RnR Rounds Podcast

Dr. Shawn Lacombe

SEME (supplemental emergency medicine experience) is a 3-month emergency medicine fellowship. Designed to give rural physicians increased experience and learning with emergency medicine.

Three sites – Toronto, Barry, and Thunder Bay.

Three blocks – Emergency medicine, anesthesia, and trauma or selective. Use high yield topics, airway management and pocus training.

Use wet lab for all major procedures – chest tubes, thors/lumbar punctures as well as ultrasound guided procedures.

Program funded by ministry of health in Ontario. Increased funding. Ideal candidate would have ties to Ontario and CPSO license.
Similar program in BC.

If in a different province, reach out and have conversations to try to increase interest.
Funding equal to approx. $40,000.00 for three months.

Vast majority of practitioners working in rural medicine are family physicians.
Curriculum focuses on airway management, critical skills, transport medicine, making hard decisions, and rare cases that take up a lot of cognitive burden.

Partner with Peer to Peer to allow people to feel not alone.

Over 233 practitioners trained approx. 4% of all active practicing physicians.
Fall and Spring Cohorts. Deadlines variable year to year. Visit website for more information.

Difficult to catch at best of times. Resource limited sites make it more difficult.

Guest – Micaela Coombs – rural family physician with 10 years practicing. Regional center still isolated with tertiary center several hours away by flight. General surgery and obstetrics support community. CT scan available with CT-angio hours limited.

79yo male Type B dissection. POCUS helpful in diagnosis due to delays of CT angiogram.

CASE
Sudden onset of back pain atraumatic in nature that increased with movement and deep breathing. Pain described as band like and radiated from sternum to back. EMS noted SPO2 in 80s with wheezes. Ventolin administered and O2 applied.

Vitals
HR – 76
Afrbrile
SpO2 – 92% on 4lpm via NC
BP - 166/98

Chart Review – no significant PMHx, looked for any previous imaging of aorta non on file.

Differential diagnosis – focused on respiratory causes due to low O2 saturation concerned about pneumothorax or PE. AAA on differential due to back pain and hypertension but low on differential.

Further History – sudden onset epigastric pain starting 7 hours ago radiating to back. Similar pain 6 mo ago resolved quickly. No SOB but pain increase with deep breath. No focal neuro s/s no infectious or GI/GU symptoms.

Patient grimacing and appearing stoic does not come to ED very often.
Physical exam – BP increased to 190’s systolic. Not taking full breath. Considered atelectasis as cause of hypoxia?, lungs clear and equal bilaterally no crackles or wheezes. Heart sounds normal no murmur. Abdo not tender to palp epigastric. Strong peripheral pulses all limbs all neuro intact.
Less suspicious about pneumothorax but PE still concern.
Concerned about aortic aneurism.

POCUS – difficult due to bowl gas. Able to small portion of aorta approx. infra renal area a few cm above umbilicus. Did not see AAA but able to see dissection flap. Able to see normal outer wall of aorta with small flap pulsating in lumen. Looks similar to retinal detachment on ultrasound and knows what wavy floaty line.
Moved pt to trauma room. Initiated pain management, labetalol, ordered chest x-ray to observe mediastinum to determine type A or B. ECG – normal. Troponin – normal. D-Dimer – elevated >7000(helped add confidence to diagnosis but would not consider a negative d-dimer as rule out).

Consulted vascular based on POCUS findings. No CT contrast available. Did not want to accept care until confirmation with CT as false positive with POCUS common, and did not want to initiate transfer until confirmed. Uncomfortable due to not knowing if A or B type. Suggest non-contrast CT that showed displacement of aortic wall calcifications through arch to abdominal aorta below renal arteries which was unable to determine perfusion of kidneys. Suggestive of type B dissection. Reconsult with vascular surgery who were willing to take patient now but transport team no longer available.

Managed with anti-impulse therapy. Treatment at this point was several bolus of fentanyl and labetalol – some improvement with pain and BP. Pt BP still in 180s and HR in 70s
Vascular surgery set target HR and BP goals of HR < 60 and BP < 110. Started labetalol infusion and gave hydralazine. Placed Arterial line to help manage BP.
No nitroprusside or esmolol available at center.
Over 45min able to reach target vitals set by vascular surgery

Monitored urine output, creatinine, neuro status, distal pulses.
If end organ damage was happening limited to how to avoid/manage due to location. Over a few hours mild hypotension happened as pt was sleeping. Titrated labetalol but continued to allow permissive hypotension.

