ED Rounds – Competency By Design

ED Rounds – September 2018

Dr. Jo-Ann Talbot

 


 


Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies.

Competence by Design (CBD) is the Royal College’s version of CBME. It is a transformational change initiative designed to enhance CBME in residency training and specialty practice in Canada.

The first stage in residency is known as Transition to discipline. It emphasizes the orientation and assessment of new trainees. Foundations of discipline, the second stage, covers broad-based competencies that every trainee must acquire before moving on to the third stage, which is known as Core of discipline. The third stage covers more advanced, discipline-specific competencies. As part of CBD, the Royal College is also exploring moving the Royal College exam to the end of this stage.5 The fourth and final stage of residency education is known as Transition to practice. During this stage the trainee demonstrates readiness for autonomous practice

RCPSC 2016


 

Dr. Talbot’s Presentation

Competence by Design – Are You Ready?

Competency by Design Are You Ready? Dr. Jo-Ann Talbot – 2018

Click link above to view


Further Reading

CBD Cheatsheet

Download (PDF, 128KB)


Emergency Medicine – Entrustable Professional Activities 

Download (PDF, 71KB)


 

Entrustable Professional Activity Guide: Emergency Medicine

EPA-guide-emergency-medicine RCPSC 2018

Click link above to view


 

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Fall ECCU Conference Workshop – 28th September

We still have availability for delegates wanting to attend the Fall ECCU Conference Workshop on the 28th September at the beautiful Algonquin Resort in St. Andrews, New Brunswick.


  • International PoCUS experts from South Africa, USA and Canada
  • PoCUS hot topics and updates
    • PoCUS in Rural Health
    • Why aren’t you doing THIS with PoCUS?
    • How to be a leader in PoCUS
  • Top PoCUS research
  • IP2 Diagnostic stream lectures
  • Hands-on scanning workshops


  • Choose your own workshop
    • Pediatrics, Cardiac, Lung, IVC, DVT, Gallbladder, DVT, Aorta, FAST, Obstetric
  • CPoCUS approved
  • CCFP CME approved
  • Bring the family and stay for the weekend
    • Top golf resort, whale watching, explore the islands

 

Click Here for More information and Booking

 


 

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RCP – PoCUS Triage Shoulder Dislocation

Resident Clinical Pearl – POCUS in Shoulder Dislocation

Luke Richardson, PGY 3 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 24 year old male rugby player presents to the emergency department with left sided shoulder pain.  He reports being hit in the middle of the game followed by a pop to his shoulder.  Since that time he has had ongoing pain and limited movement.  His vitals are normal but he appears uncomfortable.  He shows no signs of neurological or vascular injury.  History and physical exam is otherwise benign.

 

Dislocated shoulder is suspected, but is there a way to quickly diagnose prior to x-ray and therefore expedite administration of pre-procedural analgesia and preparation of procedural team and room?

 

POCUS: Shoulder Background

The shoulder is a ball-in-socket joint with a large range of motion and has a high risk of dislocation due to its shallow joint depth and limited tendinous support inferiorly.   Most commonly, the shoulder will dislocate with the humeral head anterior to the glenohumeral rim due to an superiorly placed force upon the humeral head.  Posterior dislocations are less common and commonly due to higher mechanism of injuries such as seizure or electrical shock.

 

Diagnosis of shoulder dislocation is commonly made by x-ray but this method has its downsides including time to diagnosis and increased radiation exposure.  An important consideration is the use of POCUS during shoulder reduction.  This technique allows for real time confirmation and potentially avoids the need for repeat sedation if failed reduction discovered by a trip to the x-ray department.  A recent prospective observational study of 73 patients in the emergency department revealed an accuracy of 100% sensitivity and specificity for shoulder dislocation and relocation (reference 1).   Finally, considering there is increased risk of neuro-vascular complications with time to relocation; a decrease in duration to diagnosis could potentially improve patient care.

 

 

POCUS: Shoulder Technique

Get patient to sit up to allow availability to the posterior portion of the patient shoulder.

Support the patients elbow while positioning the shoulder in adduction and internal rotation.

