Volume 02

026 - 050

 Volume 02: #026 - 050 

L. Disproportionate [abdo] Pain

Published 4 December 2022
Show Notes by Heather Lean ACP BSc

Case Synopsis:

82yo male presents with 48 hr with nausea vomiting and diarrhea – thought it was from eating bad eggs
☙ Vital signs normal
☙ Non-specific subjective tenderness all over abdomen – initially treated as food poisoning

☙ Ondansetron IM
☙ NPO 30 min
☙ trial of ORT 

Case Continued:
☙ This patient stated nausea/vomiting subsided but was still complaining of abdominal pain (4/10).
☙ Normally pain decreases or completely resolves with treatment.

Repeat Exam:
☙ Abdominal assessment found pain to be slightly more localized to epigastric region.  Non-peritoneal
☙ Might consider ASA or PPI (pantoprazole) & discharge – but NOT the best approach! 

Second line of Treatment / Tests:
☙ acetaminophen 1g PO  (possible contraindication to NSAIDs with ?peptic ulcer disease on DDx) 
Comprehensive bedside ultrasound: AAA, FAST, signs of pancreatitis – all negative
☙ Blood work: blood count, Electrolytes, Kidney Function, Liver Function, Lipase, VBG and Lactate

Case Continued:
☙ Pain increases over next 30min so hydromorphone 1-2g PO given to decrease pain to 2/10
☙ Labs return with nothing determinant: 
     WBC – 10.9 (normal 4-11)
     GFR – 48 (baseline unknown) 
     Liver function – normal
     Pancreas – normal
     VBG – normal
     Lactate – 3.4 (normal 2.2) 

Differential Diagnosis
? Dehydration from n/v and query possible acute kidney injury
? Partial ileus
Increased pain – potential other cause

Considering CT scan:
☙ Discussion with patient re risk/benefit of getting a CT Scan at this point (nearest CT scanner is 3 hours away for total 6+ hour transportation.)
☙ Not clinically necessary for urgent CT, so came up with plan to admit patient for observation. 

Proceed with Admission / Observation:
☙ Pt NPO and given IV due to possible acute kidney injury
☙ Repeat labs in morning
☙ Hydromorphone for pain over night

Morning assessment:
Over night took: 2nd dose ondansetron, 4mg hydromorphone
☙ Slept well
☙ But Coffee ground emesis just prior to rounds
     ☙ patient believed it to be undigested blueberries from previous day.
     ☙ Sample taken and on fecal occult blood card – NOT blueberries
☙ Discuss concern with patient about digested blood and more convincing indication for CT scan.
     ☙ Night sweats over last month and weight loss over last month.
     ☙  No peritonitis
     ☙ Considering subacute ischemic bowel

Patient agreed to transport to get CT scan and found to have ischemic bowel and received urgent general surgery consultation.

Discussion (CT Timing in Remote Community):
☙ Would CT the night before be wrong? No. (Many docs would have done it, especially if CT was readily available.)
☙ But might not be right choice either:
     ☙ Early pretest probability of a surgical pathology with normal vitals and labs was very low:
          ☙ overall prevalence for acute mesenteric ischemia is 0.1% (1/1000) of hospital admissions (1) 
          ☙ Risk of cancer from CT Abdo/Pelvis in 82y/o male =  1/3405 (2) 
          ☙ Plus have to consider:
               ☙ Transport risk;
               ☙ patient's increased stress from current ordeal (delirium risk) etc.  
☙ no clear "best choice" under this sort of risk/benefit analysis


  1. Nothing good comes from disproportionate pain – monitor closely!
    ☙ Keep eyes on patient don’t discharge
          ☙ Be CAUTIOUS moving forward with next steps.  (Think carefully)
    ☙ There is a small collection of catastrophic diagnosis in med that only present with disproportionate pain.  
  2. Approach to [seemingly straight forward] Nausea/Vomiting in ER: 
    ☙ Try to avoid IV’s in patients if possible – especially in patients who come to emergency looking for magical IV cure
    Oral Rehydration Therapy (ORT) 
         ☙ start only AFTER antiemetic starts to take effect (30min)
         ☙ Patients are given 5ml syringe and glass of water one syringe q 5 minutes first 30 min.
              ☙ 1mL/min is not an insignificant amount of fluid, especially in children when trying to mollify an upset stomach
         ☙ If managing well in 30 min then with no other complaints/issues:
              ☙ double rate of ORT, and/or 
              ☙ send home with education on how to manage future nausea:
                    1. Do not drink/eat when feeling nauseous or immediately after vomiting. 
                    2. Rather: make yourself NPO and let whatever vomiting is going to happen, happen.
                    3. When nausea has peaked / subsiding:
                        ☙ take oral medication with tiny sip of water.
                        ☙ After 30mins have passed and nausea is resolving start ORT
  3. Acute Mesenteric Ischemia is a very challenging diagnosis
         ☙ “Most important finding is pain that is disproportionate to physical examination findings...
         ☙ ...Typically, pain is moderate to severe, diffuse, non-localized, constant, and sometimes colicky” (1) 
  4. References:
    1. Medscape: Acute Mesenteric Ischemia
    2. Risk of harm from Diagnostic Tests: xrayrisk.com 

049 Gun Shot Wound to Pelvis 

Published 25 November 2022
Featuring Dr Adrienne Stedford: Emergency Physician in Rural BC
Show Notes by Heather Lean ACP BSc

Reference Episode 32 GSW to neck with Adrian Stedford

Case Synopsis

Day shift – fully staffed and prepped with knowledge that patient was in hospital getting a CT scan.
Local radiologist on shift.

Male in his 30s that suspect possible gang related – do not suspect a random shooting.
Uncooperative, agitated, suspected ETOH

Patient presentation
Easily identified entry and exit wounds – entry wound was from upper leg through the buttocks and concern it went through the pelvis and concerned for major blood vessels being hit – which is why patient was sent directly to CT.

IV’s established with EMS and 2 more large bore started
Immediate blood transfusion started
Worked with colleague to close both wounds
No major blood vessels impacted.
Pulses in extremities

P 120s – settled after some pain management down to 110s
R – increased with agitation
BP – normal did not get to low – did use fentanyl and had dip in BP 100/60
Vitals remained relatively stable throughout

Special Considerations (this case)
Discussed concerns with possible colon/bowel impact from GSW
Bullets leave debris that go various directions
Consideration for genitalia
Bullet disrupted some of the acetabulum – lots of debris on anterior lateral pelvis.

GSW Injury Considerations (General)
In higher levels of care, discussion around what specific weapon was used may be important. 

Bullet – creates concussion wave as it passes through tissue disrupting greater surface than just the size of the bullet.
Can also change trajectory – boomerang arc, bounce of other structures
This case could have had the bullet impact the acetabulum and changed trajectory.

Consult with trauma surgeon before considering discharging simple GSW
Top trauma surgeons currently discussing rural facilitys to keep straight forward GSW (ex. through and through limb) in rural communities rather than transporting.
When considering central body (head, thorax, abdo, pelvis) more caution needed.
Advised to keep patient in rural community over night while consult with tertiary centre to determine best cause of treatment – trauma surgeon and orthopedics
Unsure of how they were going to treat the acetabulum injury
Transport decision made around ability to manage possible complications from wound in community.

