Our ED in Bella Bella is extremely small and filled (cluttered) with aging, sometimes broken equipment that isn't particularly well organized.
We are struggling with getting a modern cart-based point of care ultrasound machine to use - lots of back and forth on this with VCH but it seems like it is finally happening.

I addition to getting a modern PoCUS machine, I am trying to advocate for an overall update to the ED, and have been tasked with putting together a list of asks. I've attached it to this post.

I'm struggling with making specific suggestions - all I really want is equity between the other VCH ER's and us so we can provide exceptional care everywhere.

Are there no resources that can help with standardization between departments?

My list is viewable here:

View List

What are your thoughts on my list?

Good Morning,

I am wondering if there has been any consideration given to the potential long-term consequences of these types of stop-gap measures [LOCUM requests].

When I see this email [Urgent LOCUM e-mail request], my thoughts are as follows: Wow, I wish I could pop over [to the requested LOCUM location] and work Dec 26, 27 and take home [The LOCUM remuneration offered ($)].  Oh, wait.  I am already covering my local, rural ED those days.  And I'm making SQUAT in comparison [on contract] for a busier emergency department.

I've applied for coverage through the locum program [before], but whose covering for me when they can go [to the requested LOCUM location]?  Clearly no one.

I am a free agent and therefore I can work where I choose.  I sincerely hope these community EDs find coverage and I appreciate the challenge [they're] facing.  I merely want to point out that I have a concern that this approach to an imploding rural ED will serve to fuel the erosion, by further frustrating those of us who are still providing care for much less remuneration in our own struggling communities.

Disclaimer:
*The contents of this message have been modified from its original version to help other readers understand the context.
*The views and opinions expressed in the public topics section are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

Some recently published data from Alberta (Hawkins, Ann Emerg Med 2021; disclosure: I am a co-author) indicate that the one-year mortality of emergency department patients with atrial fibrillation and flutter are similar no matter whether you the patient is treated in a high-volume or low-volume ED.

However, patients in low-volume EDs are more likely to be admitted, less likely to be cardioverted, and are more likely to have a 30-day revisit than those in moderate- or high-volume EDs. The reasons for these disparities in care and outcomes are unclear, but would be of great interest. For what it is worth, the data examined patients from 2009 to 2015--the CAEP AFF guidelines were published in 2018, and these may have assisted in standardizing care across EDs. (https://caep.ca/wp-content/uploads/2018/09/caep_acute_atrial_fibrillationflutter_best_practices_checklist_final.pdf)

Thoughts?

The Hawkins paper is at https://www.annemergmed.com/article/S0196-0644(21)00227-4/fulltext (paywalled of course).

For those unfamiliar with Twitter, know first that it's just a communication platform, a tool, and like any tool, needs to be used correctly. Creating a purely professional account with good "Twitter hygiene" can ensure that it remains worthwhile. What Twitter feeds to you depends on your behaviour - who you follow, what you like, what content you click on. The algorithm thrives on keeping you engaged and it will always throw trial balloons on your feed to see what you ignore or not, all the while learning what makes you angry or sad - and then sending you more of that. If these click-bait teases are ignored, you'll get more of the content you want - rich discussions with emergency medicine leaders, researchers and policy makers from BC and across the country.

It does help to define ahead of time what it is you are most interested in professionally, then go into Twitter with those interests first and foremost guiding your behaviour. For me, it's POCUS, rural medicine, emergency and crit care and BC health policy. And that's it. No posts of family, friends, holiday photos, cats, news articles - nothing. In other words, I am a rural BC doctor on Twitter and nothing else. Posts relate to my professional interests. Patients are blocked. I post interesting ultrasound clips for learning and teaching. The people and topics I follow are only those related to my professional interests. This is MedTwitter.

Individuals or organizations with accounts are indicated by "@" followed by the name. So the BC Emergency Network is @BCEmergMedNtwrk. Dr Julian Marsden is @drmarsbar. I'm @TracyMorton. You can choose whatever name you'd like.  And topics: topics are marked with a "#" followed by the topic. This is known as a hashtag. So point-of care ultrasound is #POCUS. MedTwitter is #Medtwitter. There are gazillions of topics, all signified by the #. You can deep dive into any topic just by knowing the hashtag.

So follow your peers. Follow FOAM leaders like Scott Weingart (@emcrit), Chris Hicks (@humanfact0rz), Anton Helman (@EMcases), Amal Mattu, Salim Rezaie and Haney Mallemat. Follow ultrasound wizards like Dan Kim, Katie Wiskar, Paul Olszynski, Robert Jones, Ben Smith and Jacob Avila. And follow people who they follow.

Soon you'll be getting just the ED/POCUS/crit care content you want, and not the crap you don't.

Drs Steven Green and David Schriger have now been far more eloquent in a recent Annals of Emergency Medicine publication (2021). In brief, here are the "good" aspects:

1. The study population is relevant

2. Predictor variables recorded independently of outcomes

3. The rule is widely used, clinically sensible, easy to apply, and can be integrated into practice.

Here are the "not good" aspects:

1. Initial sample size (122 patients with 29 MACE) not justified and insufficient.

2. Many predictor variables (for example, patient sex, type of pain) were missed, and included variables had poor inter-observer reliability, especially "history".

3. No justification for coding (ie 0, 1, or 2 points) For example, patients > 65 years with 3 or more risk factors have an automatic score of 4 (moderate risk) prior to any evaluation. NOT GOOD. While HEART score was supposed to be "Apgar for chest pain" the points are too heavily weighted to EKG, risk, and age, and insufficiently for history and troponin.

4. Importantly, despite many, many studies on the score, no one has compared the rule to unstructured physician judgement.

5. The rule sensitivity is not acceptable--most physicians will accept a 1% miss rate, and the sensitivity of the HEART score and its variants is greater than this threshold.

6. The HEART score does not inform clinical decisions with respect to follow-up.

Overall, the score provides a simple, comforting algorithm--in addition to a catchy nickname--and this likely accounts for its widespread popularity. However, clinicians are encouraged to think rather carefully about widespread application of the HEART score or any of its variants.

Happy to engage in further discussion!

It's surprising how few posts there are about point-of-care ultrasound use in the ED on the BC Emergency Network. It is entirely changing patient assessment and management in rural BC, with need particularly amplified by COVID-19.

On Haida Gwaii, access to diagnostic imaging entails a 7-hour ferry ride (each way) and between 2-5 nights away from home. Compounded by high rates of COVID-19 throughout Northwest BC and the risk of acquiring and returning infected, the majority of patients are very reluctant to go for indicated formal imaging. There is an imperative to scale and support safe POCUS use in rural BC while looking at ways of improving systems-level supports.

Recognizing its potential, the Rural Coordination Centre of BC (RCCBC) launched the "Intelligent Network for POCUS" - IN PoCUS, where 50 subsidized Clarius handheld probes were distributed to 50 rural GPs with education and support. The Clarius user interface integrates secure cloud image-storage that permits image review by specialists or virtual support tools (like RTVS). Building on IN PoCUS, the RCCBC will be developing a Provincial POCUS Strategy for rural BC. A working group of POCUS leadership will develop a Strategy this year, evaluating barriers to POCUS integration and means of improving its effectiveness and safety. An effective strategy will include a higher profile on the BC EM Network.

The BC EM Network could be a place we share images and clips and discuss the geography-specific role for POCUS in the ED. For austere or remote environments without CT or diagnostic US, nothing improves bedside care more than POCUS. Embedding POCUS into physical examination allows one to look into the body, seeing things that could only have been percussed, palpated or auscultated. Imagine the "rational clinical exam" fully revamped with POCUS integration.

Tracy Morton

Haida Gwaii Hospital & Health Centre