcan for overdose improves the respiratory rate from fentanyl, but patients may remain sedated due to the medetomidine.
Withdrawal symptoms include significant tachycardia, HTN, and profound vomiting. Treatment of withdrawal: high doses of sublingual clonidine combined with narcotic replacement (IV). Zofran seems to be ineffective — consider haldol or olanzapine for vomiting and benzos for agitation. Look out for QT prolongation.
Upcoming Education
Friday February 27, 11:30am–12:30pm — Toronto Opioid Overdose Action Network (TO2AN) ACS Community of Practice:
ACS considerations for medetomidine
Drs. Brendan Hart and Nicole Desai, Temple University Hospital, Philadelphia
Email Jen Ko for meeting invite.
Wednesday March 4, 10:00–11:30am — Drug Checking and TO2AN:
Frontline perspectives and responses to medetomidine in the fentanyl supply
Brad Meck, Prevention Point, Philadelphia and Dr. Serge-Emile Simpson, Jefferson-Einstein Hospital, Philadelphia
Register here
More info as it becomes available:
ACA Flow at Midtown
FYI the clerks will be monitoring the flow in ACA. As always, do not sign up for more than 2 patients at a time. Also, please don't sign up for patients if you don't plan on seeing them within 10 minutes or so — it impedes flow. The clerks will un-assign you if you sign up for patients and don't see them in a timely fashion (within 10 minutes). Please avoid picking up ACA patients until you're ready to see them.
Dr Manian's Presentation
Slides are attached. (Slides to be uploaded.)
OT / PT at Midtown
Just a quick reminder that we have full-time Physiotherapy and Occupational Therapy coverage during the day, seven days a week.
If you have an overnight admission that may be a "soft" admission and could potentially go home with therapy input, you can always leave an order for PT/OT to assess and treat — with a note in the order that the patient is a potential discharge. They will prioritize these patients in the AM.
Please feel free to take advantage of this coverage when you think therapy input may help avoid an unnecessary admission.
Oral Surgery
There are several oral surgeons in the community that do not have hospital privileges. We've posted a list at Midtown — attaching it here in case anyone is stuck with a case and we have no coverage.
📄 List of Oral & Maxillofacial Surgeons (KW 2026)
Admissions
Overnight — don't forget to write the holding orders for your patient.
Ortho — Achilles Tendon
For Achilles tendon ruptures, please ensure the patients are immobilized in plantar flexion. The ortho group prefers a splint over a script for a wedge, as some patients do not fill the prescription and do not end up appropriately splinted.
Dispensing Medications
For the occasional situation where a patient really needs medication and cannot afford it:
- Use the ED retail pharmacy to fill the script
- Get Gavin or Judy's permission to charge it to ED
- Patient gets their medication at no cost to them
GSW Reporting Guideline
Just including the hospital policy on reporting to police in case anyone wants a refresher.
NP Vacation — Micro Callbacks
FYI the 0900 doc will need to do micro callbacks starting tomorrow, as there is no NP on duty this week due to a couple of vacations.
It's the same process as the radiology callbacks, but switch the menu to lab results.