Using the curvilinear probe, landmark just inferior to the scapular spine and follow it laterally until you find the glenoid (G) and humeral head (HH) (Shol1).

Shol 1

You should find the humeral head (HH) as a circular structure lateral to the glenoid fossa (G) if in joint. Note the Glenoid labrum (L).

To confirm, you can internally and externally rotate the arm and visualize the humeral head freely moving within the glenoid (Shol2/Shol4) (reference 2). Note the overlying deltoid (most superficial) and the infraspinatus tendon that becomes more apparent during internal rotation.

Shol2

Shol4

If the shoulder is anteriorly dislocated you will see the humeral head displaced inferiorly (Shol5/Shol6) (reference 2,3)

If the shoulder is posteriorly dislocated you will see the humeral head more superficial than expected (Shol5) (reference 2,3)

 

Shol5

Shol6

 

Conclusion:

POCUS is an easily available and non-invasive tool in the emergency department.  It can be used in cases such as this to improve patient flow, decrease time to diagnosis, and confirm reduction.

 

Reference:

  1. Abbasi, S., Molaie, H., Hafezimoghadam, P., Amin Zare, M., Abbasi, M., Rezai, M., Farsi, D. Diagnostic accuracy of ultrasonogrpahic examination in the management of shoulder dislocation in the emergency department. Annals of Emergency Medicine. Volume 62:2. August, 2013, pg. 170-175.
  2. Tin, J., Simmons, C., Ditkowsky, J., Alerhand, S., Singh,M., US Probe: ultrasound for shoulder dislocation and reduction. EMDocs http://www.emdocs.net/us-probe-ultrasound-for-shoulder-dislocation-and-reduction/ January 18, 2018.
  3. Rich, C., Wu, S., Ye, T., Liebmann, O. Pocus: shoulder dislocation. Brown Emergency Medicine. http://brownemblog.com/blog-1/2016/11/30/pocus-shoulder-dislocation. November 30th, 2016.
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Fall ECCU Fest 2018 – PoCUS Conference Workshop and ECCU2 Course

September 27th – 28th 2018

The Algonquin Resort in St. Andrews by-the-Sea, New Brunswick, Canada

Atlantic Canada’s top PoCUS event

UPDATE

 

Now open for applications/booking – Only a few places still available

 

The ECCU Conference is being held in conjunction with the ECCU2 Advanced Applications Course in order to provide those attending the course and other delegates with an opportunity to access an update in the hottest clinical PoCUS topics. The focus will be on presenting the best emerging evidence, strategies for developing a local PoCUS program and developing competencies.

Includes:

  • International PoCUS experts
  • Clinical PoCUS hot topics and updates
  • Top PoCUS research
  • IP2 Diagnostic stream lectures

Conference delegates will have access to the Diagnostic stream lectures of the ECCU2 Advanced Applications Course, which will include an Gallbladder, Renal, DVT and Ocular

Invited Faculty – 2018

Dr. Hein Lamprecht – South Africa – (ECCU Fest 2018) – PoCUS Educator Extraordinaire – IFEM – WinFocus

Dr. Peter Croft – USA – (ECCU Fest 2018) – New England PoCUS disrupter –past MGH PoCUS Fellow

Dr. David Mackenzie – USA – (ECCU Fest 2018) – Canadian New Englander, PoCUS innovator – past MGH PoCUS Fellow

 

Also our top Dalhousie Faculty of PoCUS Experts

 


 

Open for applications and booking: More Information Here

 

There are only 2 places left on the 2 day Advanced Apps ECCU 2 course, however we still have good availability for the 1 day conference workshop

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SJRHEM @Calgary CAEP 2018

Congratulations to all our researchers presenting at CAEP Calgary 2018. This year we have had a total of 13 research abstracts accepted for either oral or poster presentation, 2 invited presentations and 1 track chair. We are also involved in a number of administrative, academic and research committee meetings across the conference.


