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

 

Now open for applications/booking

 

 

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. Darryl Wood – UK/South Africa – (ECCU Fest 2018) – PoCUS bushcraft on the frontline

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

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Great ideas and making things better

I heard Dr. Dylan Blacquiere speaking on the radio while driving home after one of those busy D2 shifts on Friday, and it really cheered me up to hear him describe how we all in Saint John are leading the way in managing acute stroke care. http://www.cbc.ca/player/play/1152508483846
From EMS, through Emergency Medicine, diagnostic and intervention radiology, internal medicine and neurology, Saint John Regional Hospital (probably more appropriately Saint John University Hospital) provides a world class service for stroke patients in New Brunswick.
This got me thinking about many of the other innovations and ideas that we continue to push forward locally, especially relating to emergency medicine, and how important it is not to let ourselves become disillusioned by busy shifts, perceived administrative inertia, perceived injustices, crowding and many of the negatives we face, and will likely continue to face for sometime.
To name but a few, we can be proud of the integrated STEMI program we have from EMS to Cath Lab, the Point of Care Ultrasound program that leads in this nationally and beyond, the new Trauma Team leadership program, the patient wellness initiatives such as the photography competition corridor that make things just a little brighter for patients, the regionally dominant and growing simulation program, the regional and local nursing education programs, the nationally unique and hugely popular 3 year EM residency program, the impact of our faculty on medical education at DMNB, the leading clinical care provided by a certified faculty of emergency physicians, our website, our multidisciplinary M&M and quality programs, many of the research initiatives underway including development of an ECMO/ECPR program with the NB Heart Centre, improving detection of domestic violence, innovations around tackling crowding, preventing staff burnout, better radiology requesting, encouraging exercise prescriptions, and much more.
I was particularly impressed how Dylan explained the integrative approach that was required to improve stroke care, and how that was achieved here. There are many other areas that we can also improve, innovate and lead in. Every day we see ways to make things better.
I hope that at this point in our department’s journey, we can continue to make the changes that matter, for patients, our departmental staff, physicians, nurses and support staff alike.
I encourage all of us to think of one area we can improve, to plan for change and for us all to support each other to achieve those improvements. Some of our residents are embarking on very interesting projects, such as designing early pregnancy clinic frameworks, models to improve performance under stress, and simulating EMS ECPR algorithms – all new innovations, not just chart reviews of what we are already doing. I encourage us all to support them, and others with these projects, and to begin to create innovation priorities for the department.
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New – Dal SJRHEM PoCUS Fellowship/Elective

The Dalhousie University (DU) Emergency Point of Care Ultrasound Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1 month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department

 

There are four primary components to the mini-fellowship and fellowship programs:

 

  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.

 

For more information click here

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RCP – Suprapubic Aspiration PoCUS

Suprapubic aspiration – when the catheter doesn’t cut it.

Resident Clinical Pearl (RCP) – Guest Resident Edition

Sean Davis MD, PGY2 Family Medicine

Dalhousie University, Yarmouth, Nova Scotia

Reviewed and Edited by Dr. David Lewis

 

Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.

 

RCP – The pee or not the pee: so many questions!

 

Indications:2,3

  • Labial adhesions/edema
  • Phimosis
  • Diarrhea
  • Unsuccessful urethral catheterization
  • Urethral/introital surgery
  • Urethral stricture
  • Urethral trauma
  • Urinary retention
  • Urinalysis/culture in children younger than 2 years
  • Chronic urethral/periurethral gland infection

Contraindications: 2,3

  • Genitourinary abnormalities (congenital or acquired)
  • Empty or unidentifiable bladder
  • Bladder tumor
  • Lower abdominal scarring
  • Overlying infection
  • Bleeding disorders
  • Organomegaly

Complications: 2,3

  • Gross hematuria
  • Abdominal wall cellulitis
  • Bowel perforation

Equipment: 2,3

  • Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
  • Adhesive bandaid
  • Povidone-iodine or Chlorhexidine prep
  • 25g to 27g 1” needle
  • 22g or 23g 1.5” needle
  • Sterile 5ml and 10ml syringes

Procedure (ultrasound-guided): 2,3

  • Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
  • Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
    • Landmarking: midline lower abdomen, just above the pubic symphysis
  • Mark the area and sterilize; infiltrate local anesthetic into the marked area
  • Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
  • If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
  • One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.