Consider secondary injuries
This case had minimal control over blood loss on buttock and when he came back from scan there was a large amount of blood.
Make sure to log roll and check whole body and not get focused on one injury

048 Oral Swelling

Published 15 November 2022
Featuring Dr Dave Collins:  Emergency Physician in South Dakota and Minnesota. Trained at University of Missouri Columbia with ULA Fellowship
Show Notes by Heather Lean ACP BSc

Case Synopsis

Nurse request urgent assessment of patient due to concerns with airway.

Initial assessment: 80s female patient does not appear sick but when asked history questions unable to understand any answers due to patient muffled answers. Patient tongue has been swelling for the last 12 hours, attempted Benadryl at home, with no result and came in for assessment because tongue was still swelling.

Patient Presentation:
Unable to stick out tongue – swelling up to base of uvula. Vitals within normal limits; BP also stable of 130 systolic. Only able to nod yes/no or write answers down. No drooling but had sensation of drooling, able to clear secretions

Anaphylaxis – unlikely due to 12h history and taking Benadryl
Angioedema (Hereditary Angioedema [HAE] vs drug-mediated) 
     Consider ordering C2 Esterase (time sensitive) to distinguish between HAE and other angioedema

Triggers? Has this happened before? Medications?
-> ACE inhibitors #1 suspect
Any recent changes to meds?
Patient had dose change to ramipril several months back – can have stable dosing for years with no issue and then one day have change.

Physical Exam:
no fever, chills, no brawny neck. Do patients have own teeth? (Dental Infection / gum line.) 
look for Ludwig’s angina

Case Conclusion
Within 30 min patient swelling decreased and was able to somewhat understand patient speech.
Within 1 1/2 post TXA patient swelling gone, patient had some slight slurred speech but feeling much more comfortable. Patient willing to spend night for observation after much discussion of risk of rebound swelling (No interest in being transported out).

Consult with Hospitalist who was agreeable to monitoring patient
     subsequently found – polycythemia (hemoglobin = 190)
Elevated bradykinin can cause polycythemia


  1. Sick/Not Sick?
    ☙ Are you in "Resus Mode" vs "Doctor Mode"
    ☙ Grey zone for this patient so have equipment to go if rapid decompensation
  2. Management: 
    ☙ overlap between anaphylaxis and angioedema treatment

    ☙ Bloodwork - CBC, comprehensive metabolic panel, VBG
    Benadryl 50mg IV
    famotidine 20mg IV
    solumedrol 125mg
    epinephrine 0.4mg IM – jittery, increased HR (120s) - repeat as needed
    ☙ Prep for surgical cricothyrotomy (scalpel-finger-bougie)
    ☙ Call for additional resources – someone else comfortable with managing airway on standby
  3. Additional treatment considerations (where available):
    ☙ FFP
    ☙ TXA 1g IV over 10 minutes, then start infusion in next few hours when there is time. 
    ☙ icatibant - inhibits bradykinin receptors
    ☙ ecallantide - inhibit kallikrein and a 60-amino acid polypeptide
    ☙ Angioedema mechanism for bradykinin when considering ACES & ARBS:
         ☙ it’s the elevation in bradykinin and effectively blocking the Kallikrein will reduce the swelling.

047 Part 2: Rural Transfers (for Imaging)
w/ Dr Nour Khatib


  1. What is a Rural Doc to do in place of "Low Threshold" CT scans? 
    ☙ CTs are use liberally in Urban departments, often to aid disposition planning
         ☙ A large percentage of CT's ordered in the ER are not critical nor urgent. 
    ☙ In a rural community where a CT requires transport, what alternatives might be considered? 

    I. Serial Reassessment
    (admit or recall as an outpatient) 
    ☙ most Canadian urban ERs will not have this option as readily available. 
         ☙ if no urgent indication to worry / transfer (e.g. clinically, hemodynamically, serologically stable)
              ☙ consider admitting, observing / reassessing
              ☙ OR, if stable enough, reliable enough, lives nearby - send home and recheck in ER later. 

    II. Advanced / Comprehensive Bedside Ultrasound:  
    ☙ In 2022, Rural physicians are taking advantage of only a very small percentage of what Bedside Ultrasound can offer.
    ☙ no radiation (or any other known biologic adverse effects) 
    ☙ inexpensive & robust, so easy to acquire even in smallest / most remote communities. 
    ☙ Primary Limitations: 
         ☙ most intracranial pathology  
         ☙ much [non-cardiac] intrathoracic pathology
         ☙ however, many (most?) other indications for urgent transfer for CT are very well covered. 
    ☙ Primary Barrier is lack of access to advanced / comprehensive training for physicians. 
         ☙ consider twelve-month Virtual Fellowship options (no travel required!) e.g. 
              i. UltrasoundLeadershipAcademy.com (international program, academic emergency medicine focus)  
              ii. RuralUltrasound.ca 🇨🇦 (Canadian Rural General Practice focus) 
  2. Risks of CT Radiation 
    ☙ Not good for people to be exposed to!
         ☙ Stats (table) number needed to Cancer 
              ☙ CT Head in 60yo male – CA risk of 1/2200
              ☙ CT Head of 20yo female – CA risk of 1/660 
              ☙ CT pulmonary angiogram to rule out PE in 20yo female risk is 1/300 cancer risk, CT abdo 1/500 
    ☙ Additive cumulative effects if getting multiple exams in a year 
         ☙ If same female patient gets cancer in her late 40’s they wont attribute it to exams conducted 20years ago
    ☙ Risk is invisible to practitioners in present
    ☙ Ethically, we should be carefully considering risk/benefit before ordering. 
    ☙ Tells patients how much the scan they are getting increases their risk of cancer
    ☙ Helps practitioner and patient make informed decision 
  3. Risk of Patient Transport (another hidden / underestimated risk by many physicians) 
    ☙ Rural vs Urban expectations of getting CT scans is very different
         ☙ when it is readily available patients seem to expect more vs when they have to travel they are more reluctant to go
    ☙ Really consider the value and justification of needing CT scan
         ☙ such as transport out to CT scan via ambulance or airplane in inclement weather to get test done
         ☙ can it be safely deferred at later time with better weather? 
         ☙ Consider scheduled evacuation (catch scheduled plane next day) verses medical evacuation   
    ☙ Responding crews' may suffer from “get-there-itis”
         ☙ a desire to help and evacuate patients in life-threatening situations
         ☙ Transport Team risk equation is calculated with urgency as communicated by sending physician description.
         ☙ Do not oversell severity of patient for rural facility convenience purposes; lives are at risk 

    Physician ordering transport is making the decision on how critical the need for the patient to be transported and the extent of how much the transport crew needs to push / risk their lives and the patient life during transport.
Nour Khatib

046 Part 1: Vertical Vertigo Case
w/ Dr Nour Khatib

Published 28 October 2022
With Dr Nour Khatib
Show Notes by Heather Lean ACP, BSc 

Case Synopsis:

Part 1
- 60 yo male arrived in rural ED with 12-hour history of generalized light-headedness with brief periods of vertical vertigo. In seated position, he had looked up hyperextending his neck and had instant onset of headache and vertical vertigo lasting for 15s and immediately went to lay down. 
- Remainder of day had ongoing light-headedness at rest: no significant vertigo at rest and had nausea (no vomiting).  Positional worsening and flair up of posterior headache every time he tried to stand up

- With this history, we're concerned that the presentation is not benign – symptoms did subside a bit while in waiting room after 10h since initial onset. Horizontal vertigo and nystagmus: more comfortable managing on site. But Vertical vertigo more concerning especially with history of headache. 

