Introduction: Point of care ultrasound is a burgeoning tool in clinical medicine and its utility has been demonstrated in a variety of contexts. It may be especially useful in rural areas where access to other imaging equipment (such as CT) is limited. However, there exists debate about the utility of teaching ultrasound theory and technique to medical undergraduates, particularly those in their first two years of study. This study evaluated the efficacy of teaching undergraduate-tailored ultrasound training sessions to first and second-year medical students at the Northern Ontario School of Medicine (NOSM), a rural-focused medical institution. Methods: Sixty students participated in tailored ultrasound teaching sessions that involved both lecture and hands-on components. Participating students were assessed following each session, as well as at study completion, in terms of ultrasound knowledge, anatomy, pathology, orientation, and interpretation of computerized tomography (CT) scans (transferability). Participants’ performance was measured against a control group of their peers. Program evaluation was completed using Likert-type scales to determine participant comfort with ultrasound before and after the training, and areas of strength and improvement. Results: Participating students showed statistically significant improvement in ultrasound interpretation and anatomical orientation with trends toward improved anatomy and pathology knowledge, and ability to interpret computerized tomography (CT) scans compared to controls. Students participating in the course expressed improved comfort with ultrasound techniques and desire for future integration of ultrasound into their training, but noted that increasing frequency of training sessions might have improved retention and confidence. Conclusion: Results suggest that using an undergraduate-focused and system-specific ultrasound training course yields retention in ultrasound interpretation ability and objective improvement in relational anatomy knowledge. Trends toward improvement in general anatomy, pathology and CT interpretation suggest areas of future study.

Introduction: Emergency Department (ED) health care professionals are responsible for providing team-based care to critically ill patients. Given this complex responsibility, simulation training is paramount. In situ simulation (ISS) has many cited benefits as a training strategy that targets on-duty staff and occurs in the actual patient environment. Several evidence-based frameworks identify staff buy-in as essential for successful ISS implementation, however, the attitudes of interdisciplinary front-line ED staff in this regard are unknown. The purpose of this study is to identify contextual trends in interdisciplinary opinions on routine ISS in the ED. Methods: Qualitative and quantitative review, exploring the self-reported attitudes of interdisciplinary ED staff: before, during and after the implementation of a routine ISS pilot program (5 sessions in 5 months) at the Charles V Keating Emergency and Trauma Center in Halifax from Feb-Nov, 2018. Results: 149 surveys were received. Baseline support for ISS was high; 83% of respondents believed that the advantages of ISS outweigh the challenges and 47% favoured simulation in the ED, relative the sim bay (26%) and 28% were indifferent. The attitudes of direct participants in ISS were very positive, with 88% believing that the benefits outweighed the challenges after participation and 91% believing that they personally benefited from participating. A department wide post-ISS pilot survey suggested a slight decrease in support. Support for ISS dropped from 83% to 67%, a statistically insignificant reduction (p = 0.098) but a sizeable change that warrants further investigation. Most notably respondents reported increased support for simulation training in a simulation bay relative to ISS in the ED. Respondents still regarded simulation highly overall. Interestingly, when the results were stratified by position, staff physicians were the least positive. Conclusion: Pre-pilot or baseline opinions of ISS were very positive, and participants all responded positively to the simulations. This study generates valuable insight into the perceptions of interdisciplinary ED staff regarding the implementation and perceived impact of routine ISS. This evidence can be used to inform future programming, though further investigation is warranted into why opinions post-intervention may have changed at the department level.

Introduction: The Canadian Association of Emergency Physicians (CAEP) Atrial Fibrillation (AF) Guidelines prioritizes early cardioversion and discharge home in the management of rapid AF, however not all patients can be safely cardioverted in the emergency department (ED). Given limited ED-based evidence on rate control, we sought to better understand the burden of disease in AF patients not managed by rhythm control and identify opportunities for improved care. Methods: We conducted a health records review of consecutive AF patient visits at two Canadian academic hospital EDs over a 12-month period. We included all patients ≥18 years with AF on electrocardiogram, a heart rate ≥100 beats per minute (bpm), and who did not receive cardioversion. Outcomes included: (1) incidence of patients managed by rate control; (2) specific rate control management practices including choice of agent, route of administration, dosing, and timing; (3) adverse events; (4) compliance with CAEP AF Guidelines; and (5) disposition and outcomes. Results: Of 972 rapid AF patient visits, 307 were excluded and 665 were included, with mean age 77.2, female 51.6%. Of those included, 43.0% were given rate control medications, most common being metoprolol (72.0%). Admission to hospital occurred in 61.4% of visits, and 77.9% of AF cases were secondary to another medical condition. In those given rate control medications, 9.1% suffered adverse events and only 55.6% had a final ED heart rate ≤100 bpm. Inappropriate use of rate control medications was found in 44.8% of cases, specifically inappropriate choice of agent (4.5%), inappropriate route of administration (26.9%), over-dosed (2.4%), under-dosed (5.2%), and inadequate timing (5.6%). Conclusion: We demonstrated that for rapid AF patients not receiving cardioversion, most cases were secondary to a medical cause and of those receiving rate control, there were a concerning number of adverse events related to inappropriate choice of agent, route of administration, dosage, and timing. Moving forward, better awareness of the CAEP AF Guidelines by ED physicians will ensure safer use of rate control agents for rapid AF patients.

