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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SJRHEM at Interprofessional Health Research Day 2017

iHR day is a collaboration between Horizon Health – Saint John Zone, the University of New Brunswick – Saint John Campus, the New Brunswick Community College – Saint John Campus and Dalhousie Medicine New Brunswick.

The day featured oral and poster presentations by health researchers from these four institutions, an outstanding keynote speaker, and a great opportunity to discuss health research with your colleagues. More information here


SJRHEM Research had 8 research abstract accepted to this event:

 

 

Initial validation of the core components in the SHoC-Hypotension Protocol. What rates of ultrasound findings are reported in emergency department patients with undifferentiated hypotension? Results from the first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial.

Combination of easily measurable real time variables to predict ED crowding

ULTRASIM: ULtrasound in TRAuma SIMulation. Does the use of ultrasound improve diagnosis during simulated trauma scenarios?

Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The First Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial.

Does point of care ultrasound improve resuscitation markers in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 1) Study; an international randomized controlled trial.

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

Determining ED staff documentation practice, awareness, and knowledge of intimate partner violence questioning and documentation tools

To choose or not to choose: evaluating the effect of a Choosing Wisely knowledge translation initiative in rural and urban EM physicians

 

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Interprofessional Health Research Day 2017 – Robin Clouston

Combination of easily measurable real time variables to predict ED crowding

 

Almost every domain of quality is reduced in crowded emergency departments (ED), with significant challenges around the definition, measurement and interventions for ED crowding. The most widely known tool to measure crowding is NEDOCS; this is a validated score. In Saint John, there is a local tool based on NEDOCS, known locally as the ED Saturation Calculator. We wished to determine if a combination of 3 easily measurable variables could perform as well as these standard tools (NEDOCS score and a NEDOCS-derived LOCAL tool) in predicting ED crowding in the Saint John Regional Hospital, a tertiary hospital with 57,000 visits per year.

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Interprofessional Health Research Day 2017 – Mandy Peach

Does point of care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? The First Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED1) Study; an international randomized controlled trial.

Point of care ultrasonography (PoCUS) is now an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown to be helpful in ruling out certain shock etiologies, and improving diagnostic certainty, however evidence on its benefit in the management of hypotensive patients is limited.

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Interprofessional Health Research Day 2017 – Luke Taylor

Does point of care ultrasound improve resuscitation markers in emergency department patients with undifferentiated hypotension? The first Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHOC-ED 1) Study; an international randomized controlled trial.

Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a paucity of evidence for any outcome benefit. We undertook an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We have reported diagnostic impact and mortality elsewhere.

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Interprofessional Health Research Day 2017 – Fiona Milne and Kalen Leech-Porter

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

Patients with chronic diseases such as COPD, coronary artery disease, depression and anxiety are known to benefit from exercise. They also frequently visit the emergency department (ED). Despite the large therapeutic window and evidence supporting its role in disease management, there are few studies examining prescribing exercise in the ED. We asked: Is exercise prescription in the ED feasible and effective?

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Interprofessional Health Research Day 2017 – Janeske Vonkeman

Determining ED staff documentation practice, awareness, and knowledge of intimate partner violence questioning and documentation tools

Domestic violence (DV) rates in smaller cities have been reported to be some of the highest in Canada. It is highly likely that emergency department staff will come across victims of intimate partner violence (IPV) in their daily practice. The purpose of this study is to better understand current practices for detecting IPV, staff awareness and knowledge surrounding IPV, available screening tools, and barriers to questioning about IPV. in the emergency department (ED). Finally, we will determine whether ED staff would be willing to implement a brief 3-question IPV screening tool, the Partner Violence Screen (PVS) in their daily practice.

 

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Interprofessional Health Research Day 2017 – Kavish Chandra

To choose or not to choose: evaluating the effect of a Choosing Wisely knowledge translation initiative in rural and urban EM physicians

Choosing Wisely is an innovative approach to address physician and patient attitudes towards low value medical tests; however, a knowledge translation (KT) gap exists.

We aimed to quantify the baseline familiarity of emergency medicine (EM) physicians with the Choosing Wisely Canada (CWC) EM recommendations. We then assessed whether a structured KT initiative affected knowledge and awareness.

 

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IFEM Consensus Statement – SHoC – PoCUS use in Undifferentiated Hypotension and Cardiac Arrest

International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest.

Paul Atkinson, MB, MA*†; Justin Bowra, MB‡§; James Milne, MD¶; David Lewis, MB*†; Mike Lambert, MD**; Bob Jarman, MB, MSc†††‡‡; Vicki E. Noble, MD§§¶¶; Hein Lamprecht, MB***; Tim Harris, BM†††‡‡‡; Jim Connolly, MB†† on behalf of the International Federation of Emergency Medicine Sonography in Hypotension and Cardiac Arrest working group: Romolo Gaspari, MD, PhD; Ross Kessler, MD; Christopher Raio, MD; Paul Sierzenski, MD; Beatrice Hoffmann, MD; Chau Pham, MD; Michael Woo, MD; Paul Olszynski, MD; Ryan Henneberry, MD; Oron Frenkel, MD; Jordan Chenkin, MD; Greg Hall, MD; Louise Rang, MD; Maxime Valois, MD; Chuck Wurster, MD; Mark Tutschka, MD; Rob Arntfield, MD; Jason Fischer, MD; Mark Tessaro, MD; J. Scott Bomann, DO; Adrian Goudie, MB; Gaby Blecher, MB; Andrée Salter, MB; Michael Rose, MB; Adam Bystrzycki, MB; Shailesh Dass, MB; Owen Doran, MB; Ruth Large, MB; Hugo Poncia, MB; Alistair Murray, MB; Jan Sadewasser, MD

Canadian Journal of Emergency Medicine (CJEM) 

The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest.