- Need to rule out posterior stroke. Concerned with other central causes. No CT available, so will need to consult with neurologist before having CT

Part 2: Physical Exam: 
- Cranial nerve assessment – no clinical findings
- Limb assessment – no clinical findings
- No nystagmus
- Positioned patient up right – mild lightheaded feeling with no subjective vertigo
- Dix-Hallpike: mild subjective vertical vertigo on right sided test with no nystagmus not as severe as earlier presentation

Part 3: Consult with neuro: 
- Diagnosed with BPPV of posterior canal. Not worried about stroke because vertigo is short lived and in the absence of no other neuro findings it is not consistent with ischemic injury but fits timing of BPV.
- No imaging indicated and discharged into care of family – instructions to return if episodes get longer in duration or if focal neuro findings develop. 
- Recommended patient be referred to physiotherapy
*Be aware that in different settings expectations may be different when it comes to ordering labs and imaging. 


  1. Questions to ask to know if it is truly vertigo
    ☙ Divide dizziness into 3 categories:
         1.  Vertigo:  Do you get the sensation the world is spinning around that you have to hold on to stop body from spinning?
    If answer yes then suspect vertigo – patients feel like they are moving / spinning vs the room is moving / spinning
              Is the feeling of moving right and left or up and down? If answer no or unsure then assume not vertigo. 
         2. presyncope
         3. light-headedness
  2. Peripherial vs central causes of vertigo and red flags to watch out for:
    ☙ Peripheral vertigo – more intense and isolated without other neuro symptoms with exception of tinnitus (can be lumped into acoustic nerve type phenomenon) – no facial droop or slurred speech etc.
         ☙ Changes in head position provoking symptoms?
         ☙ Are these spontaneous episodes or what is provoking? 
         ☙ Any recent viral illness?
         ☙ Stressors? 
    ☙ DDx of Peripheral Vertigo: 
         ☙ BPPV – crystallization in inner ear canals: Vertigo episodes short lasting few seconds less than a min
         ☙ Meniere’s disease – goes with tinnitus – last few hours to days
         ☙ Labrynthitis – viral infection that causes milder symptoms lasting for 1-2 weeks
    ☙ Central – any trauma to the brain causing a bleed or pressure phenomenon, any neuro surgical history, history of weight loss, seizures, constitutional symptoms that might go with Cancer diagnosis
  3. Specialty vertigo exams: 
    ☙ Dix Hallpike – indicated if patient is not actively vertiginous 
         ☙ When vertigo is on/off or based on position and lasts only a few seconds then suspect BPV and do Dix Hallpike exam 
         ☙ Pt should not have vertigo at time of exam
         ☙ Will cause vertigo with exam – beware of nausea vomiting. Consider prophylactic ondansetron
         ☙ Lay patient on supine on bed
         ☙ Get them to sit bolt upright with legs out in front on stretcher and move their body up on stretcher 30-40cm
              ☙ (remove anything they can possibly hit head on)
         ☙ Explain procedure 
         ☙ Turn head Right and lay them down supine while chin remains on shoulder and hyperextend head back off stretcher
              ☙ hold for 30-90s – open eyes to see nystagmus. Repeat on left side 
         ☙ Talk patient through this as patient needs trust that you will catch them. Often, they go to slow so coaching needed.
    ☙ HINTS – indicated if actively vertiginous – only time you can do exam (USE CAUTION when performing this exam)
         ☙ HI – Head Impulse:
              ☙ sit in front of patient with your hands on either side of their head,
              ☙ warn them you are going to move head around and relax
              ☙ Patient to keep eyes on nose rotate out to left 30 degrees
                   ☙ snap back to center to make sure their eyes are tracking repeat other side (might need to do several times)
                   ☙  looking for oculocephalic reflux intact 
              ☙ When someone actively vertiginous with peripheral cause this reflux does not exist 
              ☙ Should see corrective saccades occur if it is a peripheral benign cause of vertigo 
              ☙If you do not have this finding and they are actively vertiginous be more suspicious of central cause –
                   ☙ only do this when actively vertiginous because when they are asymptomatic this reflux will be intact. 
         ☙ N- Nystagmus – don’t have them fixate on object to track,
              ☙ rather have them look left, right, up, down to see if they have nystagmus (more sensitive)     
         ☙ TS – Test of Skew – sitting in front of patient have them fixate on your nose, take palm of your hand and cover one of their eyes and quickly move it to cover other eyes and look to see what kind of corrective saccadic motion there is. There might be a horizontal component (acceptable benign).
              ☙ If there is a vertical or diagonal correction than highly (98% specificity) concerning for central cause of vertigo 
  4. Resources
    1. Dr. Peter Johns – The HINTS exam https://www.youtube.com/watch?v=1q-VTKPweuk 
    2. Dr. Peter Johns – What does a positive Dix-Hallpike look like? 

045 Severe Hemorrhage

Published: 14 October 2022 
Show Notes by Heather Lean ACP, BSc 



  1. What is the initial management of life-threatening hemorrhage in rural emergency department?
    ☙ Initial management of life-threatening hemorrhage: DDIT 
         ☙ Direct pressure
         ☙ [more] Direct pressure
         ☙ Indirect pressure
         ☙ Tourniquet
    ☙ Direct pressure for this case provided no hemostatic control and pt dressings soaked through
    ☙ Pressure to arteries – radial artery pressure decreased bleeding by 90% 
    ☙ Tourniquet – gave more control
  2. What is a simple surgical approach to external hemorrhage control? 
    Check for foreign debris in wound
    ☙ Clear off area and any residual clot
    ☙ Identify source of bleed 
    ☙ Several small collateral vessels – suture ligation
         ☙ Suture ligation – Method to gain control of blood vessel by wrapping around blood vessel with suture using absorbable sutures to tie off vessels as quick as possible. Put snap on vessel while tying off using hand tie over vessel.  (See video examples below.) 

  3. What are second line management considerations for massive hemorrhage?
    ☙ Triad of Death (see below) 
    ☙ Tetanus status
    ☙ ABC’s,
    ☙ neuro vascular.
         ☙ Use of OKAY symbol using fingers – gross assessment of neurovascular intactness.
    ☙ Look for tendon and ligament injuries 

    ☙ Triad of death 
              ☙ if patient has severe blood loss, or received lots of blood products (citrate) consider acidosis 
              ☙ Pushes consideration for intubation up to put them on a ventilator and control pH better
         ☙ Hypothermia
              ☙ core temp loss of ½ to 1 degree impacts ability to coagulate.  
              ☙ use warming techniques PREVENTATIVELY
         ☙ Coagulopathy
              ☙ MOST IMPORTANT is PREVENTION (Prevent further blood loss)
              ☙ Consider TXA early 1g loading dose infused over 10 min, followed by second 1g over 8 hours
  4. Case Specific Notes:
    ☙ Challenges and limitations with rural setting. This case only had two nurses and lack of manpower is difficult in these settings. Communication, and role delegation important to time management.
    ☙ Issue with rural is disposition of pt – hopefully for total surgical control – but unable to maintain reasonable amount of blood control once tourniquet released. 
    ☙ Consult with hand surgeon located over 3 hours away.  Surgeon on over telephone unable to fully appreciate gravity of situation and requested closure of wound with dressings applied and follow up with closer centre (1 hour away).
    ☙ Change in thought process for patient disposition to go to closer facility with surgical options rather than send patient 3 hours away to specialist
         ☙ Sometimes multiple phone calls needed to find options that are in best interest of patients. Logistics and barriers with telephone communication can influence decisions when deciding where to transport.
    ☙ Receiving hospital request to pack wound with TXA soaked gauze and transport.
    ☙ Consider time with issues such as closing facial planes, and skin which wastes time and will likely be undone once arrived at receiving facility. 
         ☙ Pack wound and transport in more timely fashion
    ☙ Couple grams of cefazolin administered on spec. Had slow bleed at this point. Would have taken several min to fill 5ml pocket (compared to 3s initially)
    ☙ Retrospectively would have had transport set up sooner 
    ☙ Mission is different and environment is different than regional and tertiary centres. 
         ☙ Limitation was also that emergency department was filling up while dealing with this pt and creating other challenges. 
    ☙ Total blood loss approx. 1L with fluid resuscitation of 1 Litre of normal saline
         ☙ Initial hemoglobin 144 after ¾ litre loss (elevation 4000 feet above sea level) – makes significant difference. 
         ☙ Sea level hemoglobin 125 – 150 
         ☙ High elevation hemoglobin 130 – 180
         ☙ Pt baseline hbg 175 – this pts 144 was an 18% drop over baseline
    ☙ Pt transported to another hospital and had further reduction in hemoglobin of 135 resulting in total of 23% drop from baseline – consideration for hemodilution from fluid given.
         ☙ Over and underestimate blood loss in general use of mathematical equivalence important to understanding blood loss and impact from region to region.
         ☙ Caution for this age group (early 20’s) as they can mask blood loss like children and compensate until too late and crash
    ☙ Transferred out – vitals stable considering almost 20% circulating blood volume lost
Surgical Ligation Demo
Figure Of Eight Technique

044 Rural Trauma Panel discussion
(EMU 2022)

Published 29 September 2022

To learn more about the Emergency Medicine Update conference, visit: emupdate.ca


043 Building a Rural Simulation Program


  1. To learn effectively, Humans need Repetition:
    ☙ If you are trying to learn something complex, or if you are trying to set up a program for your colleagues so as a group you can improve at something complex: you'll enjoy a lot more success if you can set it up as as a multi-session, repetitive format (as compared to a one-off bootcamp blitz format.) 
  2. Psychological Safety in Simulation:
    ☙ going into a sim lab for a new program is intimidating
         ☙ especially so for those of us who have been in independent practice for years
    ☙ Establishing ground rules, protecting Participants' dignity is paramount. 
         ☙ Participants must be applauded for their willingness to show vulnerability in order to grow their skills.
         ☙ Joking and humour is okay, but all feedback needs to be constructive.
  3. Debrief is where the majority of learning occurs:
    ☙ In RnR Rounds we aim for >33% of the time "in simulation" to be the debrief. 
         ☙ Learning does occur while in the "hot-seat" roles (as it does in "observer" roles) however: 
              ☙ the analysis and discussion from the debrief is where the majority of learning occurs. 
    ☙ We use the "GAS" acronym:
         GATHER - objective recounting of what happened (no judgment or analysis) 
         ANALYZE - round table discussion of the team's performance by the team.
              ☙ Must be constructive.
              ☙ Avoid too much talking or teaching from the facilitator (teaching can come later, e.g. via email)
         SUMMARIZE - each participant can summarize one take-home point from the exercise. 

042 Massive Hemorrhage & Transport Limitations


  1. Rural blood bank resources for massive hemorrhage:
              ☙ Resources in the typical rural hospital:
    ☙ 4-6 units total of O+ and O- and 2 units of fresh frozen plasma (FFP).
         ☙ Platelets and cryoprecipitate are not available due to short shelf life and expense.
         ☙ The time to receive blood from regional blood bank depends on location.
         ☙ E.g: for semi-rural hospital 20min away from blood bank, it takes 4+ hours for cross matched products to arrive.
         ☙ For more remote centres it can take 8 – 12 hours or 24+ hours.
    ☙ Given resource limitations, a massive transfusion protocol (ratio 1 unit pRBCs: 1 unit FFP: 1 unit platelets) is not an option in most rural centres.
  2. How is massive hemorrhage defined? 
    Bleeding more than 150ml/min.
    ☙ Half of total blood volume being replaced over 3 hours or entire blood volume being replaced in 24 hours.
    ☙ More than 10 RBCS transfused over 24 hours OR from time of ED admission to ICU transfer.
    ☙ Greater than 20 RBCs transfused in the course of a hospital admission.
  3. Transportation options:
    ☙ In Canada, there is advanced patient care transport service, but quality and expediency varies:
         ☙ Private vehicle driving times are often underestimates.
         ☙ Ground ambulance driving time is more accurate.
         ☙ Air ambulance is only available when transporting to some centres.
    ☙ Other logistical steps that take time:
         ☙ Time to get transport approval requires usually >30min.
         ☙ Handover and loading patient to transport crew requires ~15 to 20 min.
    Bottomline: it could take multiple hours to get patient to centre that provides definitive care, so your limited regional blood bank products does not buy you enough time. Therefore, you must control the bleed.
  4. MARCH approach:
    ATACC (Anasthesia Trauma and Critical Care) is an alternative to ATLS which has a great e-book resource and has more relevance to rural and remote care. ATLS provides a good introductory approach but is more applicable to larger centres.
    ☙ MARCH is an acronym from ATACC and is a modification on standard ABC approach to unstable patient:
         ☙ Massive external hemorrhage control
         ☙ Airway management
         ☙ Respiratory management
         ☙ Circulatory management
         ☙ Head trauma and other serious injuries
    ☙ MARCH is great because it focusses on controlling critical bleed which may require a few seconds assessment before jumping to secure definite airway.
  5. Steps to control bleeding:
    ☙ Top priority in rural hemorrhagic trauma needs to be circulatory preservation since we cannot buy enough time with limited regional blood blank supply.
    ☙ To preserve circulation, start with controlling external hemorrhage. ATACC has a mnemonic called DDIT which outlines quick steps to control external hemorrhage:
         ☙ Direct pressure
         ☙ more Direct pressure
         ☙ Indirect pressure (i.e: pressure to artery proximal to bleeding site)
         ☙ Tourniquet
    ☙ Other easy steps to control bleeding:
         ☙ Minimize opportunity for further internal blood loss by stabilizing pelvic fractures with a bedsheet or commercial binder.
         ☙ Remember to give TXA early (1 g over 10min). TXA is contraindicated if given more than 3 hours after the trauma.
         ☙ Reverse anticoagulation e.g: vitamin K for someone on warfarin. 
         ☙ Keep the patient warm – hypothermia is on the triad of death (hypothermia, coagulopathy, acidosis).
         ☙ Target “minimum normotension” – balance between preventing acidosis but not causing clots or diluting endogenous clotting factors.
         ☙ Give blood products if available.
         ☙ damage control surgery (DCS)
  6. Damage control surgery – an option one day?
    ☙ Damage control surgery is a military technique for bleeding control
         ☙ involves opening patient, stopping the bleeding, packing the patient, and transporting the patient open to definitive surgical care.
    ☙ Goal is to preserve normal physiology, not normal anatomy, and to return later for definitive treatment.
    ☙ Currently, DCS is not yet formally accepted in rural hospitals.
    ☙ But if you do have surgical support in your hospital, consult them for considering surgical stabilization before transportation your patient out.
  7. Summary points:
    ☙ In rural centres, prioritize controlling the bleed.
    ☙ MARCH provides a good approach to rural management of unstable patients.
    ☙ Use DDIT approach external bleeding.
    ☙ Other quick steps include early TXA, stabilizing fractures, keeping patient warm, maintaining minimum normotension and replacing blood if you have access.
  8. Resources:
    1. https://sthtrauma.files.wordpress.com/2014/05/atacc-manual-volume-ii.pdf

041 Seizure Aspiration

Published: 10 September 2022
Editing by Dr Logan Haynes
Show Notes by Dr Abir Islam coming soon. 


  1. Start with observation and watching vitals.
    ☙ Patient brought in by ambulance who had been seizing and vomited,
         ☙ with concern of possibly aspirating.
         ☙ Had 15mg of midazolam on board by EMS.
    ☙ Ongoing twitching of neck muscles and making some gaspy breathing sounds.
         ☙ Otherwise vitals stable and was given supplemental oxygen.
    ☙ At this point, given loading dose Keppra (500mg)
         ☙ unclear if mild neck twitching was partial seizure or part of post-ictal phase. 
  2. Work with the team and involve decision making among multiple team members as appropriate. 
    A team member was eager on immediately sending patient out for more definitive care.
    ☙ Respect your team member’s viewpoints, even if they differ from your own.
    ☙ If there is stark disagreement, try to get more team members involved to see if a consensual group agreement can be achieved.
    ☙ In this case, the patient was currently stable. If the patient deteriorated on the road with paramedics, there may have been less expertise/physician support to manage, whereas if they deteriorated here, we can intubate quickly with all hospital equipment ready at hand. So our team chose to observe for now. 
  3. What to do if patient aspiration event occurs?
    Patient at this point had large volume feculent emesis with brief dip in oxygenation, highly suggestive of active aspiration event. Although vitals normalized, now needs definitive care in tertiary centre.
    ☙ Now three steps for initial management:
         1. suction,
         2. broad spectrum antibiotics, and
         3. prevent ongoing aspiration/protection of airway.
    ☙ He will be transported lying supine so high risk of aspiration and losing airway protection, so we opted to intubate for protection of airway.
  4. Intubation pointers from this case.  
    Have Plan A, B, C and D. Here, this was Mac 4 blade, video scope with hyper-angulated blade, rescue device such as LMA, and scalpel-finger-bougie technique, respectively.
    ☙ Even though he had midazolam already on board, still need anaesthetic, so we used fentanyl 1mcg/kg. Also used induction with propofol as there is some neuroprotective effect, and not neurotoxic.
    ☙ RSI was not done here because patient had already aspirated.
    ☙ Patient was also doing well with trial of BVM, so was lower risk.
    ☙ Chose succinylcholine because it was short-acting. Paralysis masks seizure activity so want to know if there is residual seizure activity by using a paralytic with short duration of action.
    ☙ Lastly, we put patient on ventilator and ketamine infusion to put him to sleep, and sent him with paramedics for definitive care in bigger hospital. 

040 Foreign Body in Foot 

Published 18 August 2022
Editing by Dr Logan Haynes 

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  1. Ultrasound makes FINDING FB's easy!
    ☙ PoCUS can identify: wood, metal, glass, plastic, and other materials.
              ☙ look for artificial (non-biologic) surfaces 
    ☙ foreign bodies triggering an acute inflammation reaction are easier to see
              ☙ look for a surrounding hypoechoic (fluid) collection as in the clip above.
    ☙ you can also use ultrasound to:
              ☙ mark on the skin where the FB lies 
              ☙ measure the depth below the skin 
  2. Ultrasound makes REMOVING FB's easy!
    ☙ in addition to marking the skin (as mentioned above), consider needle-localization
    ☙ under direct visualization, align a large needle (e.g. 18g) to the end of the FB
    ☙ use a scalpel to cut down the needle (visually and by feel) until the tip of the needle is exposed
    ☙ end of the FB will now lay adjacent to your needle, as it was previously positioned. 
Nerve Block

039 Refractory Renal Colic

Published 31 July 2022:

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  1. Multimodal Analgesia & Novel Pain Interventions are a Rural Doc's Friend!
    ☙ We tend to think about "the big 3" analgesics:
         ☙ i.e. acetaminophen / NSAID / Opiates
         ☙ but there are many more options: e.g. ketamine, lidocaine infusion, nerve blocks, etc. 
         ☙ There are 5 "standard" NSAIDS available in Canada
              ☙ i.e. ibuprofen, diclofenac, naproxen, indomethacin, ketorolac
              ☙ all known to be equivalent in efficacy
                   ☙ (ref 1) is a recent study again showing equivalency between 3.
              ☙ NSAIDS do vary in side effect profiles & risk
              ☙ lower doses are generally maximally efficacious with higher doses only adding more risk
                   ☙ (ref 2) is a recent study confirming no need to exceed ketorolac 15mg intramuscularly
    ☙ Don't underestimate the value of the Placebo Effect, where a patient's anticipation often translates to a higher efficacy / satisfaction.
         ☙ e.g. "a needle" is perceived to be, and therefore often translates to better analgesia(!!)
         ☙ e.g. ketorolac 10mg IV can be perceived to be "better" than alternate like ibuprofen 400mg PO
  2. Erector Spinae Plane (ESP) Block 
    ☙ How to perform ESP Block?  
    What is the ESP Block about?:
         ☙ consider it to be a unilateral epidural block.  That is: 
              1. ESP affects only the ipsilateral nerve roots
              2. above and below target level (insertion site), based on the size (volume) of block  
         ☙ in practice, through Ultrasound Guidance:
              ☙ needle is placed posterior to a Transverse Process at the target level
              ☙ local anesthetic is infused (single shot) into the Erector Spinae fascial plane
              ☙ and spreads up and down the spine several spinal levels (based on volume of the block)
         ☙ Very helpful for unilateral thoracic or abdominal indications: 
              ☙ renal colic (target T8)
              ☙ rib # or flail segment 
              ☙ post-herpetic neuralgia, unilateral burns, abscesses, etc. 
    ☙ ESP is a great option when pain arises in a location that cannot be blocked by another large peripheral nerve site.  
         ☙ e.g. pain in arm can be blocked at Brachial Plexus or potentially at radial, median or ulnar n. sites more peripherally, so ESP is less desirable.  
  3. Other Fascial Plane blocks exist and can be used with great success
         ☙ FIB (Fascia Iliac Block) - great for hip # or proximal thigh injuries 
         ☙ TAP (Transverse Abdominus Block) - great for anterior abdominal wall 
    Fascial Plane Blocks are relatively simple to learn, but require familiarity with:
         ☙ ultrasound needle-guidance techniques
         ☙ specific anatomy specific to the block 
         ☙ Local Anesthetic Toxicity Syndrome (LAST) 
    Resources / Courses: 
         ☙ NYSORA website (FOAM -- teach yourself) 
         ☙ RuralUltrasound.ca (paid program -- comprehensive virtual ultrasound fellowship)

    (1) Irizarry E, Restivo A, Salama M, et al. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med 2021;28(11):1228:1235 
    (2) Turner NJ, Long DA, Bongiorno JR, et al. Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department. Am J Emerg Med 2021;50:142-147.

038 FP-Anesthesia Residency Insights

Published 2 July 2022:

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(No show notes for this episode.) 


037 Pacemakers & ICDs (Case)

Published 17 June 2022
Show notes by Dr Abir Islam.

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  1. Reviewing pacemakers and implantable cardiac defibrillators (ICDs)
    ☙ Pacemakers are electronic devices implanted just below the left clavicle.
         ☙ Lead enters through left subclavian vein and into heart via right atrium or ventricle
    ☙ Can be single or 2 leads
    ☙ All pacemakers can deliver impulse but most pacemakers nowadays also has sensory function
         ☙ Inhibiting mode: normally fires at fixed rate but stops if senses endogenous electrical activity
         ☙ Triggering mode: no firing at baseline, but fires if electrical activity is not sensed   
         ☙ Dual mode: combination of inhibiting and dual mode
    ☙ A pacemaker that continuously detects R-R interval of the EKG
    ☙ If detects too many short R-R intervals, either does anti-tachycardia pacing or delivers a shock
    ☙ 10% of shocks due to a non-VT-non-VF rhythm, most commonly SVT
    ☙ Many ICDs additionally have an anti-bradycardia pacing function
    ☙ ICDs are generally safe when they fire
         ☙ delivers less than 40 Joules (external pads deliver 100 to 200 joules)
         ☙ however, don’t place external defib pads on top of the ICD because can cause burns through trapped air pockets.
         ☙ Apply the pads at least 5cm away from the edge of the pacemaker
  2. How to determine a pacemaker’s programming
    Look at pacemaker information card (recipient is supposed to be carrying with them at all times)
         ☙ This card will have a 5 character code, sometimes shows 3 characters (leaves last 2 less informative characters out)
              ☙ First character position: says which chamber is paced
                   ☙ 4 options: O for none. A for atrium. V for ventricle. D for dual – both atrium and ventricle
              ☙ The second position is the chamber sensed (also O, A, V or D).
              ☙ The third position is the response to the sensor
                   ☙ 3 options: O for none. T for triggered. I for inhibited. D for dual (both triggered and inhibited)
              ☙ Fourth position: rate modulation
              ☙ Fifth position: information about multisite pacing
    ☙ Example 1: VVI
         ☙ ventricularly paced, ventricularly sensed, fires at specified rate but turns of if detects a beat
    ☙ Example 2: DDDR
         ☙ dual paced, dual chamber sensed, the response to sensing is dual. The rate modulation is R (rate adjustment present)
    ☙ ECG Findings for pacemakers
         ☙ Vertical line = pacemaker firing
         ☙ Big QRS wave after pacer spike = paced ventricular contraction
         ☙ Small p wave like bump after spike = paced atrial contraction
  3. What to do when a pacemaker is malfunctioning
    Start with ACLS
    ☙ Pacemaker malfunctioning (e.g: paced tachycardia)
         ☙ Apply magnet on top of pacemaker
         ☙ shuts off both sensing and device reactions to sensed stimuli
         ☙ goes back to factory mode (e.g: fixed 80bpm impulses delivered)
         ☙ Magnet often found stuck to crash cards (buy one if don’t have!)
         ☙ Caution: sometimes pacemaker preventing cardiac arrest.
              ☙ So if you apply magnet, have external pads ready to go in case
    ☙ ICD malfunctioning (e.g: inappropriately defibrillating patient)
         ☙ Apply magnet -> turns off defibrillation function
    ☙ All malfunctioning ICD and pacemaker needs FU with pacemaker clinic ASAP




036 Optimize Before Intubation Case

Published 1 June 2022

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  1. How to optimize prior to intubation:
    ☙ physiologic contraindications to intubation:  (things to optimize prior)   
         ☙ acidosis -
              ☙ hyperventilate to blow off more CO2 (more respiratory compensation)
              ☙ treat reversible underlying cause if possible 
              ☙ consider bicarbonate 
         ☙ hypotension - typical hypotension resuscitation with fluid / blood / vasopressors as needed 
              ☙ consider underlying cause and treat
              ☙ consider arterial line if available, for superior B/P monitoring
         ☙ hypoxemic  
              ☙ support respiration, increase FiO2
              ☙ treat any reversible underlying causes (e.g. reactive airways) 
  2. How to troubleshoot poor SpO2 Monitor reading:
    ☙ is it a reading-site problem
         ☙ e.g. poor perfusion in the body part (e.g. finger while patient is vasoconstricted.) 
         ☙ trial of "bandaid probe" even on adults - tape around a potential site (e.g. earlobe) 
         ☙ trial of "finger probe" on pinna of ear (wrap up pinna and hold inside finger probe)
         ☙ actual finger probe 
    ☙ remember clinical correlation - does patient look hypoxemic on physical exam?  (RS pattern, cyanosis etc) 
  3. How to confirm if ETT is in correct location without functioning monitor
    ☙ ETCO2 monitoring is gold standard, but not infallible.   
         ☙ correlate ETCO2 result with clinical assessment for maximally robust confirmation of tube location. 
    ☙ Clinical confirmation options:
         1.  at time of intubation SLOW DOWN.  Confirm tube is in correct location, correct depth.  
              ☙ anchor very well with extraction of laryngoscope. SLOW DOWN, ensure assistant is anchoring well. 
         2. lungs inflating (listen away from trachea / towards axilla & look at chest rise) 
         3. misting pattern on exhalation (should see a very strong misting pattern inside ETT that is constant over many breaths) 
         4. compliance in BMV (SLOW DOWN and assess. With experience we can learn the normal feel of bag compression.) 
         5. stable saturations / clinical signs of oxygenation over next few minutes.
    ☙ ETCO2 - use this device when it is available but interpret in the context of larger clinically picture. 

035 (Bonus!) Ketamine in the Rural Hospital

Published 14 May 2022:
https://anchor.fm/jonathan-wallace-md/episodes/Ketamine-Presentation-From-RHC-2022-in-Penticton-e1ikoos  (Note: this is the audio introduction only.  Find the embedded video lecture below.) 

