RnR Rounds Podcast

Laura Noack – rural generalist

Important things to note with vaginal bleeding are:

Examine patient! It can take multiple trips to ED for patient to get proper exam (often due to lack of privacy, equipment, staff)

Water safety – injury to perineum due to water sports (jet skis, watercraft, waterslides)

Example 1

44yo female riding passenger on jet ski wearing bathing suit and life jacket (PFD). Driver makes sharp turn, and she falls off resulting in severe pain and vaginal bleeding.

Need to examine to determine location of bleeding – vagina, cervix, intra-abdominal, rectum.

Vagina and uterus closely connected with lots of vascular tissue. If bleeding pack vagina. Rolled 4x4, kerlix gauze (lubricate to place in vagina, infant BP cuff wrapped around 100ml or 250ml fluid bag covered in sterile glove and lubricated and placed in vagina and inflate the BP cuff above pt systolic BP – can tamponade.

Injury comes off the forceful jet off the watercraft can result in a vaginal or perineal douche causing a laceration.

If injury just in perineum consult with OBGYN if not comfortable managing on own or if more in-depth obstetrical repair needed.

Can be same as vaginal tear during delivery. Can be high lateral wall (where vaginal arteries are located) can cause brisk bright red bleeding and cause hemodynamic instability. Needs sutures, with good lighting and most often done in OR setting.

*Waterslides – lifeguards tell people to cross their legs when going down to prevent this type of injury.

Men also at same risk.

Manufacture of jet skis – recommend neoprene shorts or wetsuit or even pair of jean shorts to prevent these injuries.

Example 2

Young woman who had never had menstrual period before and at home, started having copious amounts of bleeding and brought to ED.

Put in trauma bay, due to large volumes of blood in ED – blood was dark, brown, and thick.

Vitals

P-122

BP – 130/80

afebrile

Spo2 -normal

unknown if tachycardia caused by anxiety or blood loss.

Consult OB

Two large bore IV, crossmatch blood, started resusitation – no exam done

Abdomen had mass that went up to umbilicus felt like 20week fetus. External exam looked like a cystocele – there was a bulge with a small opening that was the source of dark red/brown blood. Internal exam – no vaginal opening patient aware for about two years but did not seek medical attention due to not wanting a period.

Facetimed with another OBGYN. Procedure was to make cruciform incision over hymen to allow for drainage. Then empty out remainder of blood. Don’t worry about the blood loss, it is old blood and hasn’t been in circulation for a long time. Will not affect hemoglobin. Could suture open but typically use vaginal dilators. Uterus will take several months to shrink back down to size

Call from prison nearby for inmate who had been stabbed in chest 15 times. Physician on site assessing patient concerned about chest, wanting x-ray and sutures.

30yo male arrived via EMS sitting bolt upright on stretcher. Patient has a slim build, complaining of some difficulty breathing noting some accessory muscle use, and not wanting to move his head. No shirt, lots of bulky dressings covering wounds (especially shoulders) and small punctures around body.

EMS – started IV, gave dose of TXA, O2 via NC @5lpm – Spo2 95%.
BP 155/95
HR – 132
T – 36.7
R - 32

No stab wounds noted to anterior of chest. 20 wounds found on back were mostly superficial and less than 1cm.
RCMP inform weapon was a stainless-steel rod approx. 5mm diameter, 25cm long and sharpened at one end with a makeshift handle.

Most concerning wound was posterior left lower back – covered with three-sided dressing and small amount of blood.

Initial exam – no major concern from most of the wounds, still suspicious due to pt dyspnea.
POCUS – want to scan the least dependent area of the chest due to air rising. Ideal position is supine to allow air to rise to anterior aspect of lungs. 3-4 intercostal.
Attempted to lay down but to uncomfortable. How to assess pneumothorax sitting upright?
- Go to x-ray – in this case would have causes significant delay (no tech on site)
- Give patient medication – concern over respiratory effort.
- Scan anyway – if pneumothorax large enough separation would be visible around second rib.

Bilateral pneumothorax clearly visible
- O2 – now trending down into low 80’s – increased O2
Two options – needle decompression or chest tube in directly.
No signs of tension pneumothorax – concerned with an impending tension pneumo.
Chest tubes time consuming opted for needle decompression
- 16g IV, froze site with lidocaine as patient was stable enough.
- 4th intercostal mid axillary line – New ATLS guidelines
- 2nd intercostal mid clavicular – old guide – went with this option due to patient position.
- No longer recommended due to higher frequency of missing lung space.