Last years presentations (CAEP Whistler 2017) can be viewed here


Q-Code Link to this page

 

 

 

 

 

 


Download (PDF, 144KB)

 


 

Training first-responders to administer anaphylaxis publicly available epinephrine – a randomized study – Presenter – Robert Dunfield

Download (PDF, 1.08MB)

 


 

Emergency Critical Care Ultrasound (ECCU) paramedical course: A novel curriculum for training paramedics in ultrasound – Presenter – David Lewis

Download (PDF, 702KB)

 


 

Critical Dynamics Study of Burnout in Emergency Department Health Professionals in New Brunswick: Revisiting  5 years later – Presenter – Felix Zhou

Download (PDF, 585KB)

 


 

Do electrocardiogram rhythm findings predict cardiac activity during cardiac arrest? A SHoC series study. – Presenter – Paul Atkinson

Oral Research Presentation – Track 5 – Sunday May 27th 15:50hrs

 


 

Introduction of extracorporeal cardiopulmonary resuscitation (ECPR) into emergency care: a feasibility study – Presenter – Derek Rollo

Download (PDF, 673KB)

 


 

Combatting sedentary lifestyles; can exercise prescriptions in the Emergency Department lead to a behavioural change in patients? – Presenter – David Lewis

Download (PDF, 803KB)

 


 

Development of a predictive model for hospital admissions by utilizing frequencies of specific CEDIS presenting complaints – Presenter – David Lewis

Oral Research Presentation – Track 4 – Wednesday May 30th 12:45hrs

Admission Prediction


 

Changes in situational awareness of emergency teams in simulated trauma cases using an RSI checklist – Presenter – James French

Download (PDF, 937KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of surgical cricothyrotomy with 3-D printed surgical airway trainers – Presenter – James French

Download (PDF, 3.9MB)

 


 

How aware is safe enough? Situational Awareness is higher in safer teams doing simulated emergency airway cases – Presenter – James French

Download (PDF, 760KB)

 


 

Interprofessional airway microskill checklists facilitate the deliberate practice of direct intubation with a bougie and airway manikins – James French

Download (PDF, 3.83MB)

 


 

Lung ultrasound – Presenter – Paul Atkinson

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

 


Design is Devine – Presenter – James French

Invited Oral Presentation – Track 1 – Sunday May 27 10:15hrs

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ED Rounds – Oncologic Emergencies and Emerging Treatments

ED Rounds – May 2018

Dr. Paul Frankish

 

Take Home Points

  1. In patients on Immunotherapy for cancer beware of diarrhea or dyspnea, as it may represent an autoimmune side effect.

  2. LMWH is the treatment of choice for the duration of Malignancy associated PE.

  3. SVC obstruction is “sneaky” and new dyspnea is far more common than facial swelling.

 

Immunotherapy

 

 

 

 


Febrile Neutropenia

A single oral temperature >38.3 deg C

or

A sustained oral temperature >38 deg C

with

An absolute neutrophil count (ANC) less than 500 cells per microliter (0.5 x 109/L)

 

*Far and away one of the most common oncologic presentations to the ED

*70% hematologic and 30% solid organ malignancies

*Treatment Timelines (as per IDSA):

1.STAT CBC within 10 minutes

2.Broad empiric antibiotics within 60 minutes

 

History

1.Diagnosis

2.Date and type of last Chemo

3.Use of G-CSF

4.Use of antimicrobials

5.History of prior infection

6.PMH/surgical history

7.Medications/Allergies

 

Exam

1.Mental Status

2.Volume Status

3.Oral Mucosa

4.Skin/Catheter Sites

5.Respiratory

6.Cardiovascular

7.Abdomen

 

Treatment

*Imipenem 500 mg IV Q6H or

*Pip/Tazo 3.375 gram IV Q6H or

*Cipro 400 mg IV and Vanco 1 gram IV Q12H if penicillin allergic

*Consider adding Vanco to monotherapy if:

1.IV Catheter Infection

2.Gram positive organism not yet identified

3.MRSA Colonization

4.Hypotension/Shock

 


SVC Obstruction

*Subacute SVCO results in milder symptoms like facial swelling, cough, dyspnea, facial redness, dilated superficial veins.