The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol.

Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend CoreSupplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the “4 F” approach: fluidformfunctionfilling. An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.

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In case you missed it, 2016…

Don’t touch – from colon to screen.

Am J Infect Control. 2016 Mar 1;44(3):358-60.

Gerba et al. compared the occurrence of opportunistic bacterial pathogens on the surfaces of computer touch screens used in hospitals and grocery stores. Clostridium difficile and vancomycin-resistant Enterococcus were isolated on touch screens in hospitals and in MRSA in grocery stores. Enteric bacteria were more common on grocery store touch screens than on hospital computer touch screens. So don’t snack while you shop over the holidays. The keywords say everything…

Clostridium difficile; Coliforms; Computer touch screen; Methicillin-resistant Staphylococcus aureus; Vancomycin-resistant enterococcus

 

It hurts, it’s tender, but it’s not appy!

J Pediatr Gastroenterol Nutr. 2016 Mar;62(3):399-402.

Siawash at al. remind us about anterior cutaneous nerve entrapment syndrome (ACNES), a frequently overlooked condition causing abdominal pain. They carried out a cross-sectional cohort in a population 10 to 18 years of age consulting a pediatric outpatient department with new-onset AP during a 2 years’ time period. History, physical examination, diagnosis, and success of treatment were obtained in patients who were diagnosed as having ACNES. Twelve of 95 adolescents were found to be experiencing ACNES. Carnett sign was positive at the lateral border of the rectus abdominus muscle in all 12. Altered skin sensation was present in 11 of 12 patients with ACNES. Six weeks after treatment (1-3 injections, n = 5; neurectomy, n = 7), pain was absent in 11 patients.

BUT WHAT IS CARNETT’S SIGN? Have them tense the abdominal wall (by pulling their legs or head off the bed) and if the pain gets worse or stays the same- it is not intra abdominal.

 

Is there a good REASON to stop CPR?

Gaspari R, Weekes A, Adhikari S, Noble VE, Nomura JT, Theodoro D, Woo M, Atkinson P, Blehar D, Brown SM, Caffery T, et al. Resuscitation. 2016;109:33-9.

Some clinicians use a lack of cardiac activity on ultrasound as a reason to terminate resuscitation efforts. We at the Saint John Regional Hospital Emergency Department (ED) participated in this prospective observational study at 20 EDs across North America. We assessed the association between cardiac activity on point of care ultrasound (PoCUS) during advanced cardiac life support (ACLS) and survival to hospital discharge in patients with pulseless electrical activity (PEA) or asystole. Of 793 patients with out-of-hospital cardiac arrest enrolled, 26% had ROSC, 14% survived to hospital admission, and 1.6% survived to discharge. Among 530 patients without cardiac activity on PoCUS, only 0.6% survived to discharge (compared with 3.8% of those with cardiac activity).

There is always an argument that the association between dismal survival and lack of cardiac activity is just a self-fulfilling prophecy, if absence of cardiac activity led to early termination of salvageable resuscitations. In this study, resuscitation had to continue until at least 2 scans were completed. So, unless there are very special circumstances, such as significant hypothermia, or post defibrillation, it seems safe to terminate resuscitation for most patients with asystole on ECG and without cardiac activity on ultrasound.

 

 

SIRS, I’m not sure what you mean? The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

JAMA. 2016;315(8):801-810.

Singer et al. lay out the new definitions for sepsis and septic shock. SIRS is out. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Quantify as a SOFA score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L  in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In emergency department, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following: quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. These updated definitions and clinical criteria should replace previous definitions, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

 

NSAIDs and Lasix – best of friends.

Eur J Intern Med. 2015 Nov;26(9):685-90.

Ungprasert and co. look at the association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs). Their systematic review and meta-analysis looked at six studies where the use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib.

 

Dispelling the nice or naughty myth: retrospective observational study of Santa Claus

BMJ 2016; 355

Park et al. report their attempt to determine which factors influence whether Santa Claus will visit children in hospital on Christmas Day. They carried out an observational study in paediatric wards in the UK. They discovered that Santa Claus visited most of the paediatric wards in all four countries: 89% in England, 100% in Northern Ireland, 93% in Scotland, and 92% in Wales. The odds of him not visiting, however, were significantly higher for paediatric wards in areas of higher socioeconomic deprivation in England (odds ratio 1.31 (95% confidence interval 1.04 to 1.71) in England, 1.23 (1.00 to 1.54) in the UK). In contrast, there was no correlation with school absenteeism, conviction rates, or distance to the North Pole. The results of this study dispel the traditional belief that Santa Claus rewards children based on how nice or naughty they have been in the previous year. Santa Claus is less likely to visit children in hospitals in the most deprived areas. Potential solutions include a review of Santa’s contract or employment of local Santas in poorly represented regions. Clearly Santa likes everyone in Northern Ireland too! Merry Christmas and happy holidays!

 

PA Dec 2016

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