Introduction: The diagnosis of non-ST elevated myocardial infarction (NSTEMI) depends on a combination of history, ECG and cardiac biomarkers. Many hospitals continue to automatically order less sensitive and specific biomarkers such as Creatine Kinase (CK) alongside cardiac Troponin (cTn) as part of an extended panel of bloodwork for work-up of patients with suspected NSTEMI. Methods: We undertook a systematic review to assess the usefulness of CK measurements in addition to cTnI in NSTEMI diagnosis. Medline, EMBASE and Cochrane databases were searched from 1995 until May 31, 2018. We added additional articles after reviewing the reference list of pertinent articles and consulting experts. A total of 1123 papers were screened, of which 8 were included in the final analysis. These papers all compared CK and troponin (TnI) testing in the diagnosis of NSTEMI. Results: Of the 8 papers included in the analysis none showed CK having a greater sensitivity or specificity than the TnI assays. Furthermore, no paper originally published evidence of CK diagnosing NSTEMI when Troponin was negative. One author, when contacted, described 10% of patients diagnosed with NSTEMI as having discordant data (eg. +CK, -Troponin). However, the outcome data such as angiography and echocardiography were not available for these patients, making definitive diagnosis unclear. Conclusion: Troponin has consistently shown to have greater sensitivity and specificity than CK in the diagnosis of NSTEMI with CK adding no improvements in diagnosis. We believe CK should not be used in the emergency department work-up for NSTEMI diagnosis.

Introduction: Vasopressors are routinely utilized to treat systemic shock, a significant source of morbidity and mortality in the pediatric population. Local tissue ischemia has been classically implicated with peripheral use of these medications. However, peripheral administration (PVC) has theoretical benefits, and avoids many of the risks associated with central venous catheter (CVC) placement. There appears to be paucity of literature in pediatrics examining this subject. We conducted a systematic review investigating local tissue complications and extravasations of both PVC and CVC administration in the pediatric population. Specifically we examined the type of vasopressor used, the site used, the duration of the infusion, and finally the overall outcome for patients. Methods: A systematic search was conducted using PubMed, Embase, Cochrane, and CINAHL databases. Terms for IV administration, specific vasopressor use, complication of interest, and pediatric population were combined. We included studies that satisfied our predetermined criteria. All search results were imported into Covidence software where the primary author conducted an initial title and abstract review. Papers that met the pre-identified criteria were selected for full text review. Papers selected for full text review were independently reviewed by two of the authors. Agreement between the authors was measured utilizing a κ statistic. Results: Our search yielded 14784 results, of which 237 were assessed for full text review. The κ between the authors is pending. 13 studies were selected for final inclusion. There were 14 patients with 15 total events. 13 were from PVC use while 2 occurred with CVC's. 11 of the 13 complications associated with PVC administration occurred through extravasation, with 2 events from local ischemia. 9 children were administered dopamine, 1 norepinephrine, and 14 were on multiple vasopressors. 3/13 events were “proximal” or occurring at or above the AC or popliteal fossa while 10/13 events were “distal”. The average time to ischemic injury or extravasation peripherally was 56.1 hours with a range of 1.5 to 360 hours. 9 of the total patients did not have any long-term sequelae. One patient had toe amputations, while two others died because of illness. One CVC patient died as a result extravasation leading to asphyxiation. Conclusion: There is a lack of significant literature reporting serious adverse events related to peripheral or central administration of vasopressors in the pediatric population.

