Heart Failure Risk Scale and Atrial Fibrillation

This week we had the pleasure of welcoming a guest speaker for grand rounds, prominent EM researcher and well-known clinical decision rule/tool expert from Ottawa, Dr. Ian Stiell. The focus of his talk was on the Canadian Heart Failure Risk Scale and atrial fibrillation, with some personal travel blogging and joking scattered throughout. Beginning with its derivation and subsequent validation, Dr. Stiell provided a background to the current phase of study that Queen’s will be a part of, the revision and validation of the Canadian Heart Failure Risk Scale. Approximately 1 million people are seen in the ED annually in Canada for acute heart failure, 40-60% of which are admitted to the hospital.  The Heart Failure Risk Score hopes to provide guidance and standardize practice for ED physicians across the country with respect to admission decisions in this population.  The group had a rich discussion about factors included, surprises found in the literature, and predicted utility of the tool. Dr. Stiell pointed out that in order to find out whether this tool will change practice, an implementation trial would have to ensue – stay tuned! In the meantime, check out the score and look for the bright yellow forms to fill out on your next shift in the ED!

The Canadian Heart Failure Risk Scale

Dr. Stiell finished his talk with a review of his work on management of acute atrial fibrillation and flutter. Refer to the updated Canadian CV Society Guidelines for the latest (see algorithm below). Dr. Stiell is now working with CAEP to adapt these guidelines to the ED – stay tuned!

BONUS feature: Dr. Stiell sold us on two new phone applications to check out – The Ottawa Rules Application and Thrombosis.

Thanks for coming Dr. Stiell (@EMO_Daddy)!



Mass Gatherings and ED Ultrasound

On February 2 we had the pleasure of welcoming back Dr. Colin Bell, a recent FRCP EM grad, all the way from Denver for a talk on ED Ultrasound and hearing some more stories from Dr. Terry O’Brien.

The legendary TOB started the morning off with a talk on mass gatherings, using the last Tragically Hip concert as an example. He took us through the planning, equipment, personnel involved, and lessons learned on the day. Our crew of one nurse (thanks Patti!), multiple residents, staff physicians, and essential administrative assistants provided excellent care and diverted 35 people away from the crowded hospital. EMS was instrumental in the success of the event as well. Kingston’s population received an additional 25, 000 that day!

Here are some resources on mass gatherings to take a look at in preparation for the next big event:

Colin Bell then took us through ‘The Second Phase of POCUS’, illustrating the growing utility of ED ultrasound with a few key cases in which management was altered based on bedside images. It is an exciting time for POCUS and is becoming more of an essential adjunct to diagnostic workups in the ED, especially when time is of utmost importance.

Don’t be shy to ask Colin about the cool new initiatives he is taking part in across the border – he also has some interesting stories to tell practicing EM in an entirely different context than we see here in Kingston.

Here is a reminder of a previous post in which we included a number of valuable online resources for ED ultrasound.


Thyroid Emergencies and CBME EPAs

On January 25th Dr. Andrew Hall gave us a reminder the concept of CBME and what it will look like next year. Dr. Heidi Wells followed with an excellent overview of Thyroid disorders encountered in the ED.

Andrew re-iterated the model of CBME and how it will fit into our emergency medicine program starting July 2017. He provided a list of the current entrustable professional activities (EPAs) for emergency medicine and a rich discussion ensued. Overall, it is an exciting time in medical education and Andrew convinced me that our already great program will only get better with this shift towards an outcomes-based, learner centered model! Feel free to ask Dr. Hall all about it, or refer to the PGME website for more information.

Heidi then took us through an approach to thyroid disorders in the ED – with tons of clinical pearls and important take home points to use on your next shift. See the infographic below for a summary of the key messages, and click here for a downloadable pdf version:

Interestingly, Queen’s wasn’t the only institution focused on thyroid disorders that week – the twittersphere was lighting it up!

In true FOAMed spirit, check these resources from the Bold City EM program in Jacksonville, Florida on endocrine, metabolic and nutrition themed topics. Thanks Bold City EM!


Exploring the Spectrum of Burnout to Wellness

Just in time for #CAEPWellness2017 Mikayla presented at Grand Rounds on the topic of Burnout to Wellness.She presented a great deal of literature on the topic and made a convincing case for finding ways to help each other thrive.

My favourite part of the presentation was when she displayed word clouds made from our group’s responses to a quick survey she had sent ahead of time. The words below represent how our group manifests burnout.

Better yet was her forward-looking, optimistic look at how we might thrive! Mikayla highlighted some things our department already does and pointed to a couple of other institutions and online discussions on the topic including the ALiEM Journal Club “Thriving, Not surviving, in Residency“. This word cloud displays the strategies that our group uses to get and stay well.

At the end of the day as institutions, friends, colleagues, peers, and individuals we have the ability to support each other in being the best version of ourselves possible. At QEmerg we will continue to find ways, big and small, to navigate the spectrum of burnout to thriving.

Check out information about International Emergency Medicine Wellness Week with lots of available resources and important discussions here. Please add your favourite wellness hacks below!

Grand Rounds: don’t RUSH ortho

In this week’s edition of Grand Rounds Zack performed a quick review of the RUSH exam for undifferentiated shock and Theresa outlined some easy to miss orthopaedic injuries. Below are a few resources on both below! 

The RUSH Exam

In the patient with undifferentiated shock you can use the power of the ultrasound to evaluate the “Pump, Tank and Pipes” or the HI-MAP. See the EMCrit post from the original creators.


For a super primer on the RUSH/HI-MAP exam check out this video from 5 minute soon here or this post from ALiEM.

Happy scanning with our new high frequency probe!!!

Easy to Miss Ortho Injuries

There is far too much to cover from Theresa’s awesome review on this topic. I’ve decided to highlight a couple of the injuries that she mentioned with links to the resources about those injuries for some quick reading.

There is a spectrum of scapholunate injuries that are easy to miss. These range from scapholunate dissociation (widening of the scapholunate joint) to peri-lunate dislocation to lunate dislocation.

The posterior shoulder dislocation can be easy to miss. Keep your eye for the lightbulb sign. Maybe we can consider using ultrasound for catching the diagnosis?

The lateral elbow x-ray is your friend. Keep your eye out for signs of occult fracture in this view.

I really appreciated Theresa’s discussion of the Ottawa Ankle rule. She reminded us that these rules can help assess the need for imaging but the components do not make up a complete or thorough ankle exam. Remember to check the proximal fibular head and examine the whole ankle and foot.

Theresa’s 10 Commandments for Ortho Injuries

  1. Know what you are looking for
  2. Obtain proper, perpendicular views, multiple views and specific views
  3. Be aware of specific, occult and dislocation radiographic signs
  4. Know what “normal looks like”
  5. Avoid being distracted
  6. Develop a systematic approach to xrays
  7. Use cognitive forcing strategies – (i.e. always document snuffbox tenderness and DRUJ findings in wrist exams)
  8. ALWAYS obtain post reduction films
  9. Examine the joint above and below
  10. History and physical trump ALL. Examine, image, re-examine.