Could easily palpate ribs in this patient and as needle placed noticeable hissing sound of air being released.
Attached 3way stop-cock to catheter, hooked up to 20ml syringe to second end, third end open to atmosphere. Able to close valve and withdraw air as needed. Repeated process on other side of chest – no air release but able to aspirate air easily. Spo2 – increased to 100%, patient able to layback on stretcher, no longer able to aspirate air. Patient reported easier breathing. Decreased O2 from 10lpm via NC to 2lpm and maintained SPO2 of 100%, and within a few min was able to discontinue oxygen completely and patient maintained 100% Spo2

Vitals improved
BP – 150/90
P - 122
R – 22

Beware of measurement – gauge – the higher the number the smaller the diameter. French – the higher the number the larger the diameter.

No chest tube tray on site, had to use materials from different trays to make up correct equipment.
Ketamine 30mg to start (episode 34 is all about ketamine if wanting to know more). Benzodiazepines and opioids will not allow for respiratory security the same way. This does did not change patient respirations.
- Numbed site 1% lidocaine with epinephrine
- 6cm incision down to muscle (three finger breadth)
- 5ml Lidocaine into intercostal muscles
- Blunt curve scissors used to dissect and felt a pop and rush of air
- Used finger to feel into cavity – no organs felt just air.
- Advance chest tube using Kelly clamp along finger into chest cavity trying to guide posteriorly and superiorly
- 20cm went in with no resistance.
- Attached to pleur-evac
- Suture wound and secure chest tube.
- Second chest tube placed, and x-ray taken to confirm location of tube. Confirmed with
- Sedation q 20 min prn.

Ultrasound – pneumothorax decreased significantly on right. Left side was decreased but still present. Both pleur-evacs bubbling.
Heart Ultrasound – no pericardial effusion. Good left ventricular function. IVC was good.
FAST scan of abdomen difficult due to dressings of chest tubes to fully appreciate any fluid. Could only visualize inferior pole of kidneys. Unable to see triad of diaphragm, renal interface, or spleen or liver tips. Pelvis clear.
Hemoglobin – 144 gave more reassurance no major internal bleeding.

Retrospective - missed out on calling in second physician.

After stabilizing patient, EMS dressings removed and most covered with clear occlusive dressings as they did not require stitches
Total 150mg Ketamine given over an hour – possible cause to persistent increased HR.

Take Aways
1. Size and location of stab wound means nothing. These wounds were unassuming and did cause a lot of damage with potentially fatal outcome.
2. Do as I say not as I do. ALWAYS call for help – based on EMS patch alone or as patient roles in and notice an issue or at any point – call for help.
3. When recognize life threatening situation – must act immediately. HALO – High Accuity Low Occurrence events can cause practitioners to freeze and delay care waiting on consult or help.

Over 150 Ultrasound courses offered in Canada this year. Most people need 2-3 courses to start feeling comfortable with using POCUS.

*Some chest wounds are so severe they require multiple chest wounds so don’t limit yourself to just one per side if patient presentation requires more.

2025 – worlds worst measles outbreak in many decades. Was considered irradicated in 2008.
Measles 101 as per Alberta Health Services.

☙ Highly contagious virus that spreads through air when infected person breathes, coughs, sneezes
☙ Can have serious and lasting impact on those affected.

☙ Can be serious at any age but more so in children less than 5, pregnant women, and those who are immunocompromised
☙ 1:10 develop ear or lung infections including
☙ 1:1000 develop encephalitis that can lead to seizures, deafness or bran damage
☙ 4-11:100,000 develop fatal brain disease 10 years after infection.
☙ 1-10:10,000 death

Common signs and symptoms
- Fever
- Four C’s
o Cough
o Coryza (runny nose)
o Conjunctivitis – extreme
o Koplik’s spots – small white spots inside mouth or throat
- Rash starts 3-4 days after fever starts.
o Starts behind ears and on face
o Spreads down the body to arms and legs
o Appears red and blotchy on lighter skin, purple on darker skin that appears to be spackled on creating larger plaques that look almost layered.

Cough, Coryza, and Koplik spots are more subtle. But looking at conjunctivitis and rash on patient’s body unmistakable in diagnosis. Patients look unwell.

How to manage extremely contagious patient in limited resource setting
- Had patient call in before entering department and nurse would go triage patients from their cars and remain in their cars pending no major findings.
- Physician would then go out and assess wearing full PPE, with stethoscope, otoscope, and Spo2 monitor and assess patient outside in well-ventilated area.
- Checking regular viral assessment
o check ears for no otitis media
o listen to lungs, check work of breathing and SPO2 normal limits
o check LOC
o look for signs of encephalitis
o check for dehydration

No good treatment for measles. Good at preventing it but otherwise it is supportive therapies.

Kids with some complications who needed oxygen due to low SPO2 – consult pediatrics who would sometimes discharge to home as levels were ok, and others when they were sent to tertiary hospital for further evaluation.

Several children had complications with pneumonia requiring intubation. No pre-existing conditions or co-morbidities

One patient had encephalitis and transported to ICU – prognosis poor once developed up to ten years later.

Moving forward when asking a patient who presents with confusion need to question if patient had measles within last 10 years.