*Acute SVCO is more severe and can result in altered LOC, increased ICP, airway obstruction.

*Test of choice is a contrast enhanced CT chest

 

 

Treatment

1.Elevate HOB

2.Dexamethasone 10 mg IV

3.Symptom control

4.Airway management if indicated

5.Urgent Radiation Oncology Consult

6.If known Small Cell Lung Cancer, then worth a call to Medical Oncology

 

 


 

Pulmonary Embolus

*New dyspnea of unknown etiology in patient with active malignancy is a PE until proven otherwise

*Alternate explanations for new dyspnea are pericardial effusion, SVCO, lung tumor burden, anemia.

*Preferred treatment is LMWH indefinitely

 

Investigation of choice is CTPA

 

ECG may show S1QT3 – But don’t rely on this sign

PoCUS may also be helpful for initial triage of acute dyspneic patient – look for dilated RV and IVC

 

Treatment

*Dalteparin 200 units/kg sc for 1 month

then

*Dalteparin 150 untis/kg sc thereafter

*Main evidence for LMWH over warfarin comes from CLOT trial

*50% reduction in recurrent VTE with LMWH vs. warfarin

*Presumed to be because of poor tolerance of PO meds in patients with cancer nauseated from chemo

*May not be relevant in era of modern anti-emetics and anticoagulants, data pending

 


 

Epidural Spinal Cord Compression

1.Back pain (90% of cases)

2.Motor weakness

3.Sensory impairment

4.Autonomic dysfunction

5.Perianal numbness

6.Conus medullaris syndrome

 

Investigations and Treatment

*Dexamethasone 10-20 mg IV immediately if SCC is suspected

*MRI is preferred (generally T/L spine)

*Radiation Oncology if previously diagnosed malignancy

*Neurosurgery if new diagnosis of malignancy

 


 

 

 


SJRH Oncology Services – On Call Consults

 

 

 


Full Presentation

 

Download (PDF, 43.05MB)

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SJRHEM Journal Club – March 2018

DEM Journal Club Report

 

  1. Host/Presenter/Date:

    Dr. Talbot /Dr. Chandra/ March

  2. Title of paper/citation:

Sergey Motov, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: an RCT. Ann Emerg Med. 2017; 70:177-84.

  1. Research question/PICOD

Question: Does increasing the dose of intravenous Ketorolac improve analgesia in emergency department patients with a variety of pain syndromes?

Population: 240 patients, 80 allocated to each group

Adult patients (18-65) who presented to the emergency department with acute (less than 30 d) moderate to severe (intensity of 5 or greater on a standard 0-10 pain scale) flank, abdominal, musculoskeletal, or headache pain, who would routinely be treated with ketorolac by the attending emergency physician.

(Exclusion criteria: Older than 65 yrs, pregnancy or breastfeeding, active PUD, acute GI hemorrhage, history of renal or hepatic disease, allergy to NSAIDs, unstable vitals systolic BP <90 or > 180 mmHg or HR < 50 or > 150, and patients that had already received analgesic.

Intervention (1): Ketorolac 10 mg IV  (given over 1-2 minutes)

Intervention (2): Ketorolac 15 mg IV (given over 1-2 minutes)

Intervention (3):  Ketorolac 30 mg IV (given over 1-2 minutes)

Patients who still desired pain medications after 30 minutes were offered Morphine 0.1 mg/kg IV as a rescue analgesic.

Outcome:  Primary: Reduction in the numeric pain scale score at 30 minutes from medication administration

Secondary: Rates and percentage of subjects experiencing adverse events or requiring rescue analgesia.

Design: Randomized control trial

  1. Results

Ketorolac dose Pain Score

Initial

Pain Score

30 min

Difference
10 mg 7.73 5.13 2.6
15 mg 7.54 5.05 2.5
30 mg 7.8 4.84 3.0

 

Patients in all dosing regimens had clinically significant improvement in their pain scores after 30 min. The reduction in pain persisted through to 120 minutes.

There was no difference in the rate of rescue morphine use by group over time.