Introduction: Identification of severe bacterial infections (SBI) among infants presenting to the emergency department (ED) for fever without a source (FWS) remains challenging. Controversies persist on the usefulness of blood biomarkers, especially when used for assessing infants 22 to 60 days old. Although C-reactive protein (CRP) and white blood cells count (leucocytes) are commonly prescribed, this practice relies on poor and conflicting evidence. Our objective was to determine the performance of those two markers at identifying SBI. Methods: This is a sub-analysis of an ongoing retrospective cohort study conducted in an academic pediatric ED in Quebec City, that aims to determine whether a lumbar puncture should routinely be performed in the FWS workup of 22 to 60 days old infants. All consecutive charts of eligible febrile infants were reviewed. Premature infants (<37 weeks), as well as infants with chronic diseases, immunodeficiency, previous antimicrobial therapy, in-dwelling catheters, or septic shock were excluded. Among others, data related to final diagnosis and investigations were gathered. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, positive (LR+) and negative (LR-) likelihood ratios were estimated for each blood biomarkers. Results: Out of 1261 charts reviewed, 920 patients were included in this analysis. SBI prevalence was 13.0% (95%CI: 10.9-15.2) among infants of our cohort. The sensitivity, specificity, PPV, NPV, LR+ and LR- of the leucocytes <5000 or≥15000/□L were 43% (95%CI: 34-53%), 80% (95%CI: 77-83%), 25% (95%CI: 21-30%), 90% (95%CI: 88-91%), 2.1 (95%CI: 1.7-2.8), and 0.72 (95%CI: 0.61-0.84), respectively. The sensitivity, specificity, PPV and NPV of CRP >= 25 mg/L were 46% (95%CI: 37-56%), 96% (95%CI: 94-97%), 65% (95%CI: 55-73%), and 91% (95%CI: 89-92%), respectively. ROC curves analysis indicates that a CRP≥25 mg/L offers the best LR+ (10.4; 95%CI: 6.9-15.6) with a corresponding LR- of 0.56 (95%CI: 0.47-0.67). Conclusion: When evaluating febrile infants in the ED, leucocytes appear to have limited added value, while CRP≥25 mg/L significantly increases the pre-test probability of SBI. CRP should be considered for inclusion in the workup of FWS for infants of 22 to 60 days of age.

Introduction: Oxygen is commonly administered to prehospital patients presenting with acute myocardial infarction (AMI). We conducted a systematic review to determine if oxygen administration, in AMI, impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central, clinicaltrials.gov and ISRCTN for relevant randomized controlled trials and observational studies comparing oxygen administration and no oxygen administration. The outcomes of interest were: mortality (≤30 days, in-hospital, and intermediate 2-11 months), infarct size, and major adverse cardiac events (MACE). Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. A meta-analysis was performed using RevMan 5 software. Results: Our search yielded 1192 citations of which 48 studies were reviewed as full texts and a total of 8 studies were included in the analysis. All evidence was considered low or very low quality. Five studies reported on mortality finding low quality evidence of no benefit or harm. Low quality evidence demonstrated no benefit or harm from supplemental oxygen administration. Similarly, no benefit or harm was found in MACE or infarct size (very low quality). Normoxia was defined as oxygen saturation measured via pulse oximetry at ≥90% in one recent study and ≥94% in another. Conclusion: We found low and very low quality evidence that the administration of supplemental oxygen to normoxic patients experiencing AMI, provides no clear harm nor benefit for mortality or MACE. The evidence on infarct size was inconsistent and warrants further prospective examination.

Introduction: 9-1-1 telecommunicators receive minimal education on agonal breathing, often resulting in unrecognized out-of-hospital cardiac arrest (OHCA). We successfully piloted an educational intervention that significantly improved telecommunicators’ OHCA recognition and bystander CPR rates in Ottawa. We sought to better understand the operations of Canadian 9-1-1 communications centers (CC) in preparation for a multi-centre study of this intervention. Methods: We conducted a National survey of all Canadian CCs. Survey domains included information on organizational structure, dispatch system used, education curriculum, and performance monitoring. It was peer-reviewed, translated in French, pilot-tested, and distributed electronically using a modified Dillman method. We designated respondents in each CC before distribution and used targeted follow-up and small incentives to increase response rate. Respondents also described functioning of neighboring CCs if known. Results: We received information from 51/51 provincial and 1/25 territorial CCs, representing 99.7% of the Canadian population. CCs largely utilize the Medical Dispatch Priority System (MPDS) platform (93%), many are Province/Ministry regulated (50%) and most require a High School diploma as minimum entry level education (78%). Telecommunicators receive initial in-class training (median 1.3 months, IQR 0.3-1.9; range 0.1-2.2), often followed by a preceptorship (84.4%) (median 1.0 months, IQR 0.7-1.7; range 0.4-6.0). Educational curriculum includes information on agonal breathing in 41% of CC, without audio examples in 34%. Among responding CCs, over 39,000 suspected OHCA 9-1-1 calls are received annually. Few CCs maintain local performance statistics on OHCA recognition (25%), bystander CPR rates (25%) or survival rates (50%). Most (97%) expressed interest in future research collaborations. Conclusion: Most Canadian telecommunicators receive no or minimal education in recognizing agonal breathing. Further training and improved OHCA monitoring may assist recognition and enhance outcomes.

Introduction: Mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH) is a common cause of Emergency Department (ED) visits. Over the past years, several authors have debated the relevance of radiological and clinical follow-up of these patients, as the main challenge is to identify patients at risk of clinical deterioration. Objectives: To determine whether demographic, clinical or radiological variables can predict patient deterioration. Methods: Design: An historical cohort was constituted in two level-1 trauma centers (Chu de Quebec - Hôpital de l'Enfant-Jésus (Québec City) and Hôpital du Sacré-Coeur (Montréal)). Participants: Medical records of mTBI patients aged ⩾16 with an ICH were reviewed using a standardized data collection tool. Consecutive medical records were reviewed from the end of 2017 backwards until sample saturation. Measures: Deterioration was defined as either death, deterioration of the control CT scan according to the radiologist, clinical deterioration or neurosurgical intervention. Analyses: Logistic regression analyses were performed to ascertain predictors of deterioration. Interobserver agreement was calculated. Results: A total of 274 patients were included in our analyses. Mean age was 60.8 and 68.9% (n = 188) were men. Four variables were found to be associated with all outcomes: radiological deterioration, clinical deterioration, death, and neurosurgical intervention. Diabetes (odds ratio (OR) = 2.6, 95% CI [0.97-6.94]), confusion as an initial symptom (OR = 2.8, 95% CI [1.42-5.61]), anticoagulation (OR = 2.8, 95% CI [1.01-7.84]) and significant subdural hemorrhage (≥4 mm) (OR = 3.4, 95% CI [1.42-5.61]) seen on the first computed tomography scan were strongly associated with these outcomes. Age had a neutral effect (OR = 1.01, 95% CI [0.99-1.03]) while high initial Glasgow Coma score seemed to have a protective effect (OR = 0.4, 95% CI [0.24-0.69]). Radiological deterioration was not systematically associated with clinical deterioration. As for the 46 patients with a deterioration of CT scan, only 30.4% vs. 69.5% without deterioration (p = 0.0035) showed a clinical deterioration. Conclusion: Diabetes, anticoagulation, significant subdural hemorrhage and confusion as an initial symptom seem to be predictors of deterioration following a mild traumatic brain injury with positive CT scan.

Introduction: Opioids are routinely administered for analgesia to prehospital patients experiencing chest discomfort from acute myocardial infarction (AMI). We conducted a systematic review to determine if opioid administration impacts patient outcomes. Methods: We conducted a systematic search using MeSH terms and keywords in Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Central and Clinicaltrials.gov for relevant randomized controlled trials and observational studies comparing opioid administration in AMI patients from 1990 to 2017. The outcomes of interest were: all-cause short-term mortality (≤30 days), major adverse cardiac events (MACE), platelet activity and aggregation, immediate adverse events, infarct size, and analgesia. Included studies were hand searched for additional citations. Risk of Bias assessments were performed and GRADE methodology was employed to assess quality and overall confidence in the effect estimate. Results: Our search yielded 3001 citations of which 19 studies were reviewed as full texts and a total of 9 studies were included in the analysis. The studies predominantly reported on morphine as the opioid. Five studies reported on mortality (≤30 days), seven on MACE, four on platelet activity and aggregation, two on immediate adverse events, two on infarct size and none on analgesic effect. We found low quality evidence suggesting no benefit or harm in terms of mortality or MACE. However, low quality evidence indicates that opioids increase infarct size. Low-quality evidence also shows reduced serum P2Y12 (eg: clopidogrel and ticagrelor) active metabolite levels and increased platelet reactivity in the first several hours post administration following an increase in vomiting. Conclusion: We find low and very low quality evidence that the administration of opioids in STEMI may be adversely related to vomiting and some surrogate outcomes including increased infarct size, reduced serum P2Y12 levels, and increased platelet activity. We found no clear benefit or harm on patient-oriented clinical outcomes including mortality.

Introduction: The treatment of cutaneous abscesses in the Emergency Department (ED) is common. While most sources describe only incision and drainage (I&D) followed by healing through secondary intention, recent literature suggests that primary repair following I&D results in similar rates of healing as well as treatment failures when compared to standard care in the ED. The primary goal of this research project was to describe the variability in practice with respect to self-reported management of abscesses among Canadian ED physicians and explore potential reluctance in adopting primary repair as a management strategy. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 9-question survey probed the willingness of physicians to perform primary closure of abscess in the ED as well as factors that dissuade them from performing this type of closure. The primary outcome was the quantification of practice variability among ED physicians with respect to abscess closure in the ED. The data was presented with simple descriptive statistics. Results: 217 surveys were completed out of 1145 eligible physicians. Physicians working at academic centres comprised 53% of responses, with 47% coming from community centres. Over half of responses were from physicians in practice at least ten years (65.9%). The overwhelming majority of physicians indicated that they manage abscesses following I&D by secondary closure (96.3%). The two main concerns dissuading respondents from performing primary closure of abscesses included risk of treatment failure (47.8%) and the procedure not being considered standard of care (36.7%). Despite these concerns, 67.3% of physicians indicated a willingness to perform primary closure if further evidence supported its use. These physicians were most likely to consider primary closure at the head and neck, breast, trunk, and extremities, however, only 1.5% considered primary closure appropriate for perianal or pilonidal abscesses. Conclusion: This study demonstrates that almost all Canadian ED physicians, regardless of experience or practice centre, manage cutaneous abscesses with I&D followed by healing via secondary intention. With increasing evidence supporting the use of primary closure, many physicians may be willing to adopt primary closure as part of the management of cutaneous abscesses in the ED.

Introduction: Many drugs, including cannabis and alcohol, cause impairment and contribute to motor vehicle collisions (MVCs). Policy makers require knowledge of the prevalence of drug use in crash-involved drivers, and types of drugs used in order to develop effective prevention programs. This issue is particularly relevant with the recent legalization of cannabis. We aim to study the prevalence of alcohol, cannabis, sedating medications, and other drugs in injured drivers from 4 Canadian Provinces. Methods: This prospective cohort study obtained excess clinical blood samples from consecutive injured drivers who attended a participating Canadian trauma centre following a MVC. Blood samples were analyzed using a broad spectrum toxicology screen capable of detecting cannabinoids, cocaine, amphetamines (including their major analogues), and opioids as well as psychotropic pharmaceuticals (including antihistamines, benzodiazepines, other hypnotics, and sedating antidepressants). Alcohol and cannabinoids were quantified. Health records were reviewed to extract demographic, medical, and MVC information using a standardized data collection tool. Results: This study has been collecting data in 4 trauma centres in British Columbia (BC) since 2011 and was launched in 2 trauma centres in Alberta (AB), 1 in Saskatchewan (SK), and 2 in Ontario (ON) in 2018. In preliminary results from BC (n = 2412), 8% of injured drivers tested positive for THC and 13% for alcohol. Preliminary results from other provinces (n = 301) suggest a regional variation in prevalence of drivers testing positive for THC (10% - 27%), alcohol (17% - 29%), and other drugs. By May 2018, an estimated 4500 cases from BC, 600 from AB, 150 from SK, and 650 from ON will have been analyzed. We will report the prevalence of positive tests for alcohol, THC, other recreational drugs, and sedating medications, pre and post cannabis legalization. The number of cases with alcohol and/or THC levels above Canadian per se limits will also be reported. Results will be reported according to province, driver sex, age, single vs. multi vehicle crashes, and requirement for hospital admission. Conclusion: This will be among the largest international datasets on drug use by injured drivers. Our findings will provide patterns of drug and alcohol impairment in 4 Canadian provinces pre and post cannabis legalization. The significance of these findings and implication for impaired driving policy and prevention programs in Canada will be discussed.