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  1. Ketamine use for Procedural Sedation
    (a) Therapeutic dose ranges for Ketamine's 3 effects [2:22]
         ☙ analgesia 0.1-0.3mg/kg (IV) 
         ☙ dissociation (for psychiatric indications & neuropathic pain) 0.5-1mg/kg (IV)  
         ☙ induction 1.5-2mg/kg (IV) 
    (b) Ketamine's "Anesthetic Signature" [7:52]
         ☙ ketamine is unique among anesthetics because it doesn't cause apnea or hypotension(*) 
              ☙ *see video for caveats
              ☙ thus it is safer than fentanyl (or other opiates) for procedural sedation
         ☙ ketamine is a powerful analgesic (opiate-replacement) at low doses and offers good amnesia
         ☙ ketamine does not cause muscle relaxation (paralysis) 
    (c) Procedural Sedation Recipe for Ketamine  [14:20]
         ☙ Queen's University Recipe: 
              (i) ketamine loading dose: 0.3mg/kg IV (single dose, up front with 60s head start) 
              (ii) propofol loading dose: 0.4mg/kg IV (single dose) 
              (iii) propofol titration dose: 0.1mg/kg IV q 30-90 seconds to effect
              ☙ excellent procedural sedation for procedures up to 45min in length without needing to re-dose ketamine.
  2. Ketamine use for acute & chronic Pain Control
    (a) Multiple Categories of Pain (at least 3) combine to create a unique "pain experience" [16:40]
         ☙ Patients benefit from targeted treatment for each contributing category 
              ☙ There is no "one-size fits all" to pain management. 
         (i) Tissue Type Pain (e.g. spinothalamic tract, prostaglandin mediated swelling) 
              ☙ may respond to: acetaminophen, NSAIDs, opiates, ketamine (analgesic dosing)  
         (ii) Psychological / Anxiety type pain (e.g. anxiety, psychosomatic) 
              ☙ may respond to: counselling, anxiety treatments (SSRI), etc. 
         (iii) Neuropathic Pain (e.g. CRPS, trigeminal neuralgia, post-herpetic neuralgia, phantom limb pain) 
              ☙ may respond to: gabapentin, anticonvulsants, spinal cord stim, rizotomy, lidocaine or ketamine (neuromodulator)  
         see episode 004 Back Pain, for a more detailed discussion. 
    (b) Ketamine use for Acute pain as an opiate alternative [22:03] 
         ☙ ketamine 0.1mg/kg IV q 5 minutes 
         ☙ consider adding a sedative (e.g. midazolam 1mg IV prn) if symptoms are uncomfortable / above 0.2mg/kg total dose 
    (c) Ketamine use as a neuromodulator (for neuropraxic pain) [23:20] 
         ☙ Large doses of ketamine (or lidocaine) as an IV infusion can "reset" irritable nerves causing significant relief. 
         ☙ "Success" is defined as:  50% reduction in pain symptoms, lasting > 2 weeks(!) 
         ☙ Initial Titrating / Testing requires high-acuity monitoring (e.g. Recovery Room) 
         ☙ Once correct dose / frequency is determined, this can be set up through a SC infusion pump via home care. 
         ☙ Neuromodulation is a promising new therapy but may be technically challenging to access. 
              ☙ in BC refer to Dr Jill Osborn & St Paul's (Vancouver) Pain Outpatient Clinic [29:05] 

Video Description


033 Severe GIB

Published 14 May 2022: 

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  1. Managing a GI Bleed in Rural Community
    pantoprazole 40mg PO bid is as effective as IV infusion 
         ☙ IV infusion if unable to tolerate PO:   80mg IV bolus ± 8mg/hr IV x 24 hours 
    ☙ consider octreotide if bleeding esophageal varices suspected (hematemesis) 
    ☙ consider need for blood transfusion early, especially if bleeding is suspected to be ongoing
         ☙ if significant bleeding and hypotension, resuscitate to just "minimal normotension"
    ☙ consider urgent surgical consult
         ☙ especially in rural centre where blood bank is small and rural surgical support is more readily accessible 
    ☙ TXA is rarely indicated, since GIB is likely outside the 3 hour first-administration time window. 
    Blakemore Tube is a Hail-Mary device for severe hematemesis.  
         ☙ seek consultation as this is a complicated device to place properly
         ☙ likely requires sedation. 

032 GSW to Neck

Published 11 April 2022:

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  1. The Neck Zones and Important Structures
    ☙ Zone 1 : Suprasternal notch to cricoid cartilage
         ☙ Important anatomy: 
              ☙ Vessels: prox common carotid aa., vertebral aa., subclavian vessels, innominate vessels
              ☙ Aortic notch, lung apices, esophagus, trachea, brachial plexus, thoracic duct
    ☙ Zone 2 : Cricoid cartilage to angle of mandible
         ☙ Important anatomy: 
              ☙ Vessels: common/internal/ext carotid aa., int/ext jugular vv.
              ☙ Larynx, hypopharynx, prox esophagus.
    ☙ Zone 3 : Angle of mandible to base of skull
         ☙ Important anatomy: 
              ☙ Vessels: internal/ext carotid a., vertebral a., jugular vv., prevertebral venous plexus
              ☙ facial n. trunk.
  2. Approach to a Neck GSW
    ☙ Call for Help
         ☙ GSx
         ☙ Anesthesia
         ☙ RN
         ☙ Xray Tech, Lab for Bloodwork
         ☙ Consider need for early Transfer to Tertiary Centre
    ☙ ABC’s
         ☙ Airway: Speaking (patent), secretions, spitting, stridor, swelling
         ☙ Breathing: Oxygenating, aspiration of blood
         ☙ Circulation: Vascularly intact -> aLOC, control of bleeding
         ☙ Deformity: Neuro vitals, GCS, pupils, entry + exit of bullet vs location of bullet if no exit wound
  3. Airway Management
    ☙ Maintenance: Chin lift, jaw thrust, suction, locate bleed
    ☙ Definitive Airway with hard indications (respiratory distress, stridor, aLOC)
         ☙ Consider RSI vs Awake Intubation vs contingency airway planning
         ☙ Devices Options: Fibre Optic, video laryngoscopy, LMA, Stylet / Bougie.
         ☙ Surgical Airway: Cricothyroidotomy, Scalpel-Finger-Bougie, jet insufflation.