There was no difference in the common adverse effects (dizziness 18% vs 20% vs 15%, nausea 11% vs 14% vs 10%, headache 10% vs 2.5% vs 3.8%, itching 0% vs 1.3% vs 1.3%, or flushing 0% vs 1.3% vs 0%).

Other more serious side effects were not documented (gastrointestinal bleeding, renal impairment, changes in bleeding times). There are other studies that suggest that some of these adverse effects are dose related and therefore lower doses would be expected to reduce these complications.

 

 

  1. Authors conclusions

Ketorolac had similar analgesic efficacy profiles at doses of 10 mg, 15 mg and 30 mg IV for short term treatment of acute moderate to severe pain in the Emergency Department.  The results of the study provide a basis for changes in practice patterns and guidelines in the Emergency Department supporting the use of the 10 mg IV ketorolac dose.

 

  1. Discussion at Journal Club

    1. Strengths
      1. Randomized control blinded design
      2. Excellent data collection for primary outcome (99%)
  • Groups were treated the same
  1. Weakness
    1. Single center
    2. Although randomized, the patients were also only recruited between 8 am and 8 pm Monday to Friday as a convenience sample. This could lead to selection bias.
  • Although the patient, nurse, research coordinator, research fellow and the physicians were blinded to the group allocation, the pharmacist, research manager and the statistician were aware of patient allocation.

 

  1. Bottom line/suggested change to practice/actions

 

Patients presenting to the emergency department with moderate to severe pain receiving a single dose of intravenous Ketorolac had a significant reduction in pain with no difference between the dosing regimens of 10mg, 15 mg and 30 mg IV.

We recommend a change to our renal colic protocol and our ED Assessment order set to administer Ketorolac 10 mg IV instead of 30 mg IV of the treatment of a variety of conditions with moderate to severe pain. Unfortunately, the Ketorolac used in the emergency department comes in a 30 mg/ml vial. It is more efficient to draw up the full dose for each individual patient than be taking 1/3 of a ml out and possibly throwing the remainder out. Recommend asking Emergency Department pharmacist to determine if other solution strengths are available. Ketorolac could be a narcotic sparing analgesic, where in the opinion of the attending physician, appropriate patients can be given ketorolac and then reassessed at 30 minutes and rescue mediation given as required.

 

 

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ED Rounds – Epistaxis

ED Rounds – March 2018

Dr Christopher Chin MD FRCSC

Rhinology, Anterior Skull Base, Head and Neck Oncology

Otolaryngology- Head & Neck Surgery

Saint John Regional Hospital

 

Objectives

  • Cover basic and advanced techniques to obtain hemostasis in the ER
  • Review what options are available if that fails

Agenda

  • Review of anatomy
  • Management algorithm
  • What options are available when traditional packing fails
  • What’s new in epistaxis?
  • Special scenarios

 

Download (PPTX, 11.86MB)

 

Download (PDF, 16.26MB)

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EM Reflections – March 2018

Thanks to Dr. Paul Page for leading the discussions this month

Edited by Dr David Lewis 

 


 

Top tips from this month’s rounds:

Abdominal Aortic Aneurysm – Size matters, but it isn’t everything

CME QUIZ

 

 


Abdominal Aortic Aneurysm – Which patients require urgent consult / transfer ?

AAA is a disease of older age. The prevalence of AAA among men aged 65 to 80 is 4 to 6 times higher than in women of the same age. The Canadian Task Force on Preventative Healthcare have recently (2017) made the following recommendations on screening:

Recommendation 1: We recommend one-time screening with ultrasound for AAA for men aged 65 to 80. (Weak recommendation; moderate quality of evidence)

Recommendation 2: We recommend not screening men older than 80 years of age for AAA. (Weak recommendation; low quality of evidence)

Recommendation 3: We recommend not screening women for AAA. (Strong recommendation; very low quality of evidence)

 

Emergency Physicians are trained to recognize the signs and symptoms of ruptured AAA (hypotension, tachycardia, pulsatile abdominal mass, back pain) and are always on the lookout for those curveball presentations e.g renal colic mimic, syncope, sciatica etc.