Introduction: Biphasic anaphylactic reactions are a concern in emergency medicine. Risk factors associated with this type of reaction remain ill-defined. The aim of this study was to investigate elements associated with biphasic anaphylactic reactions and to determine the impact of anaphylaxis treatments on biphasic reactions. Methods: From the multicenter Cross-Canada Anaphylaxis Registry prospective cohort, we selected adults (≥18 years) with a visit to the emergency department (ED) of Sacré-Cœur Hospital, an urban tertiary-care hospital. Then, a structured chart review was done to collect additional information on types and timing of treatments for the initial anaphylactic reaction, presence and treatment of biphasic reactions during the initial ED visit or upon patients’ return. Biphasic reactions were defined by the recurrence of any anaphylaxis symptoms within 72 hours of a resolved anaphylaxis episode. Potential factors associated with biphasic reactions were studied using Chi-Square and Mann-Whitney tests. Results: Patients with anaphylaxis were enrolled between April 2014 and February 2018. From the cohort, 401 adult patients were identified. We found 37 patients who developed a biphasic reaction. Amongst them, 33 received treatments and 9 required more than one dose of intramuscular epinephrine. None of the biphasic reaction patients required intravenous epinephrine, other vasopressors, ICU admission, or endotracheal intubation. Biphasic reactions appeared in a median time of 13.3h after the initial reaction ranging from 1.1h to 69.6h (IQR 30.2). There was no difference in age or gender of patients who developed a biphasic reaction compared those who did not. Pertinent past medical history, daily medications, mean of arrival to the ED, allergen type, ingestion route, or initial symptoms during the anaphylaxis episode were not significantly different in the two groups. Treatment with corticosteroids was similar in the two groups (9.0% vs. 8.1% p = 0.82). Treatment, dose and route of administration of epinephrine was not different in the two groups but longer delays before treatment with the first dose of epinephrine was more frequent in biphasic reaction patients (median delay of 64 minutes, p = 0.015). Conclusion: No patient characteristic, allergen, route of ingestion, symptom, nor treatment with corticosteroids has shown to be significantly different in patients with and without biphasic reactions. Delayed treatment with epinephrine is significantly associated with biphasic reactions.

Introduction: In recent years, there has been growing interest in the field of physician wellness and burnout. Past research has shown that the prevalence of burnout is non-uniform between specialties and is most prevalent amongst emergency medicine physicians. Additionally, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. To date, there is no national perspective of burnout amongst Canadian Royal College of Emergency Medicine (EM) residents. Our study looks to provide a national survey of burnout in this population as well as characterize mentorship programs at training sites. Methods: An anonymous electronic survey was e-mailed to Canadian EM residents via local program directors. Characteristics of mentor-mentee relationships and quality of residents’ mentorship experiences were assessed on a 6-point Likert scale. The Maslach Burnout Inventory – Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment). Burnout was dichotomized as present or absent if the MBI criteria are met (emotional exhaustion score > 26 or depersonalization score > 9 or personal accomplishment <34). Results: To date, 52 responses have been collected. Respondents are primarily male (63%) and in their PGY year 1-3 (71%). Responses were collected from 6/14 (43%) of eligible programs. 84% of residents currently had an emergency medicine mentor. Of these, 8% were dissatisfied with their residency's mentorship program and 55% were satisfied/very satisfied. 72% of residents met the threshold for burnout in at least one dimension of the MBI (3 dimensions = 17%; 2 dimensions = 17%; 1 dimension = 38%) and 13% cited considering suicide during their training. Conclusion: Results thus far suggest significant burnout amongst Royal College of Emergency Medicine residents. Alarmingly, 13% of responders cited having contemplated suicide during their training. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout. Our findings suggest a high prevalence of residents with established mentors and future analyses will examine the correlation between mentorship characteristics and resident burnout levels.

Innovation Concept: Emergency medicine physicians must maintain a broad knowledge base and procedural skillset while fulfilling their academic roles as teachers, researchers and administrators. Most academic departments do not have a regular, affordable, formal continuing professional development (CPD) and faculty development (FD) curriculum for their staff. We set out to design and implement a novel continuous practice enhancement program to address this issue. Methods: Strategic planning by the Ottawa academic Department of EM identified CPD and FD as priorities. A program was created to support high quality, monthly CPD/FD courses provided by physicians. We had 5 goals: (1) enhance clinical and academic skills, (2) disseminate group best practices, (3) sustain skills in high impact/low frequency scenarios, (4) support physician academic careers, and (5) acquire new procedural skills. A CPD/FD Committee composed of local meded experts and experienced clinical teachers was tasked with overseeing the creation and evaluation of these sessions. Curriculum, Tool or Material: The longitudinal curriculum was informed by perceived needs (group survey), ascribed needs (M&M rounds, physician metrics and departmental leadership priorities) and participant feedback. The committee identified local experts to present on their areas of expertise in order to promote group best practice. Topics to-date have included clinical skills updates, teaching and coaching strategies and academic career planning. A comprehensive monthly simulation-based curriculum was rolled out simultaneously to give participants the opportunity to develop crisis resource management and critical care skills. Except for sessions requiring advanced equipment or cadavers, sessions are financed by academic funds and free for participants. Conclusion: Faculty academic learning and engagement is an important goal and participation in this curriculum is reviewed at each physician's annual reappointment. To-date, 18 physicians (21% of our group) have presented topics and 92% of physicians have participated in at least one session with 63% having attended three or more. Evaluations have been overwhelmingly positive, and a recent survey identified the CPD/FD program as a significant contributor to our physicians’ wellness. We introduced an innovative, structured CPD/FD program in response to perceived and ascribed needs of our physicians and departmental leadership. Our successful CPD/FD curriculum represents a model for other departments who are considering similar initiatives.

Introduction: Competence in procedural skills is vital within the emergency department. Challenging procedures such as cricothyroidotomy are difficult to master as they are rare and hard to train for. Additionally, common procedures such as chest tube insertions require practice to become sufficiently competent. Opportunities to hone these skills are essential in residency training. This project aimed to create instructional video modules for specific emergency medicine (EM) procedures and gauge their utility as adjunctive resources for procedural learning in the EM residency curriculum. Methods: Tutorial videos for clamshell thoracotomy, cricothyroidotomy, and chest tube insertion were filmed within a cadaver lab with step-by-step instructions. The footage was edited and overlaid with a pre-prepared audio narration using Camtasia®/Apple® Video Editing software. These videos were embedded within modules that included foundational knowledge relevant to the procedures, including anatomy, physiology and pathophysiology. The modules were peer-edited by licensed EM staff physicians and distributed to EM residents and staff physicians for analysis. Qualitative and quantitative analysis relied upon participants’ answers to questions and a Modified Task Value Scale, respectively. Results: Ten participants were included in the analysis, including EM residents (n = 6) and staff emergency physicians (n = 4). Qualitative feedback suggested that positive aspects of the modules included visuals, content, narration, and review of anatomy. Negative aspects included the lack of indications for procedures, technical details, real patient examples, and a speed up function. Quantitative feedback resulted in scores of 4 and above out of 5 on the Motivated Task Value Scale across all aspects for all the modules. Furthermore, analysis revealed an average score of 3.9 for inclination to access more modules such as these, and a score of 4.4 for overall perception of the modules. Conclusion: Participants found the video modules valuable to their learning, both qualitatively and quantitatively. This study was limited by a small sample size of modules and a low number of participants. Furthermore, a more detailed analysis with further measures, including self-efficacy and self-confidence, would yield more comprehensive conclusions. However, video-based modules provide an effective and easily accessible adjunctive tool to acquire skill and confidence with EM procedures, for medical learners and staff physicians.

Introduction: We examined our local sepsis patient population, and specifically our most vulnerable patients - those presenting to the emergency department (ED) in septic shock - for variables predictive of survival to hospital discharge. We applied the familiar ED paradigm of, “Door to,” to calculate the impact of time to antibiotics against patient survival to hospital discharge. Methods: Retrospective chart review of patients aged > = 18 years, presenting to tertiary care ED between 01 Nov 2014 and 31 Oct 2015. Patients determined to have sepsis if A) > = 2 SIRS criteria and ED suspicion of infection (ED acquisition of blood/urine cultures or antibiotic administration) and/or B) received ED or Hospital discharge diagnosis of sepsis (ICD-10 diagnostic codes A4xx and R65). Patients sub-classified with septic shock if A) triage SBP < = 90mmHg, B) triage MAP < = 65mmHg or C) serum lactate > = 4mmol/L. “Door Time” was defined as the earliest time recorded for the patient encounter, either the time the patient registered in the Emergency Department, or the triage time. A generalized linear model was performed with a binomial distribution using survival to discharge as the response variable. Age, sex, ED arrival method, time to antibiotics, ED serum lactate and ED serum glucose level were the predictor variables. Results: 13506 patient encounters met inclusion criteria (10980 unique patients). Linear regression of time to antibiotics against survival to hospital discharge failed to achieve statistical significance. Linear regression of the secondary outcome variables achieved statistical significance for age and serum lactate level. Per the model, as age increased by 1 year, the odds of dying prior to hospital discharge increased by 3.8% and as serum lactate increased by 1 mmol/L, odds of dying prior to hospital discharge increased by 11.1%. Conclusion: We found no association between time to antibiotic treatment and mortality. Causal relationships require randomized controlled trials, and this analysis contributes to clinical equipoise.