 

 

From: Performing Medical Procedures – NEJM

 

References

    1. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from https://reference.medscape.com/medline/abstract/22537082 on December 10, 2017
    2. Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from https://emedicine.medscape.com/article/82964-overview#a4 on December 10, 2017
    3. Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMvcm1209888 on December 10, 2017
    4. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
    5. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.

 

Other PEM PoCUS Videos Here

 

 

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RCP – the “Easy IJ”

The “easy IJ”, a quick solution for difficult intravenous access?

Resident Clinical Pearl (RCP) – September 2017

Kavish Chandra, R3 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

The importance of intravenous (IV) access is something seared in the mind of every practicing emergency department physician. Over the years, central intravenous access for difficult IV access has been obviated by the intraosseous drill and line. Furthermore, we just see and do less central IV lines. The likely reasons for this are that running vasopressors in peripheral intravenous (IV) lines is becoming more accepted as well as the increased time associated with placing a fully sterile central line (draping, etc.) as well as the risks of the over-the-wire procedure (infection, deep vein thrombosis, cardiac arrhythmias).

Enter the internal jugular vein catheterization using a peripheral IV catheter1, which is placed under a limited sterile environment. Is the 5 minutes to establish access that “easy” when peripheral access and external jugular catheterization has failed?

The materials required:

  1. US machine with high-frequency linear transducer probe
  2. Chlorhexidine swab
  3. 4.8-cm, 18-gauge single lumen catheter
  4. Two bio-occlusive adherent dressings
  5. Sterile ultrasound jelly
  6. A loop catheter extension
  7. A saline flush

Figure 1. Visual diagram of required materials for the “easy IJ”, adapted from Moayedi et al. (2016).

 

The steps:

  • Place your patient in the Trendelenburg position or instruct them to perform a Valsalva maneuver
  • The needle is inserted into the skin at approximately 45 degrees
  • Ultrasound is used to confirm real-time placement out of plane, followed by in-plane visualization to see the catheter in the vessel lumen
  • See this video for a demonstration: https://www.youtube.com/watch?v=FjSmbUWXznY

 

 

 

What does the evidence say2?

  • When studied in stable emergency department patients when peripheral or external jugular venous access was unsuccessful, the success rate of this procedure was 88% (95% CI 79-94)
  • The mean time to procedure completion was 4.4 minutes (3.8-4.9)
  • In 83 access attempts, there were no cases of pneumothorax, infection or arterial puncture
  • There was a 14% loss of IV patency immediately after insertion
  • Painful? Don’t forget, these lines were placed without local anesthesia; however, the mean pain score was 3.9 out of 10 (3.4-4.5)

Practical considerations:

So will this technique change your practice? A few things to be aware of:

  • In obese patients, the target vessel will be inherently more difficult to visualize, as well as the catheter length in this study may not be long enough to ensure patency. The median BMI in the Moayedi et al. (2016) study was 27
  • Operator skill: the vast majority of lines were placed by clinicians experienced in ultrasound guided line placement. Success and time to placement may be increased as experience decreases
  • Will more definitive access be required? The catheters placed in this study were largely only used for 24 hours. This would certainly be more than sufficient during the treatment of an ED patient, but usage time increases, infection rates will likely increase
  • Will this line achieve the infusion rate you need? See this article on infusion rates of various IV catheters

 

The bottom line: the “easy IJ” is a rapid, effective and safe alternative to establish IV access in stable patients in whom peripheral and external jugular venous attempts have failed.

 

References

(1) Teismann NA, Knight RS, Rehrer M, Shah S, Nagdev A, Stone M. The ultrasound-guided “peripheral IJ”: internal jugular vein catheterization using a standard intravenous catheter. J Emerg Med 2013 Jan;44(1):150-154.

(2) Moayedi S, Witting M, Pirotte M. Safety and Efficacy of the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access. J Emerg Med 2016 Dec;51(6):636-642.

 

 

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PoCUS – Measurements and Quick Reference

Developed by Dr. Heather Flemming as part of her PG PoCUS Elective at SJRHEM.