With the organization of centralized vascular services predominating in the majority of developed national health systems, patients with ruptured AAAs are now being transferred for specialist care. Recent evidence from the UK suggests that this practice is safe with no observed increased mortality or length of stay. and other studies have shown a benefit, with reduced mortality post service-centralization.

While there maybe benefits of centralization for patients, vascular surgeons and health economies, the initial management of the patient with AAA disease can be increasingly challenging for the Emergency Physician, especially if they are located in a peripheral hospital.

Let us consider a few scenarios:

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with severe back pain and hypotension. Point of Care Ultrasound (PoCUS) confirms the diagnosis of a 7.5cm AAA.

This scenario is relatively straightforward. The patient is judiciously resuscitated (avoiding aggressive fluid infusion), and transferred, after discussion with on-call vascular surgery, as quickly as possible directly to the receiving hospital’s vascular OR.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They are known to have a 3.7cm AAA (last surveillance scan 6 months ago). PoCUS confirms the presence of an AAA measuring approx. 3.7cm. Urinalysis is negative.

This scenario is also relatively straightforward. While the cause of the flank pain has not been determined, the risk of AAA rupture is highly improbable. For men with an AAA of 4.0 cm or smaller, it takes more than 3.5 years to have a risk of rupture greater than 1%. Given the stable vital signs, low pain score and lack of significant change in AAA size, this patient can be safely worked-up initially at the peripheral hospital pending transfer for abdominal CT if diagnosis remains unclear or symptoms change.

 

  • A 70yr old man presents to a peripheral hospital (without CT), 120km from the vascular centre, with moderate flank pain and normal vital signs. They have no past medical history. PoCUS confirms the presence of a new 4.7cm AAA.  

This scenario starts to become more challenging. Is the AAA leaking? Is the AAA rapidly expanding? Has PoCUS accurately measured the AAA size, Is the AAA causing the symptoms or is there another diagnosis? While this AAA is still below the elective repair size (5.5cm), the rate of growth is not know (and this is important), 4.7cm AAAs do occasionally rupture and rapidly expanding AAA’s can cause pain (the phenomena is more common in inflammatory and mycotic aetiologies). In this scenario the safest approach would be to organize transfer for an urgent CT and to arrange for Vascular Surgey consult immediately thereafter.

 

 

Salmonella aortitis may appear after a febrile gastroenteritis. The common location of primary aortitis and aneurysm formation is at the posterior wall of the suprarenal or supraceliac aorta – . 2010; 3(1): 7–15.

 

Aortitis is the all-encompassing term ascribed to inflammation of the aorta. The most common causes of aortitis are the large-vessel vasculitides including GCA and Takayasu arteritis. The majority of cases of aortitis are non-infectious, however an infectious cause must always be considered, as treatment for infectious and non-infectious aortitis is significantly different.

This article provides a detailed summary of the diagnosis and management of Aortitis

 


CME QUIZ

EM Reflections - March 2018 - CME Quiz

EM Reflections – March 2018 – CME Quiz

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CPoCUS Independent Practitioner Certification Workshop

 CPoCUS Independent Practitioner Certification Workshop

Halifax, Nova Scotia

June 22-24, 2018

This intensive workshop will give participants the opportunity to obtain all of the required observed scans PLUS complete the three-part examination series towards CORE Independent Practitioner certification with the Canadian Point of Care Ultrasound Society (formerly the Canadian Emergency Ultrasound Society). This includes the addition of basic lung (hemothorax and pneumothorax) certification. There will be many instructors, ultrasound machines and many models available while you are here.

A CPoCUS approved introductory ultrasound course is strongly recommended prior to taking this workshop but is not required.

Cost for this workshop: 

$4600 + GST (Space is limited so register early)

Eligible for 25 Royal College Section 3 OR 60 CCFP Cert+ credits.

Registration fees are refundable (minus a $300 processing fee) up to one month prior to course dates. After this time, full course payments are non-refundable.

The course will take place at the Best Western Plus in Dartmouth.

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