24 hours later patient sent to tertiary CCU and had CT angio – confirmed patient had perfusion to kidneys and lower limbs. ECHO – largely unremarkable. Esmolol infusion started. Medically managed eventually started on oral metoprolol. No surgical intervention needed. Patient sent home. Patient religion did not allow for him to accept blood products - possibly a consideration from surgical team to increase risk over benefit.
Patient had cognitive decline over time which is common around aortic syndromes. Appears more common in type A dissections that go on to have surgeries due to hypoperfusion. Unsure of causes in Type B cases treated medically.

Of the four presentations seen non have had “typical” presentation on exam of sudden ripping/tearing migrating pain. All had normal chest x-ray.

Anecdotally symptoms that worry the most is sudden onset severe pain with hypertension.
POCUS – Study
- aneurism flap sensitivity low 41% but specificity between 94-100%.
Mortality at 24-hour mark for dissections is 50%.
Have confidence if you are worried about dissection. Build on POCUS training use it as much as possible even on patients not overly worried about.

Learning to cope in severe resource limited environments with Ryan Bartholomew

Ryan - Other experiences in Guatemala with North American providers. This experience worked with providers from Kenya. Brought first patient into operating room, wanted to use propofol as part of induction and non was readily available. Anesthetist asked if there were other induction agents to use (which there was), but the staff were very good at looking at what was available to them in the moment rather than waiting for preferred medication.

Staff in Kenya protective of the resources they had and things were reused and cared for carefully. Western medicine treats everything as one time use and disposed of even if not used but opened.
Anesthetic machine did not have a gas analyzer. Every patient got 100% oxygen. Able to make ETCO2 monitor using T-piece in line with endotracheal tube.

Site only had one surgeon who’s available sporadically due to working multiple sites. Patients who needed surgery such as hernia repair had prolonged wait times where their hernias were problematic. Compared to North America, hernia repairs and management are done sooner and tend to be a nuisance diagnosis rather than debilitating.
Lipoma removal in North America often done in doctor’s offices. In Kenya getting access to remove lipomas is hard and very large in size ex. Removing 3 liters of fat off a patient’s scapula or 1 liter off a patient’s forehead.

Jon trauma case – 11 y.o. girl hit head and had a head fracture. General surgeon in Kenya wanted to do craniotomy. General surgeon from Canada surprised they do craniotomy as a general surgeon.

Ryan case - Patient with huge neck mass removal and total thyroidectomy. Normally with neck surgery use special ET tube that has wires inside and placed specifically to monitor nerves as you do the surgery. Kenya hospital had laryngoscope blades that stopped working at site a long time ago and were very hesitant to intubate anyone. If they had to, they used the hospital light staged behind anesthetist to try to light up the vocal cords. Pt woke up with some difficulties, concern for damage to the nerves in neck. Monitored patient for 2-3 hours and able to regain voice and speak normal. Came away from this case with a great appreciation for access to specialty equipment.
Equipment between 2-3 monitors did not work fully and needed to use multiple machines just to get normal set of vitals.

Motivation for volunteering for these experiences.
Ryan – has done this three times, two to Guatemala and once to Kenya. Got started by wanting to go help a friend and then fell in love with the idea of the training can be of help to others.

Guatemala – the foundation that volunteered with paid for the patient’s procedures. No bureaucracy and just able to help people.

Learn a lot about medicine and anesthesia and culture. More grateful and appreciative for what western medicine has.

As providers gained more experience by having to think outside the box and learning from locals and being brought back to basic principles of medicine. Also able to help teach others about tools used in western medicine.

https://thetangofoundation.com/

Encourage you to look at healthcare through a different societal lens and appreciate what we have.

Training pathway for CRNA – bachelor’s in nursing, 2-4 years experience in ICU then you can apply for graduate nursing program (3-year program).
Experience in major trauma centre under supervisor and rural hospitals had more independent practice.