Most patients were from a community who chose not to vaccinate.
Testing similar to COVID with nasal swab. Process time 24-36h
Outbreak management remains, supportive care for majority of patients, and transport for those with more severe complications. Tracking of outbreak important.

Another patient came in with cough and rash that was not like measles rash. Rash was more isolated lesions more dark brown in color that appeared scabbier, that appeared at different times over several days. Other child had chicken pox. Once you have seen and dealt with it you can start to see the difference in presentations.

Have a high degree of suspicion with cold and flu season for ordering virology but keep in mind patient presentation.
**Have your immunization info up to date and readily available because if not you might be required to quarantine if unable to prove status until infectious period over.

Melissa Bulloch

Logistical considerations around transport
- Unable to use air ambulance – had to use ground ambulance. This required sending staff to go on transport. Needed someone who could manage ventilator and airway. RT and nurse sent to manage airway and medications.

Update on patient – extubated, follow some commands. Significant vision issues, requires PEG tub. Concerned for long-term impairments. Had emergent neurosurgery – ongoing cerebral spinal fluid diversion. Unsure of management. Query as to why patient had the bleed in the first place (still unknown). Possible factor of uncontrolled BP or an underlying aneurism? Lifestyle a known major factor but can also be genetic predisposition.

Take away
1. Always worry about AB in ABCs with danger zone patients that you know need imaging and their potential to decompensate rapidly.
2. Ask for clarification on ventilation and adjunct medications to help with ICH. Did ask about PCO2 targets. No arterial line available but was able to use ETCO2.
Understand that based on un-infused CT scan that requirements to continue with infused CT scan no longer required as confirmation of ICH found, and patient deteriorating condition takes priority. Good communication to team on why not to continue is important and understanding that overriding specialist request can be intimidating but patient safety is priority.

POCUS – did not factor much in this case. Did use it in primary survey for quick look at cardiac function which was normal. Also looked at lungs due to work of breathing and O2 requirements – normal. After intubation noted some issues with the ventilator and used to check lungs again. Not overly helpful in ICH. Babies with unfused fontanels can be used, or to look at circle of willis in adults.

Case with Melissa Bulloch
Located in regional rural facility 1 hour away from Winnipeg (main tertiary site)
- CT, on call general surgeon, anesthesia for obstetrics. No ICU or Pediatrics.

Temp -20s, EMS patch for 50yo male found down, hypothermic.

Solo physician, called for additional nursing backup. Bear warmer.
GCS 12 on arrival, intermittent responsiveness with EMS.
Larger sized patient, no past medical history or meds. Concern about acute injury and concerned with head injury.

First impression was concern of stroke was cause of collapse. Lateralizing symptoms noted. Abnormal vitals.

Airway – was being maintained but sleepy with intermittent snoring. NPA rejected
Motor exam – holding left lower extremity in extended stiff position, upward Babinski bilaterally. Held in flexed position at elbow and wrist. Right side spontaneous movement initially – fighting IV. Right leg flexing and extending at knee.

Vitals
Rectal temp 36.8 remove cold clothing and apply warm blankets.
BP 214/117
P – 110
R - 30
Spo2 - 98% via NRB decreased to NC and maintaining

Code 25 Stroke – CT scanner present and can consult via video with neurology.
Brought all airway management supplies to CT scan
Labs – basic metabolic panels, ETOH, acetaminophen, rule out.
ECG – sinus tach no ischemic change

Moving pt to CT – pt begins to vomit. Suction airway order for Zofran. Pt becoming more combative. Managed to get uninfused scan done. Acute hemorrhagic bleed noted on right side. Vomiting. GCS 9 discontinue injection portion of CT and head back to resuscitation bay.

Messaging APP – allows for connection with specialists throughout province. Message previous neurologist to update.
Intraparenchymal hematoma – Right basal ganglia thalamus region 4.5cm with associated mass effect cerebral edema left midline shift and central herniation extension of bleed intraventricularly.

Treatment – usually followed with neurosurgeon consult
- Elevate head of bed
- Lower blood pressure – labetalol decreased to 180s/100s. considered additional bolus
- Secure airway – intubation went well. RT helped with setup. RSI etomidate and rocuronium. Due to unknowns and more contraindications of using succinylcholine went with longer acting paralytic even though it’s not recommended due to possible delay of neuro exam at tertiary centre. Consider total time between patient transport to hospital – most likely will wear off. Patient safety most important! Challenge with intubation – caught on tooth and bulb did not inflate. Exchanged tubes. Used glide scope with hyper angulated blade. Know your site and equipment.
- Osmotic agents to try to reduce edema

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

114 - Vaginal Bleeding Made Bloody Easy

113 - The Shivving (Fifteen stab wounds to the chest)

112 - Surviving Measles in 2025

111 - Full Rural Resus & Stabilization (ICH) - Part 2

110 - Full Rural Resus & Stabilization

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: