CAEP Definition of an Emergency Physician and the Importance of Emergency Medicine Certification

CAEP Definition of an Emergency Physician

An emergency physician is a physician who is engaged in the practice of emergency medicine and demonstrates the specific set of required competencies that define this field of medical practice. The accepted route to demonstration of competence in medicine in Canada is through certification by a recognized certifying body.*

CAEP recognizes that historically many of its members are physicians who have practiced emergency medicine without formal training and certification. Many have been, and continue to be key contributors to developing emergency medicine and staffing emergency departments in Canada. CAEP acknowledges the contributions of these valued physicians and recognizes them as emergency physicians. It is CAEP’s vision going forward that physicians entering emergency practise will demonstrate their competencies by obtaining certification.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency Physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

CAEP Statement on the Importance of Emergency Medicine Certification in Canada

It is CAEP’s vision, that by 2020 all emergency physicians in Canada will be certified in emergency medicine by a recognized certifying body.*

Toward that vision, provincial governments and Faculties of Medicine must urgently allocate resources to increase the numbers of emergency medicine postgraduate positions in recognized training programs so the Colleges are able to address the gap in human resources and training. Furthermore, physicians who have historically practiced emergency medicine without certification must be supported in their efforts to become certified. CAEP is committed to facilitate this process by cataloguing and nationally coordinating practice- and practitioner-friendly educational continuing professional development programs designed to assist non-certified physicians to be successful in their efforts.

* Recognized certifying bodies in Canada are:
The Royal College of Physicians & Surgeons of Canada
The College of Family Physicians of Canada
(Emergency physicians with equivalent non-Canadian training and certification are also recognized in Canada eg The American Board of Emergency Medicine)

We have also published on this topic, highlighting the need for more resident positions in New Brunswick and PEI. Read our paper here.

 

Read more from CAEP here.

 

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EM Reflections – April 2017

Thanks to Dr. Joanna Middleton for her summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:


Syncopal/Pre-Syncopal Episode – Usually benign, but sometimes serious…….

Red flag symptoms of potentially life-threatening causes of syncope are syncope with exercise, chest pain, dyspnea, severe headachepalpitations, back pain, hematemesis / melena before the syncopal episode. Palpitations before loss of consciousness are a significant predictor of a cardiac cause of syncope. Focal neurologic deficits, diplopia, ataxia, or dysarthria after the syncopal episode.

 

2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society


Syncope Risk Scores

San Francisco Syncope Rule

Canadian Syncope Risk Score


ECG in Syncope

CanadiEM – Medical Concept – ECGs in Syncope

Download (PDF, 2.02MB)

 


Subarachnoid hemorrhage can present with syncope…

  • 97% – sudden, severe headache – “worst”
  • 53% – syncope
  • 77% – N/V
  • 35% – meningismus

How To Be A Clinical Rock Star Managing Subarachnoid Hemorrhage

 


 

Abdominal Aorta – Aneurysm vs Dissection

Only 2% of all aortic dissections originate from abdominal aorta. Almost all aortic dissections originate in the thoracic aorta.

The majority of abdominal aortic aneurysms are infrarenal

AAA – A comprehensive review

Download (PDF, 516KB)

 


Management of the Unruptured AAA

  • Symptomatic or asymptomatic
  • How can an unruptured AAA be symptomatic???
    • (rapid expansion of the aortic wall, ischemia from blocking off blood vessels, compression of other structures etc)
  • Symptomatic – admit for repair, regardless aneurysm diameter
  • Asymptomatic
    • <5.5cm – likely outpatient
    • “Very large aneurysm” (>6cm) – likely admit for repair

 

Transfers to and from Major Emergency Departments

  • Emergency transfers from referring sites for diagnostic imaging are potentially high risk
  • Adverse events have been reported in the medical literature for this group of patients
  • A detailed handover between referral and receiving site will reduce risk
  • Patient stability must be assessed prior to transfer, on arrival at receiving site and prior to return to referral site.
  • The results of the diagnostic imaging should be taken into context with the patient’s condition prior to release for return to referral site.

