SJRHEM @Whistler CAEP 2017

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SJRHEM Physicians win SJRH Foundation Dragons Den and Audience Choice Awards

Congratulations to Paul Atkinson, Michael Howlett, Jay Mekwan, Mark Tutschka and Bill O’Reilly for taking the SJRH Foundation Dragons Den top prize of $75,000 for their Cardiac Arrest ECMO project. James French, Tushar Pishe and Ian Watson won the Audience Choice award for their Trauma Simulation project. A great performance by SJRHEM Physicians!

 

 

The Dragons

Scott McCain, Dr. David Elias, Derek Pannell

Click here for video

 

The Teams

Team: Dr. Paul Atkinson, Dr. Michael Howlett, Dr. Mark Tutschka, Dr. Jay Mekwan, and Mr. Bill O’Reilly. Department of Emergency Medicine

Despite modern advances in CPR and resuscitation, the average survival rate for adults suffering a cardiac arrest outside of hospital is 4 out of every 100. Right now, if defibrillation does not work immediately, there is little hope of survival. We in Emergency and Critical Care Medicine want to investigate the use of new technology called ECMO and how it could help with untimely death. ECMO (Extra-corporeal membrane oxygenation) is essentially cardiac bypass in a box – portable and potentially available outside the Heart Centre in places such as the Emergency Department. Using it during CPR (ECPR) keeps a persons vital organs such as their brain supplied with blood and oxygen until we can treat the cause of their cardiac arrest. In some European countries, this technology is now available in specialized ambulances. Although extremely expensive, and with the potential to impact other services, this technology has the potential to allow many more patients to survive cardiac arrest. We wish to see if introducing ECPR is feasible in New Brunswick. The $75,000 would cover the two of the four stages needed to fully implement ECPR.

 

Team: Dr. James French, Dr. Tushar Pishe, Ian Watson. New Brunswick Trauma Program

We offer lots of education to health-care providers already, but we know that a really important element in saving the life of a critically injured patient is providing healthcare professionals with the chance to practice in advance of an emergency – just as pilots do in cockpit simulators. Physicians, nurses and other professionals working in emergency departments see critically injured patients infrequently. When they do, they need to be able to immediately work as a team to save a life, and to ensure rapid, safe transfer to a major trauma centre like the Saint John Regional Hospital. The Mobile Simulation initiative of the New Brunswick Trauma Program brings education by simulation to these smaller centres – bringing the equipment and the expertise to work with local teams, in their local environments, to make sure that the public gets the very best care possible, regardless of where or when a major injury occurs. $75,000 would allow us to purchase an advanced human simulator – essentially, a robotic patient who blinks, moans and breathes just like a real person.”

 

Team: Dr. Sohrab Lutchmedial and Dr. Ansar Hassan. Department of Cardiology

Our project’s goal is to bank a cash of tissues for medical research while introducing two cutting edge medical techniques. The first we call chemical fingerprinting, where we process blood using nanotechnology to reveal each person’s unique biochemical signature. This allows us to know if drugs are working or perform enhanced diagnosis. The second is called pharmacogenomic screening, where specific gene panels let us quickly determine whether a patient is better suited for certain drugs or medical procedures. Our project will leapfrog our medical approaches about 10 years into the future, where treatments are tailored to an individual patient. Not all solutions can be imported to New Brunswick and be as effective as those created and developed at home. Therefore, we will create a unique New Brunswick reference library of medical information to improve how we treat the specific and unique features of our New Brunswick population. This $75,000 will support a full-time BioBank Analyst and cover part of the expenses for the first 500 patients investing in the New Brunswick BioBank Project. We plan to grow that investment, commercialize some of the reagents we have developed and eventually become a major medical solutions exporter.

 

Team: Dr. Neil Manson and Dr. Robert Stevenson. Department of Orthopedics

For our project, we will be doing a study that merges the cardiac rehabilitation program with our pre-operative spine surgery patients who have multiple cardiac risk factors. This is a great project because it is simultaneously caring for patients and validating the research. In the short-term, the patients enrolled in the study are getting superior care, and will gain direct benefits in terms of surgical benefit when it comes time for their operation. In the long-term, were validating a program that could change the way we prepare our patients for spine surgery on a larger scale, and showcasing New Brunswick as a province that does ground-breaking research that addresses issues directly within our health-care system. The $75,000 would support the entire study, including the purchase of equipment, paying staff and independent reviewers. “Our goal with this money, is to take care of our patients right now, but also prove that the program works, so we can develop a long-term, self-sustained program for all of our patients who need it.

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SHoC blog from @CanadiEM

Social media site @CanadiEM recently featured the @CJEMonline @IFEM2 #SHoC Consensus Protocol, featuring authors from @SJRHEM among others.

So why do we need another ultrasound protocol in emergency medicine? RUSHing from the original FAST scan, playing the ACES, FOCUSing on the CAUSE and meeting our FATE, it may seem SHoCking that many of these scanning protocols are not based on disease incidence or data on their impact, but rather on expert opinion. The Sonography in Hypotension (SHoC) protocols were developed by an international group of critical care and emergency physicians, using a Delphi consensus process, based upon the actual incidence of sonographic pathology detected in previously published international prospective studies [Milne; Gaspari]. The protocols are formulated to help the clinician utilize ultrasound to confirm or exclude common causes, and guides them to consider core, supplementary and additional views, depending upon the likely cause specific to the case.

Why would I take the time to scan the aorta of a 22 year old female with hypotension, when looking for pelvic free fluid might be more appropriate? Why would I not look for lung sliding, or B lines in a breathless shocked patient? Consideration of the shock category by addressing the “4 Fs” (fluid, form, function, and filling) will provide a sense of the best initial therapy and should help guide other investigations. Differentiating cardiogenic shock (a poorly contracting, enlarged heart, widespread lung B lines, and an engorged IVC) in an elderly hypotensive breathless patient, from sepsis (a vigorously contracting, normally sized or small heart, focal or no B lines, and an empty IVC) will change the initial resuscitation plan dramatically. Differentiating cardiac tamponade from tension pneumothorax in apparent obstructive shock or cardiac arrest will lead to dramatically differing interventions.

SHoC guides the clinician towards the more likely positive findings found in hypotensive patients and during cardiac arrest, while providing flexibility to tailor other windows to the questions the clinician needs to answer. One side does not fit all. That is hardly SHoCing news. Prospective validation of ultrasound protocols is necessary, and I look forward to future analysis of the effectiveness of these protocols.

References

Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assessment with Sonography for Trauma (FAST): results from an inter- national consensus conference. J Trauma 1999;46:466-72.

Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Journal of the American Society of Echocardiography. 2010 Dec 31;23(12):1225-30.

Hernandez C, Shuler K, Hannan H, Sonyika C, Likourezos A, Marshall J. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation 2008;76:198–206

Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009;26:87–91

Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in Shock in the evaluation of the critically lll. Emerg Med Clin North Am 2010;28:29 – 56

Jensen MB, Sloth E, Larsen KM, Schmidt MB: Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004, 21: 700-707.

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016 Dec 31;109:33-9.

Milne J, Atkinson P, Lewis D, et al. (April 08, 2016) Sonography in Hypotension and Cardiac Arrest (SHoC): Rates of Abnormal Findings in Undifferentiated Hypotension and During Cardiac Arrest as a Basis for Consensus on a Hierarchical Point of Care Ultrasound Protocol. Cureus 8(4): e564. doi:10.7759/cureus.564

Sonography in Hypotension and Cardiac Arrest: The SHoC Consensus Statement

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