☙ Radiopedia https://radiopaedia.org/articles/penetrating-traumatic-neck-injury

031 Pediatric (22 months) Sedation

Published 1 April 2022:

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  1. Trick for Foreign Body up a Nose?
    ☙ Have the parent blow it out: 
         ☙ parent makes seal over child's mouth
         ☙ parent blocks unobstructed nostril 
         ☙ blow really hard!  
    ☙ a conscious child will close their glottis, thus parent's breath will exit through occluded nostril.
         ☙ can be  messy so have a tissue handy 😊 
  2. Procedural Sedation choices for a young child (too young to be able to cooperate)
    0. Screen time.   
         ☙ ask parent show their child an engaging video on their phone (cartoon etc)
              ☙ has been shown in studies to be equivalent to a certain level of midazolam or other anxiolytic
              ☙ so great distraction if you need to do something quick (e.g. IV start or IM injection) 
    1. Oral Sedation
         ☙ e.g. apple juice ± codeine ± midazolam ± ketamine (etc) 
         + least difficult route to convince child to cooperate with 
         - may taste terrible so could still be a challenge
         - long time to onset (30+ minutes) 
         - difficult to titrate 
    2. Intranasal Sedation
         + much faster onset (15 mins)
         + makes definitive IV insertion much more comfortable / tolerable for everyone once patient is settled
         - involves brief "water up nose" experience
              ☙ have piece of gauze to cover nose immediately afterward in case fluid comes back up (child sneezes) 
              ☙ use high concentration to minimize volumes 
              ☙ max 1 mL per nare (if more needed, space out multiple doses over time)
         ☙ have suction, monitors, airway equipment, IV start equipment, all laid out ready to go
         ☙ best to do this with child wrapped in blanket, parent engaging with them (eye contact), and holding their head
         ☙ e.g. ketamine 3-9 mg/kg IN q 15 mins prn  
              ☙ probably will not require a top up as IV start + immediate sedation with e.g. propofol should be easy @ 15 mins
    3. IM or IV injection 
         + best control, best titration
         - potentially frightening for child
         - may need to fully restrain child (traumatizing)  
    4. Nothing ("barbarian method") 
         + fast
         - not patient-centred / most traumatizing: 
              ☙ save as a last resort in bonafide emergency / resuscitation? 
Mountain Meadow

030 Don't Anchor! (a SOB case)

Published 25 March 2022:

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  1. Don't Anchor!
    Anchoring: the tendency to perceptually lock on to salient features in the patient’s initial presentation too early in the diagnostic process, and failure to adjust this initial impression in the light of later information.
          ☙ This bias may be severely compounded by the confirmation bias. [1]

    Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive. [1] 

    ☙ Always go back to the "high level view" 
         ☙ recap often (for your own benefit as well as your team's)
         ☙ consider other [plausible] hidden diagnoses / contributors that are yet unidentified.
  2. Sick vs Not-Sick?
    ☙ most important step as this will help guide your disposition thinking and planning:
         1. move to resuscitation area / apply critical interventions while: 
         2. asking for more help (local hands, tele-consultation, expedited transport arrangements) 
  3. If you're feeling overwhelmed: prioritize small tasks within your abilities.
    ☙ problem solving / thinking on your feet is a cornerstone to successful rural-resuscitation
         ☙ practice and simulation helps!  check out: sim.rnrrounds.ca 
    ☙ ask yourself of the things this patient needs:
         ☙ what do you have available / can initiate? 
         ☙ is the the transport team able to add / bring anything further? 
         ☙ what is the most effective means to get this patient the definitive care they require now? 

         1. https://sjrhem.ca/wp-content/uploads/2015/11/CriticaThinking-Listof50-biases.pdf

029 Ludwig's Angina Case

Published 6 March 2022:

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  1. Epidemiology / Presentation of Ludwig's Angina 
    Ludwig's Angina is a life threatening soft tissue infection involving the floor of the mouth & neck
         ☙ 3 zones involved: sublingual, submental, submandibular 
         ☙ rapidly progressive leading to airway compression / asphyxiation 
         ☙ 90% are triggered by dental infection, usually lower 2nd or 3rd molars,
              ☙ but any regional infx can trigger
    ☙ Historic insights:   
         ☙ mortality was > 50% prior to discovery of antibiotics
         ☙ in modern times, mortality is ~ 8%
    ☙ Symptoms:
         ☙ neck swelling, neck pain, difficulty swallowing, difficulty speaking
         ☙ also: trismus, mouth pain, hoarse voice, drooling, tongue swelling, stiff neck, sore throat
    ☙ Physical Exam Findings: 
         ☙ "Bull neck" (submental fullness, loss of mandibular angle definition)
         ☙ fever,
         ☙ intraoral finings: swelling of floor of mouth, elevation of tongue, tenderness over involved teeth
         ☙ extraoral findings: induration of submental neck "woody", edema of upper neck 
         ☙ often NO lymphadenopathy 
  2. Ultrasound Findings: Ludwig's Angina
    (1) look for signs of abscess (cystic collections) 
         ☙ remember to use Colour Flow (ideally Power Doppler)
              ☙ vascular flow inside "an abscess" indicates it's actually a lymph node etc - do not lance! 
              ☙ increased vascular flow in the periphery of a fluid collection is consistent with abscess
              ☙ internal flow inside a "cystic structure" means look again: it's almost certainly a blood vessel.
    (2) "Dirty Grey" gas shadow from gas bubbles (follows fascial planes in soft tissue) 
         ☙ implies gas gangrene / necrotizing fasciitis and is a medical emergency 
         ☙ ensure no recent trauma or surgical instrumentation (alternate explanations for "air" in soft tissue)
  3. Treatment of Ludwig's Angina:
    (1) Secure airway 
         ☙ fibreoptic intubation is helpful if airway swelling (usually not available in Rural) 
         ☙ alternatively: intubate at earliest possible indication to maximize success
              ☙ as always, be prepared to do surgical cricothyroidotomy 
    (2) Imaging after airway is secured!  (or no risk to airway in near future) 
         ☙ NIH recommends contrast-CT or MRI as first line.
         ☙ [expert opinion only]: in most rural centres (where CT is unavailable): 
              ☙ PoCUS is best first choice: sensitivity for gas gangrene & abscesses can approach CT
              ☙ XR might show gas gangrene & soft tissue edema if disease is sufficiently advanced
                   ☙ in other words, they probably should be intubated if sick enough to consider XR. 
    (3) Early broad spectrum Antibiotics 
         ☙ don't forget to order cultures,
         ☙ but don't introduce an unreasonable antibiotic administration delay 
    ☙ consider steroids (weak evidence / case reports only) 
    ☙ surgical decompression may be indicated for drainage of pus / gas gangrene



028 Career Advice [Part 3 of 3]
FRCP vs CCFP-EM routes: an FRCP third year resident's reactions and advice.

Published 26 February 2022:

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Note: no Show Notes for this bonus episode.

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027 Career Advice [Part 2 of 3]
EM Training Opportunities in Canada: FRCP | CCFP-EM (res) | CCFP-EM (challenge) | CCFP-FPA | other opportunities.

Published 24 February 2022:

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Note: no Show Notes for this bonus episode.


026 Career Advice [Part 1 of 3]
For students, residents & new grads.

Published 13 February 2022: 

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Note: no Show Notes for this bonus episode.

(2:17) FRCP residency vs CCFP-EM residency
(18:21) *Anesthesiology* gives the best resus training (?!)
(35:20) How easy is it to change careers / 'FM-specialities' as a family physician?
(36:14) How accessible is "+1" residency training for family physicians? (general)
(37:53) How accessible is "+1" residency training for family physicians? (CCFP-EM)
(38:50) If I don't match to CCFP-EM year, where should I go to get experience / prepare to challenge?
(40:05) Can I become a FRCP specialist (in various specialties), after training in family medicine?
(47:16) Alternative EM training options for family physicians (that don't match to CCFP-EM)
(48:15) GP-Anesthesia Training as an alternate to EM residency (and in general as a career)

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