Download (PDF, 293KB)

 


 

Hyponatremia – How low is too low?

 

  • All patients with severe (< 120)
  • Any patient that is symptomatic from the hyponatremia

LIFL – Hyponatremia – Diagnosis and Management

 

For the budding critical care physiologist – Deranged Physiology – Hyponatremia

 

 

 

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EM Reflections – January 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

Top tips from this month’s rounds:


1. Presenting Complaint: Abdominal Pain – Might not be due to Abdominal pathology

Keep in mind other life threatening causes of abd pain not in the abd. ( ie Aortic Dissection, PE, ACS, Pneumonia).

ECG on all pts who present with pain between chin and umbilicus.

 

 


 

2. Presenting Complaint: Back Pain – Careful with diagnosis of MSK Back Pain

Careful review of vital signs (current and recorded – including EMS). Persistent hypotension or even an episode of recorded hypotension should warrant further evaluation to rule out other more serious diagnoses (AAA, Pancreatitis, bowel perf, hemorrhage etc). (see article pdf below). PoCUS for AAA is highly sensitive and specific and should be considered in all patients >60 who present with back pain, syncope, transient hypotension etc. Although this study found that Routine Screening for Asymptomatic Abdominal Aortic Aneurysm in High-risk Patients Is Not Recommended in Emergency Departments That Are Frequently Crowded

 

Midline Abdomen, Transverse PoCUS view of the Abdominal Aorta – Spot the abnormality?

 


 

3. Can you reliably differentiate Cardiac Chest pain from Non Cardiac Chest pain by history alone?

Whilst the history is very important in the assessment of a patient with chest pain, it cannot reliably exclude Cardiac Chest Pain. Neither can examination (chest wall tenderness etc). All patients who present to ED with chest pain should have an ECG.

Link to a good article on Non Cardiac Chest Pain here.

 

 


 

Download (PDF, 179KB)

 


 

Download (PDF, 445KB)

 

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Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

PURPOSE:

To assess and address dehydration and initiate treatment to prevent further clinical decline in children >6m with vomiting +/- diarrhea triaged CTAS 3,4,5


The hydration guidelines will be implemented in Triage level 3, 4 and 5 children who are greater than 6 months old presenting with a history of vomiting and/ or diarrhea with no abdominal pain other than expected cramping.

See the Guideline Here

 

 

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EM Reflections – December 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

Top tips from this month:


Inotropes in Cardiogenic Shock

1)  Time-to-revascularization is one of the primary determinants of survival in patients with cardiogenic shock secondary to ACS so early consultation with cardiology is needed. Vasopressors and inotropes are a bridge to revascularization.

CAEP 2015 guidelines

Which vasopressors and inotropes should be used in the treatment of ED patients with cardiogenic shock?

– Recommendation: Cardiogenic shock patients in the ED should receive norepinephrine as the first- line vasopressor. (Strong)

– Recommendation: Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. (Conditional)


Labs alert

2)  Remember to repeat hemolyzed lab values (especially potassium levels)

what-are-the-causes


Dyspnoea in Pregnancy

3) Asthma in pregnancy – include other pregnancy related causes of SOB (PE, cardiomyopathy, pre-eclampsia etc) in pregnant patients who present with an asthma exacerbation.


SJRH Obstetric Pathway

4)  Pregnant patients – who goes directly to L and D?  Who gets seen in the ED?  See Dr. Sanderson’s suggestions below.

In general, the current triage process for pregnant patients presenting to the ED at > 20 weeks gestation has been working well:

–          Pregnant patients > 20 weeks gestation who have a presenting complaint that may involve a condition relevant to the pregnancy are triaged directly to the Labour and Birth Unit (eg. Abdominal pain, vaginal discharge, vaginal bleeding)

–          Pregnant patients that have a clearly non-pregnancy-related condition, with no apparent risk to the pregnancy, are managed in the ED (eg. Lacerations and minor injuries). Consultation with the Obstetrician on call is available if there are any questions.

–          Pregnant patients with an acute condition with an immediate risk to the maternal health are assessed and managed for that condition in the ED, with urgent consultation to the Obstetrician on call for input regarding any relevant concerns for the pregnancy, including fetal surveillance (eg. Cardiac arrhythmia, acute respiratory compromise, and multiple trauma need to be assessed and managed in the ED as there are not the facilities or the expertise to safely deal with these conditions in the Labour and Birth Unit)

5)  Reminder that Labor and Delivery are able to bring fetal monitor to the ED to assess fetal status.


Posterior Circulation Strokes

arteries_beneath_brain_gray_closer

6)  Review of posterior circulation strokes – I have attached a good review article (BMJ 2014;348:g3175 ).

SUMMARY POINTS

Posterior circulation stroke accounts for 20-25% (range 17-40%) of ischaemic strokes

Posterior circulation transient ischaemic attacks may include brief or minor brainstem symptoms and are more difficult to diagnose than anterior circulation ischaemia

Specialist assessment and administration of intravenous tissue plasminogen activator are delayed in posterior circulation stroke compared with anterior circulation stroke

The risk of recurrent stroke after posterior circulation stroke is at least as high as for anterior circulation stroke, and vertebrobasilar stenosis increases the risk threefold

Acute neurosurgical input may be needed in patients with hydrocephalus or raised intracranial pressure

Basilar occlusion is associated with high mortality or severe disability, especially if blood flow is not restored in the vessel; if symptoms such as acute coma, dysarthria, dysphagia, quadriparesis, pupillary and oculomotor abnormalities are detected, urgently seek the input of a stroke specialist


Ordering CT Angio

vein_of_galen_ax_direct_av_arrow

7)  Reminder to request CTA for patients with persistent neurological deficits suggestive of CVA.


Thanks

Joanna

Download (PDF, 447KB)

Download (PDF, 1.27MB)

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EM Reflections – October 2016

Thanks to Dr Joanna Middleton for this summary

Edited by Dr David Lewis

 


1)  A fracture of the ulna should raise suspicion for a radial head dislocation (i.e. -Monteggia) – these can be subtle.  Proper elbow x-ray films assist in the diagnosis –  look at the radiocapitellar line to r/o radial head dislocation.

http://www.rch.org.au/clinicalguide/guideline_index/fractures/Monteggia_fracturedislocations_Emergency_Department_setting/

figure-1_1372210_monteggia-type-1_ulna-shaft_lat


2)  The posterior interosseous nerve is the most common neuropraxia seen with a Monteggia fracture-dislocation  The PIN is a branch of the radial nerve and is the motor supply to most of the extensor muscles (thumb and wrist extension).

22_thompson_aprch_06_540n


3)  A lactate >4 is a red flag and is associated with higher mortality, particularly if the lactate does not rapidly clear.

http://sinaiem.org/10278-2/

Prognostication: Lactate predicts badness and whether your treatment for badness is working.

capture-1024x346


4)  Crohn’s patients are at risk for intrabdominal abscess, in particular, psoas abscess.  Consider this diagnosis in Crohn’s patients who present with hip pain, particularly if their pain is increased by hip extension

42475ed112f1ca5e40e2cec9e3ffdc7b-1

 

images


5)  EtOH and head injury….low threshold for CT, particularly if there are any focal neurological findings.

iv-fluids-for-alcohol-intoxication


 

6)  EMS records are not always available when we initially see a patient but they often have helpful information.  It is worthwhile to have a look at them, particularly if the history from the patient is vague.

hi-kw-ems

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SJRHEM Photo Contest 2016

We are very excited to announce the 2016 SJRHEM Photo Contest. This photography competition is open to all personel who work in the Saint John Regional Emergency Department in any role including clinical, admin, support, volunteers etc.

The themes of this competition mirror our mission statement and now include a new ‘open’ category:

CARING, RESPECT, INTEGRITY AND FAIRNESS

WHILE WORKING AS A PROGRAM TO ACHIEVE EXCELLENCE

Our aim is to improve the look and feel of our facility, for both staff and patients, by decorating the walls and corridors with high quality, thought inspiring photographic artwork that reflect the themes above.