Medicine in the developing world

Kenya – surprising that most health care is run by government entities. Administrators of the hospitals were elected officials. Whereas in the USA most hospitals are run as a business. Canada is similarly run. Goal is not to profit, rather how many people can they help for lowest amount of money.
Facilities built in 1970s and not kept up. Departments connected by outside corridors due to warm weather.
Beds did not have linen, patients just laid on the vinyl mattress. Focus was not on patients’ satisfaction and engaging/communicating with them. Did not really discuss plans with patients as patients who were there for surgery were just supposed to follow instructions with no question.
Speculating that for many patients who were seen that they perhaps did not have the money to afford a surgery and were grateful for the opportunity from the program and did not question the physicians. Could also be a cultural difference.
Ex. 11yo male patient in for an elective procedure hospital experience – day 1 patient had to wait to see a doctor, day 2 – fasted all day but unable to get to him that day – was given dinner. Day 3 – fasted all day till 3-4pm and patient was grateful just to get issue fixed.

Stats
☙ In the county (state/province) 1million people live and a total of 1000 surgeries each year.
☙ Canada in a small rural community of 15,000 people there are 1000 procedures a year. Getting surgery in that county is a lot more difficult.
☙ In 3 1/3 days completed 107 surgeries. Pace felt really slow.
☙ Find that non-western countries have a more relaxed approach to life

Resources
Day 1 – had gloves, Day 2 – scarce, Day 3 – no more gloves. Informed that the hospital bought gloves for the team but generally do no provide gloves on regular basis. This area has high rates of HIV.

Other site ran out of soap. They grate the soap into fine powder to preserve it.
Air conditioning at site but temperature was kept at a warmer state – around 27degrees, compared with most north American sites that keep it around 21degrees to help with infection control.

One OR had normal functioning lights, second OR had plug in light that functioned at approx. 10% brightness. Surgeon brought camping headlight as there was not enough light.
Power outages 9-10 times a day in OR. Batterie back up was enough to run a light and the anesthesia machine.
Many places had service for delivering babies but only during the day as there were no lights after dark. Some places were managing deliveries/post-partum issues using the lights from phones.

In North America many supplies are single use only. In Kenya things are reused such as LMA’s and disinfected in cleaning solution for 5 min.

20yo male MCV – pickup truck vs Semi. All other occupants were pronounced dead on arrival. This patient was the only one transported. Prolonged extrication (over 1 hour), head injury, left femur deformity. Conscious and talking with EMS - initial BP 90/60.

STARS auto launched to hospital as per protocol. EMS patch - List of concerns when receiving patch from EMS
- Hypothermia
- Hemorrhagic shock
- Other traumatic injuries
Prep for patient
- Turn on bear hugger
- Get ultrasound ready
- Get non-crossed matched blood (this site only has two unit)
- Anticipate intubation – meds and equipment
- Nurses assigned team roles – team very well practiced
EMS arrival – CPR in progress
- PEA whole time
- EMS only able to place pads and get iGel for airway
- Left femur was double/triple size of unaffected side.
- BMI approx. 35
- Tourniquet applied by EMS
- No vascular access obtained

Priority of obtaining vascular access – IO started and began infusing blood. Multiple IV attempts made – difficult due to hypothermia and hypovolemia with success eventually in peripheral site.

Airway – poor air entry to both sides of chest. BVM not being effective. Intubation attempted – laryngoscope blade light dies prior to intubation – unable to get new one with light. Replace iGel – challenges to ventilate due to poor seal. Reattempt intubation with ET tube once batteries changed with success and good ventilation and ETCO2.

Look for H’s and T’s challenging to remember. Look for MECHSDEATH
M - MI
E - Embolism
C - Cardiac Tamponade
H – Hemo/pneumo
S – Shock
D – Drugs and toxins
E – Electrolytes
A – Acidosis
T – Temperature
H – Hypoxemia

Ultrasound

Rule out tamponade and pneumothorax first as many of the other factors are being treated.
☙ Lung slide on left of chest absent – 14 g IV catheter – anterior approach attempted with no success. Lateral attempt also attempted with no hiss of air but able to withdrawal several ml's of air. Moved on as there was not enough to spend time doing finger thoracostomy.
☙ Cardiac tamponade – no pericardial effusion but does show poor filled ventricle and cardiac standstill. CPR has been ongoing for 25 min with left thigh continuing to expand. 250ml blood infused at this point.

