In an ER episode in 2001, a doctor quizzed a young medical student about the Ottawa Ankle Rules. These rules – used in real life emergency rooms worldwide – were developed by Dr. Ian Stiell at The Ottawa Hospital.
Ten years earlier, after working as an emergency room doctor for a number of years, Dr. Stiell decided to do a Master’s of Epidemiology. He needed to collect a lot of patient data in a very short timeframe. At the time, the emergency staff saw numerous ankle sprains every day, but didn’t pay much attention to them, assuming every one needed an X-ray. Dr. Stiell decided to explore ankle injuries in his master’s thesis.
He was able to study 760 patients in a period of six months between the Civic and General campuses. Because 90 percent of people who twist their ankle don’t have a break but a sprain that normally heals in a couple of days, Dr. Stiell devised guidelines, or decision rules, to help physicians decide if the patient needs an X-ray.
“I got a lot of cases and learned a lot about how to create clinical decision rules. From that data and analysis, I came up with a simplified list of things the doctor can ask, such as ‘Can you walk?’ They check around and feel your ankle in a couple of specific places to see if it hurts. Then they can judge if you need to stick around for an X-ray or can just go home,” he said.
Dr. Stiell published about the ankle rules in several papers, including JAMA, one of the top medical journals in the world. However, he said the decision rules became more widely used after they were mentioned on the TV show ER. They are now part of the medical school curriculum.
“While the Ottawa Ankle Rules are well known around the world, they are actually the seedlings that started the whole program of decision rules we are now studying,” said Dr. Stiell.
The Ottawa Knee Rule, Canadian CT Head Rule for concussions, the Canadian C-Spine Rule for spinal injuries, the Canadian Heart Failure Risk Scale and the Ottawa COPD Scale for patients with COPD are other decision rules that Dr. Stiell has developed to provide objective guidance for emergency room doctors to determine the necessity of imaging and other tests that can be costly, expose the patient to unnecessary radiation, and mean more time spent waiting in the hospital.
“We’re probably one of the premier emergency departments in Canada because of the academic work we do,” said Dr. Guy Hebert, Head of the Emergency Department at The Ottawa Hospital. “We have the biggest ER research program in Canada. Ian is the top emerge researcher in Canada, and has a worldwide reputation.”
Dr. Stiell said there has been a resurgence in the medical community with the Choosing Wisely campaign to educate doctors to be more cautious in ordering tests. An ankle X-ray has relatively low radiation, but CT scans have about 200 times more radiation and the risks are much higher. The Choosing Wisely campaign encourages doctors to be more thoughtful and judicious in the use of CT scans, X-rays, antibiotics, and other procedures and tests that aren’t helping the patients and might harm them, and also raise health-care costs in Canada.
Ottawa Hospital doctors Phil Wells, Jeffrey Perry, and Venkatesh Thiruganasambandamoorthy have also developed decision rules that are gaining widespread use in hospital emergency departments. Decision rules being developed at The Ottawa Hospital are changing how doctors practice medicine around the world.