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  • Dr. Paul Dhillon MB BCh CCFP

When to Say NO in the Emergency Department

Do you kNOw how to say NO?

(Canadian Association of Emergency Physicians & Choosing Wisely Canada)

Have you ever had a patient ask you to do a test or investigation that you don't think they need, or that might end up harming the patient. Are you prepared to answer that question in real life and perhaps in a SOO station?

CAEP, the Canadian Association of Emergency Physicians just released a list of commonly used tests, treatments or procedures to question and to discuss with your patients. So much of your exam is based on counselling so you would be remiss to not know these CAEP recommendations. Remember, you might need to write 'no investigation' on the exam or say no to a patient in a SOO and it shouldn't be awkward or your first time. You need to know when the evidence backs you up!

We have summarized and split up the don’ts into Trauma, Vascular, and Infectious sub-categories to make them easier to remember.

So without further ado, here are some adon’ts for life and the exam!


  • NO CT head in minor head injuries (unless positive validated head injury clinical decision rule).

  • NO ankle and/or foot X-rays in Ottawa ankle rule negative patients.

  • NO lumbosacral spinal imaging with non-traumatic low back pain who have NO red flags.

  • NO neck radiographs with a negative Canadian C-spine.



  1. adults with bronchitis/asthma & children with bronchiolitis.

  2. I&D of uncomplicated abscesses unless extensive cellulitis exists.

  3. uncomplicated sore throats.

  4. adults/children with uncomplicated acute otitis media.


  • NO CT head in adult patients with simple syncope in the absence of high-risk predictors.

  • NO CT pulmonary angiogram/VQ scan in suspected PE without risk stratification/decision rule and if required, D-dimer results.

EXAM TIP: For the exam and in practice it is not only important to know the inclusion criteria but also the EXCLUSION criteria. Applying a rule indiscriminately won’t help you make the correct decision, nor the patient. Remember exclusion criteria for all rules and remember that some rules do not apply to children and infants/neonates.

RESEARCH? Many residents struggle in looking for a resident research project. If you are interested in Emergency Medicine you might think about implementing some of the recommendations from CAEP at your institution. If you do make sure you check out this link to connect with other physicians to see how they are implementing the list!

To learn more about Choosing Wisely Canada and to view the complete lists and additional detail about the recommendations and evidence supporting them, click here.

We would like to thank the CAEP CWC Committee for allowing us to share these recommendations with you.

REGISTRATION OPEN. The Review Course Winter 2017 is open now. See our registration page for details.

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