Patient required greater care than what was available – trauma center with surgeon and blood bank.
Site did not stock central lines

Retrospective review would to be obtain central vascular access ASAP. IO was slow to infuse and challenges with obtaining vascular access and other IO sites limited ability to infuse blood faster.
Called code and had debrief with nurses and paramedics

Learning points
1. In an arrest or peri-arrest stopping the bleed is priority. TXA and crystalloid would not have made a difference. In many other cases however, they do.
2. Don’t trust airways. Clinically evaluate them and make sure that the chest rise and ETCO2 readings are matching the surface appearance.
3. Try to maintain situational awareness.
Patient was known to hospital and community, and the day before had gotten engaged. Normally attempts to forget and depersonalize experience would be made but try not to, this is what leads to burnout. Avoiding feelings and processing of what terrible things happen to others doesn’t help us, it bottles up until it becomes a problem later. If feeling dread before going to work take 5min to do Maslach burnout inventory and take steps to prevent burn out.

With Dr. Sarah Giles

Tools available for burnout
- Acknowledging the sense that something is not right
- Maslach Burnout Inventory

☙ 6 Risk factors in burnout
- Mismatch in workload
- Mismatch in control
 - Lack of appropriate rewards
 - Sense of positive connection in the workplace
 - Perceived lack of fairness
 - Conflict between values

Know there is an issue when you stop caring about the injustices seen at work.
Every province has a Physician Health Program (PHP)
Ask for help earlier – similar to how you want a patient to come see you sooner with a problem rather than waiting until it spirals.

Know that sometimes leaving is part of cure – it is not a failure.

Assault – Patient came in after binge drinking after abstaining for a prolonged period due to incarceration. Was agreeable to getting baseline labs, as there was no record and medications to treat symptoms. Reassessed patient several times, and last time in on moment patient was on top of Sarah. No security in hospital, no one saw anything, but they heard it, and Sarah was able to get away, not physically hurt and the patient did not pursue. Felt incredibly shaken and had to change clothes due to being incontinent. Went to locker, changed and went back to seeing patients immediately, and next patient had similar presentation to patient who just jumped Sarah.
Nursing supervisor came down, police called – stated no charges to be laid and that Sarah probably just woke the patient up in the middle of sleep. Didn’t not hear from anyone from hospital for seven days. Sarah had to reach out, and everyone was on vacation so no clear line of communication for this type of event.

Changes since this event include renovation of the ED, increased night staff, dedicated security.
Didn’t matter how well patient was treated, there was no control in that situation.
Changed approach to how to deal with patients in ED.

If you are dreading your job and life, you owe it to yourself and those around you to make a change. You only get one life

IF interested in working in Kenora - look up hospital number and ask switchboard for physician recruiter who manages locums.

Dr. Sarah Giles

April 22- 26 SRCP Conference

Sara wrote Article about burnout
Working as a locum – covering physicians. Moved to Kanora Ontario during COVID. Initially saw a decrease in patient volume due to people being scared in early time of COVID

Started to develop feelings of being overwhelmed and that nothing she was ever enough.

Study comparing physician burnout rates because of the pandemic 2020 vs 2022. Increase in emotional exhaustion and increase in depersonalization. Common themes include:
- Broken healthcare system
- Lack of societal support
- Systemic workplace challenges leading to physician distress
- Loss of physicians from workforce.

Reading accounts of what was happening in major cities like New York and countries like Italy felt like you were putting your life on the line going to work so others could live. Felt that healthcare workers became the bad people and dealt with open distain from patients and community

Mistrust with vaccinations and treatments and people’s beliefs in conspiracy theories.

Attacked by a patient – realized that community, institutions can’t love you back and only want services and don’t think about the providers.

Writing the article was about creating awareness and giving a human face to the issues that healthcare workers. We see patients frustrations with the system and understand because we work in that same system.

Pandemic changed society to be more focused on the individual rather than the collective when they had to pick and choose who was in their bubble and nations became more nationalist and regions focused more on themselves.

