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Primary care needs immediate support for longitudinal care
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I wonder if we can be a louder voice for our primary care colleagues for faster reform and assistance for longitudinal primary care.
There is an urgency to this in that the system is already collapsing and by some estimates 1/3 of FP's are over the age of 54. All those patients with nowhere to go will be coming to our ER's, and the urgent care clinics have not proven an effective solution to long term care issues.
Read my post and let's get a thread going as to how we might be able to advocate:
https://www.timescolonist.com/opinion/comment-physicians-need-to-be-paid-fair-salaries-5256489
Jason Wale
April 13, 2022
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Rural ER Equipment and Organization
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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:
What are your thoughts on my list?
Gregory Costello
November 26, 2021
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I would love to see a standardized baseline equipment list for emergency rooms/departments in the province of BC. I'm unsure what body would be best to generate such a list or if one already exists.
OH BOY. The first strong data on long-term cardiovascular complications is far from reassuring.
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Researchers at Washington University in St Louis analyzed 154 000 Veterans Affairs (generally whiter and 90% male, median age ~63) patients who survived Covid in 2020, and compared them to 2 cohorts of nearly 11 million patients.
The 1-year rate of excess major cardiovascular events (acute coronary syndrome, stroke, heart failure, cardiac arrest, atrial fibrillation) was 45 per 1000 patients. Over this short time frame, it appears as though Covid-19 is a major independent new risk factor for cardiovascular disease.
It is unclear whether the mechanism is direct myocyte damage, viral persistence, inflammatory response, thrombotic issues, vascular endothelial damage, or any other mechanism or combination thereof.
While this will need to be replicated in other groups, over different time frames, and with vaccinated patients, it may be reasonable to inquire about prior Covid infection when assessing patients for potential cardiovascular concerns.
What do you think of these findings?
Best, Frank.
Admin
February 22, 2022
Template for Document of recovery from COVID for travel
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I'm doing my best to streamline the process in an already busy ER.
Thanks.
Michael Garrard
January 24, 2022
Concerned about increasing LOCUM coverage needed.
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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.
Admin
December 13, 2021
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First of all. Thank you for the work you do supporting your rural community and we regret the negative impact these crisis funding measures have had. Your comments highlight the extreme tensions we felt with implementing this funding. Multiple factors lead to the breakdown in services at these rural ED's. We had a choice to implement or close an emergency department. Closing the department would have left the rural community and multiple surrounding smaller communities with a 2-3 hr drive to the closest ED. Despite the potential harms, the decisions was made for patient safety. This is a short term solution. Ongoing discussions are happening on how to better support stable high quality emergency care in our Rural ED's. We are open to any suggestions you might have on how we can stabilize ED care in our rural communities.
Kind Regards,
Dr. Aron Zuidhof
Atrial fibrillation in small-volume EDs
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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).
Frank Scheuermeyer
August 10, 2021
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1. Rural hospitals often have more beds to admit to - a major influencer on admissions is a capacity to admit. Rather than thinking rural hospitals admit too often, it could be that high volume hospitals don't admit enough.
2. Often rural/remote patients are well, remote from even the hospital so follow up is more challenging. For example, in our catchment, we have a community of 400 on a nearby island with no overnight access to hospital. Patients with new fast AF from Sandspit will be admitted out of compassion and common sense.
3. Electrical CV is inherently more risky in lower volume EDs as many won't have anesthesia, IM or cardiology and comfort varies with sedation.
4. Revisit rates - rural EDs have much shorter wait times and often handle lesser acuities as a result, lowering barriers for many who may not wish to present to a busy ED and sit long periods in a WR.
#MedTwitter
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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.
Tracy Morton
May 16, 2021
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The HEART score is popular and awful. Fight me.
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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!
Frank Scheuermeyer
June 6, 2021
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Jason Wale
Royal Jubilee Hospital
April 13, 2022