A useful Point of Care Ultrasound (PoCUS) guide to common normal values, measurements, pathological values and quick reference tips. A pdf version is also provided in this post which can be downloaded, printed and attached to your ultrasound machine for easy access.

 

 

 


 


Download (PDF, 1017KB)

 

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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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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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Resident Clinical Pearl – A New Focus for PoCUS

A New Focus for PoCUS

Elective Resident Clinical Pearl – December 2016

Heather Flemming, PGY4 Emergency Medicine, Dalhousie University, Saint John, New Brunswick

Reviewed by Dr. David Lewis

 

A 70 year old female presents to the emergency department with central abdominal pain and one episode of vomiting.  Her vital signs are stable, but she appears uncomfortable.

You bring the ultrasound machine to the bedside to assess her abdominal aorta. Your exam is challenged by the presence of bowel gas, causing scattering of your ultrasound beam, but is ultimately negative for an abdominal aortic aneurysm. You note that the patient has a midline scar, which she states is from a remote hysterectomy. With increased suspicion for bowel obstruction, you move the curvilinear probe across the abdomen and generate the following images: (Video Below)

The images demonstrate dilated loops of bowel and alternating peristalsis (a ‘to and fro movements’ of bowel contents). This confirms your suspicion for a small bowel obstruction (SBO).

 

Discussion:

Bedside ultrasound is a useful tool in evaluating any patient with abdominal pain, and has shown to be more sensitive and more specific than abdominal xray in diagnosing SBO1. Additional advantages of ultrasound include lack of radiation to the patient, bedside availability and potential to improve ED flow2. Treatments, such as nasogastric tube insertion, and early consultation to general surgery can be expedited by rapid identification. In individuals with recurrent sub-acute SBO, PoCUS may become the investigation of choice, reducing radiation exposure for this group of patients.

 

Pearls for performing a bedside ultrasound for SBO:

Multiple regions of the abdomen should be assessed, including the epigastrium, bilateral colic gutters, and suprapubic regions2. (Image 2).

Image 2 (overlapping survey of all quadrants)

 

Typical SBO ultrasound finding include:

  • ≥3 bowel loops dilated >25mm (Measurements taken at 90° to bowel wall)
  • Transition point – dilated peristalsing small bowel visualized adjacent to non-peristalsing collapsed bowel
  • Increased intraluminal fluid
  • Abnormal peristalsis: Hyperdynamic, alternating or absent peristalsis
  • Abdominal free fluid may also be present

 

Credit: ACEP.org

 

References

  1. Jang, Timothy B. Schindler, Danielle. Kaji, Amy H. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011 28:676-678.
  2. Chao, Gharahbaghian. Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? https://www.acep.org/content.aspx?id=100218
  1. http://www.emdocs.net/ultrasound-small-bowel-obstruction/
  1. A video on Ultrasound in Small Bowel Obstruction by the Academy of Emergency Ultrasound can be found here: https://vimeo.com/69551555
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SJRHEM congratulates it’s two newest CEUS certified PoCUS practitioners

Dr Jacqueline Mackay and Dr Kyle McGivery have both completed their CEUS Core IP Certification.

Both recently assisted with the ECCU IP school here in Saint John. The ECCU IP school is now in it’s 3rd year and has given many physicians an opportunity to receive expert supervision in completing the required portfolio. Next year the ECCU IP school will be on April 29th 2017.

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NB Emergency Medicine Research Day 2016

NB EM Research Rounds

5DN Amphitheatre, Saint John Regional Hospital

November 8th 2016

Research plays an important role in advancing everyday clinical practice. Questions such as what drug to order; do guideline improve outcomes; and how can we evaluate system processes that impact patient care. Over the past year, our Emergency Medicine Research Program has undertaken projects that attempt to answer such questions that impact our department. Today, you will hear about some of these projects and publications.

Today’s session provides medical learners the opportunity to present and receive feedback in a friendly format. We will present a prize to acknowledge the best research presentation. The other goal is to encourage formation of a collaborative research network in emergency departments throughout the province of New Brunswick.

Dr. Paul Atkinson MB MA FCEM CFEU Professor, Department of Emergency Medicine Dalhousie University
Horizon Health Network
Saint John Regional Hospital
Saint John, New Brunswick

The program including all the abstracts can be viewed / downloaded below:

Download (PDF, 304KB)

 

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