Recognizing burnout
- Slow boil
- Took on scheduling
- Working more shifts so colleagues could have time off

Started feeling undervalued at a time patient volume was increasing – created anxiety with worrying about getting patients what they needed.
Got to the point of feeling like “I can’t do this anymore.” Turned to department head who helped sort out what was needed to continue moving forward.
- Having supportive community makes a huge difference

Being able to take a step back and not work as many shifts allowed for more time to not worry and obsess about work as much
Feel that by stepping back was able to become more efficient in work
Learned that different people have different capacities, and different preferences for workload and that changes with time.
Encourage residents close to graduating to consider locum work and experience different sites.

https://www.cbc.ca/news/canada/first-person-burnout-health-care-rural-doctors-1.7382033

https://www.sciencedirect.com/science/article/abs/pii/S0196064424000210

https://media.discordapp.net/attachments/1017835177407414322/1325925511423066132/IkYm8FSAAAAAElFTkSuQmCC.png?ex=67a279dc&is=67a1285c&hm=f43d40d78d98f588702a99d959c18d3a1c565d824c8204381e56d2252fad16c0&=&format=webp&quality=lossless&width=1658&height=936

Question of “what is the worst thing you have ever seen” from non-medial people and for some practitioner’s death in children and infants can be the hardest most emotional calls.

When dealing with poor outcomes in children it can have long standing effects.

Don’t be caught off guard by the magnitude of the emotional impact and the length of time to process.

Debrief – within first 24 hours and follow up within a few days to answer any additional questions maintain open dialogue

- Debriefs help to bring some degree of closure

- Don’t underestimate the impact of a debrief and different needs/care that members of the care team may or may not need

- hold space for them when they do need help

Case

Only Anesthetist on call in community, at home and called in for 10week old not breathing that EMS was transporting to hospital.

6 min drive along highway and made it to hospital in 4 min and arrived before the ambulance. But outcome made no difference driving to save seconds or min not worth the risk.

15min to prep – grabbed neonatal warmer for resuscitation.

- Try to think about all equipment you need and different possible outcomes to be ready if you have time to prepare.

- Assign roles

- Able to get PICU team on phone and consult

EMS arrived – iGel in place, ventilating, CPR in progress, cardiac monitor stickers applied.

Scooped baby and brought into ED and placed in warmer – rather than trying to move giant stretcher and then move.

Baby is pale, cyanotic, no tone.

Continuing with resuscitation. IO placed, labs drawn.

Following PALS and consulting with PICU

History – family put baby to sleep around 4:30 and check on her an hour later pale and not breathing and call 911.

- CPR given by EMS for approx. 25 min

Parents confirm patient is healthy to best of knowledge. Considering SIDS as cause of death

Intubated pt, managed to maintain continuous CPR and follow PALS algorithm on point.

- Blood work had no major clues as to cause of patient condition

- Ultrasound – looking for reversable cause

Two sides of being a doctor – Doctor mode – 99% of the time. Resuscitation mode 1%

Attempted resuscitation mode for approx. 25 min longer

At one point during resuscitation had a moment of human connection and realized emotions were starting to get higher and had to turn resuscitation switch back on.

Colleague who was on phone with PICU ultimately stated they did not think there was more to be done. Asked the room if there is anything else that can be done before ending resuscitation. Parents were in different room – went to talk to parents and see if they wanted to witness resuscitation and parents did want to see what was happening. After a few min of touching babe while continuing with the resuscitation asked the parents if it was ok to stop and dad nodded yes.

Hardest part of resuscitation is dealing with the parent’s reactions to the news.

Removed IO, monitor, ET tube removed so the family could hold baby

After family had time with baby, protocol followed to transport to morgue.

Found EMS crews and had a debrief for crew. Be mindful of the different scopes of practice that rural communities have and the power differential for each profession. You may have people with basic training and minimal exposure to these types of events.

After a few days found all the staff and checked on them.

***If you are struggling don’t suffer in silence and reach out to a trusted colleague who understands your situation.***

If you are struggling with anything work related reach out to any of the numerous mental health supports in your area. DON’T suffer in silence.

Volume 05:

Quick Links:

Volume 05: #101 - present

109 - All about the SEME Program

108 - Aortic Dissection

107 - International Healthcare/Volun-tourism

106 - Medicine in Rural Kenya (Part 2)

105 - Medicine in Rural Kenya

Description: 24 Minute Video

104 - PEA Exsanguination

103 - Assault by Patient (ENJOY your career Part 2)

102 - Burnout (ENJOY your career Part 1)

101 - Death of an Infant

Quick Links: