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

We want to make this a minimal barrier process, ideally with patient leaving with a blister pack of Suboxone micro dose with instructions and daily partitioned doses and linkage to outpatient OAT providers.  It may take several days to get to outpatient provider so dispensing multiple days of the induction regime makes sense.

We have come up against a hard barrier of inability to dispense more than 24 hours of medication from the ED according to our pharmacy colleagues.

Is this a legislative barrier, an edict from college of pharmacies or a local health authority ( Island Health) issue?

Has anyone been able to set up a program that allows them to dispense blister packs from the ED for this vulnerable population?

It seems with the opioid death rate and the extra financial and political resources cast into this arena that this sort of barrier should be easily surmountable?

Jason Wale, Victoria BC

Just wondering if there is any work/research/thoughts anywhere about what are the minimum standards to work in an ER. I see some ERs have no lab or XRAY. Some have limited POC. Some have one nurse and others have none. In some ERs , the docs are first call.

Is there a link between the population, which in turn dictates the acuity and frequency of the cases and the minimum standards ER docs need to have to support quality care?

Just curious if anyone has ever thought about this?

Hopefully the attachment works for everyone--while the document is 102 pages, the relevant points for emergency physicians have been highlighted to avoid eyestrain and guideline rage, and most of the germane information starts on page 38 (anticoagulation) and on page 51. (ED management)

Good news: The main points of ED management are now aligned with the CAEP guidelines.

1. Ensure patient is stable, otherwise immediate cardioversion (this is rare).

2. Ensure no acute underlying cause; if there is an underlying cause, please identify and treat

3. a. For patients with acute onset atrial fibrillation or flutter, (generally less than 48 hours, but less than 12 hours if CHADS2 > 1) please use a rhythm control method.

3.b. For patients who cannot be undergo rhythm control, attempt rate control.

4. Unless a patient is still symptomatic after treatment, or if the heart rate cannot be decreased to less than 110 beats per minute, patients can be safely discharged.

5. Pay attention to anticoagulation! At least discuss with patients and document appropriately.

Bad news: CCS has again emphasized 4 weeks of anticoagulation in every patient who undergoes rhythm conversion. CAEP has published 2 editorials arguing for a more nuanced approach (ie does every 35 year old mountain biker need a month of anticoagulation) but CCS is holding firm despite admittedly weak evidence.

A group of motivated CAEP members will be updating the CAEP 2018 guidelines to ensure congruence with the CCS approach, while hopefully maintaining some flexibility.

Keep ya posted!