CARING

Genuine concern for the well-being of others

caring


RESPECT

The dignity of all people

respect


INTEGRITY

Honest with strong moral principles

Dalai_Lama_1430_Luca_Galuzzi_2007crop


FAIRNESS

Making judgments that are free from discrimination

fairness


New OPEN CATEGORY

Landscapes, Architecture, People, Animals etc

2014-03-26 08.46.27

There will be a winner for each category and an overall winner. All will receive a framed print of their winning photo. The overall winner will be awarded the “Winner of the SJRHEM Photo Contest 2016” award.

The closing date for applications is October 10th 2016.

Click Here for More Information (Rules, Entry Forms etc)

Each entry must be accompanied by a separate application form and necessary consent forms.

Each entry must be emailed to :admin@sjrhem.ca  (subject: photo contest) or via online entry below

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EM Reflections – May 2016

Presented by Dr Paul Page

Edited by Dr David Lewis

 

Top Tips this month:


Trauma

Reminder to use the NB Trauma – Transfer Protocols

Lower GI Bleed in the Elderly

Because of the broad differential diagnosis for hematochezia, taking a careful medical and surgical history is mandatory to guide the subsequent evaluation. Based on its favorable safety profile, as well as diagnostic and therapeutic capabilities, colonoscopy is the preferred modality for managing patients with severe hematochezia and suspected colonic hemorrhage. Urgent colonoscopy has been reported to increase the diagnostic yield and treatment of bleeding stigmata, as well as reduce the rebleeding rate. While most cases of colonic bleeding can be diagnosed endoscopically and treated appropriately, physicians should be able to recognize the situations when alternatives such as radionuclide imaging, angiographic, or surgical management are indicated.

Colles Fracture

CAST vs Slab
Some debate as to whether a full cast or backslab splint is required after MUA of displaced Colles fracture.
Link to – A practical guide to the application of backslabs, splints, CAM boots and Darco shoes for your paediatric and adult patients.The videos are designed to show you how to do each backslab when required, indications are listed but those that are not are usually discussed with orthopaedics (protocols may vary at different sites). In addition you can follow the links at the bottom for additional tips and videos.
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EM Reflections – April 2016

Thanks to Dr Joanna Middleton for this summary

Top tips from this month:

1)  The removal of chest tubes for simple pneumothorax was discussed.  Most physicians send the patient home for 24-48 hours, then reassess with an x-ray.  If the lung is inflated, most physicians clamp the tube for a certain period of time +/- check for air leak (placing end of tube in basin of water) then re-xray and pull the tube if the lung is still expanded.  If it is not expanded, some physicians will send the patient home with a recheck in 24-48hrs, other physicians attach to wall suction and consult surgery.

2)  When checking for lung expansion, consider ordering a single view of the chest.  Often times a patient with a PTX will have numerous X-rays and the lateral is not needed in most cases – this saves on radiation exposure.

3)  Ensure the Heimlich valve is attached correctly by looking for the “flow” arrow that is engraved on the side.  The arrow should be pointed away from the body.

4)  Pericarditis may not always present with the classic EKG findings of diffuse ST elevation.  There should always be a low threshold to exclude a STEMI and consult cardiology if there is any symptoms suggestive of ischemia.

5)  We see lots of people with falls/MSK injuries – be sure to ask WHY the patient fell.  Did they simply trip on the coffee table, or did they trip because they have a visual field deficit from a stroke and couldn’t see the coffee table?

6)  Management of severe asymptomatic hypertension in the ED – most physicians in our department do not treat the asymptomatic patient, although some will start a medication if the patient has no family doctor/uncertain follow-up.  Everyone agreed that the rapid lowering of BP is potentially harmful and should not be done.  This is in keeping with the ACEP guidelines.

EMCRIT link on this:  http://emcrit.org/practicalevidence/2013-acep-management-of-asymptomatic-htn/

I have also attached the 2013 ACEP guideline on this topic.

Download (PDF, 426KB)

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New NICE Guidelines for the whole Trauma System!

Not content with producing evidence-based clinical guidelines for trauma management e.g. Head Injury Management, NICE are taking on the whole Trauma System. NICE have recently published new guidelines for fractures, complex fractures, spinal injury assessment, major trauma and major trauma service delivery. Yes, there is now a NICE guideline that covers the organisation and provision of major trauma services in pre-hospital and hospital settings, including ambulance services, emergency departments, major trauma centres and trauma units. 

It aims to reduce deaths and disabilities in people with serious injuries by providing a systematic approach to the delivery of major trauma care.

Banners_and_Alerts_and_MAJOR_TRAUMA_SERVICE_DELIVERY

 

Banners_and_Alerts_and_MAJOR_TRAUMA_SERVICE_DELIVERY

 

The full list of recommendations can be seen here and include:

1.1 Pre‑hospital triage
1.2 Transferring patients with major trauma
1.3 Pre‑alert procedures
1.4 Procedures for receiving patients in trauma units and major trauma centres
1.5 Transfer between emergency departments
1.6 Organisation of hospital major trauma services
1.7 Documentation
1.8 Monitoring and audit
1.9 Information and support for patients, family members and carers
1.10 Training and skills
1.11 Access to major trauma services

 

This well-researched document delivers quality evidence and recommendations and should be considered essential reading for all those involved in organising regional Trauma Services.

 

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Academic Emergency Physician – Knowledge Translation, Dalhousie University, Saint John, NB

Join the team in the Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada. An exciting opportunity to combine a 0.25 FTE role as lead for Knowledge Translation, with 0.75 FTE clinical time, at this teaching hospital and Level 1 trauma centre. See below for job details and explore sjrhem.ca for program details.

 

Download (PDF, 376KB)

Download (PDF, 388KB)

 

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EM Reflections – December 2015

Thanks to Dr Natasha DeSousa for her M&Ms presentation today.

Thanks to those who attended M&Ms. For those of you who missed it, here are the top tips:

1. When burring or curetting a corneal FB from an eye, remember there is always a risk of a scar and too much or too deep anteriorly means a scar in the visual field. Be careful.

Watch this video on corneal FB removal:

2. Transferring unstable patients within a hospital (e.g ED to CT, ED to Cath Lab etc) is associated with risk and requires careful consideration. 

See this article on Medscape (Crit Care. 2015;19(214) ) that discusses the risks involved during intrahospital transfers and proposes a checklist that can be used to ensure preparedness.  See the form proposed below (or here : http://www.ncbi.nlm.nih.gov/pubmed/25947327 )

Checklist_for_Intra-Hospital_Transport_of_Critically_Ill Checklist_for_Intra-Hospital_Transport_of_Critically_Ill 2

3. Personality traits can impact on the clinical interview. When considering a differential diagnosis, ask yourself: “If this were a different patient with the same presenting symptoms and signs, what diagnoses would I be considering?” Some physicians endorse having a list of at least three possibly life-threatening conditions on one’s radar for each presentation. Try it – this is a great way to mitigate the potentially life-threatening impact of fundamental attribution error.

See last month’s report for a full list of clinical decision making biases

4. What is fundamental attribution error?  This is the tendency for people to place an undue emphasis on personality to explain someone else’s behavior in a given situation rather than considering other potential factors.  For instance, “he is wailing out in pain because he has an opiate addiction problem” rather than “he is wailing out in pain because his bowel has just perforated.”

5. Management of Acute pain in the Emergency Department is a priority. See the SJRHEM pain control resource page.

STOP SUFFERING v2015May25

6. The management of spontaneous pneumothorax remains controversial. There are a number of international guidelines e.g British Thoracic SocietyConsider consulting Thoracic surgery when a lung has failed to fully re-inflate after 72 hours of standard treatment.

7. Flexor tendon injuries need to see plastic surgery within 48 hours. Delaying the repair beyond this can result in poorer outcomes. See this article for a further information on flexor tendon injuries in the hand.

TOORTHJ-6-28_F1

Open Orthop J. 2012; 6: 28–35.

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