Introduction: Telephone Triage Services (TTS) manage phone calls from the public regarding general medical problems and provide telephone advice. This telephone based care can overlap with care provided by Poison Centres. Our objective was to examine the impact of a provincial 811 TTS on the IWK Regional Poison Centre (RPC). Methods: This is a retrospective descriptive study using interrupted time series methodology. We compared monthly IWK RPC call volume in the pre-811 era (January 2007-July 2009) and the post-811 era (September 2009-December 2017). We summarized the characteristics of callers who accessed the IWK RPC in terms of client age, sex, intentionality, time of day, call disposition and outcome. Caller characteristics were compared between the pre- and post-811 eras using chi-square test for categorical variables. We used segmented regression analysis to evaluate changes in slope of call volume in the pre- and post 811 eras. The Durbin-Watson statistic was performed to test for serial correlation and the Dickey-Fuller test to investigate seasonality. Results: The dataset included 82683 calls to the IWK RPC – 27028 pre-811 and 55655 post-811. Overall, 55% of calls were for female clients and the largest age group was children aged 0-5 years (37%). Most calls originated from home (47%), followed by a health care facility (23%). Most calls were managed at home (65%). Less than 3% of calls resulted in major effect or death. The Durbin Watson statistic was not statistically significant (p = 0.94). The Dickey-Fuller test indicated series stationarity (p = 0.001). There was no statistically significant change in call volume to the IWK RPC due to the introduction of 811 (p = 0.39). There was no significant variation by time of day, day of week or month, with most calls occurring in the evening. There were significantly more calls regarding intentional ingestions in the post-811 era (23% vs. 19% pre-811, p < .001). Outcomes in the pre and post 811 eras were as follows: minor/no effect/non-toxic/minimal 80% vs. 78%; moderate 7% vs. 10%; and, major/death 1.7% vs. 2.0%. Conclusion: The introduction of a TTS did not change call volumes at our RPC. The increase in the percentage of calls about intentional ingestions may reflect an increase in call acuity as the 811-TTS likely manages calls about minor/non-toxic ingestions without consulting with the RPC. Our future research will examine the nature of poison related calls to the 811-TTS.

Introduction: Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. Tranexamic acid (TXA) has been shown to be efficacious and safe in reducing mortality and morbidity if given within 3 hours of bleeding onset. Delayed PPH of more than 24 hours after delivery is a rare but high-risk ED presentation that requires timely management with TXA. This study aims to evaluate the patterns of TXA administration to treat delayed PPH in the ED using a retrospective review of medical reviews from 4 centres across a major urban Canadian city. Methods: We conducted a retrospective medical record review of patients presenting with PPH to 4 large urban EDs from 2013 to 2017; from 1.5 million ED visits, using a search for ICD-10 diagnostic codes of interest. Of these, the study cohort included only patients that were admitted to the hospital. Univariate analyses using Chi-squared tests and t-tests for non-continuous and continuous variables, respectively, were used to determine patient demographics and clinical characteristics significantly associated with TXA administration. Results: A total of 238 patients were included in the study cohort. Of these patients, 72.7% presented to the ED with mild hypovolemic shock, defined by a shock index score greater than 0.6. A total of 12.6% (95% CI 0.09-0.17) of patients were given TXA for PPH management in the ED. 67% (95% CI 0.47-0.82) of patients received the TXA within 3 hours of triage, whereas 33% (95% CI 0.18-0.53) received it after 3 hours, with the total mean time at 3.43 hours. 4.2% of patients required a blood transfusion and 2.9% required surgery. Univariate analyses indicated that greater maternal age (p = 0.028), lower hemoglobin levels (p = 0.014), higher shock index scores (p = 0.001), greater heart rate (p = < 0.001)), and use of oxytocin (p = <0.001) or blood products (p = < 0.001) in the ED were all significantly associated with TXA administration. Conclusion: The results from this study demonstrate that only 13% of delayed PPH patients presenting to the ED received TXA, and among those treated, 66% received TXA within 3 hours of presentation. The use of TXA was correlated with variables associated with an increased risk of morbidity. Given the rarity of delayed PPH presentation to the ED, the development of a treatment algorithm is recommended to ensure higher levels of timely TXA administration.

Introduction: Bleeding in the first trimester of pregnancy is a common presentation to the Emergency Department (ED) with half going on to miscarry. Currently there is no local consensus on key quality markers of care for such cases. Point of Care Ultrasound (PoCUS) is increasingly utilized in the ED to detect life threating pathology such as an ectopic pregnancy or fetal viability. PoCUS leads to improved patient satisfaction, quicker diagnosis and treatment. The purpose for this study was to examine the rates of formal ultrasound and PoCUS when compared to reported and recommended rates, and also to understand the use of other diagnostic tests. Methods: A retrospective cohort study of pregnant females presenting to the ED with first trimester bleeding over one year (June 2016 – June2017) was completed. A sample size of 108 patients was required to detect a moderate departure from baseline reported rates (67.8 – 77.6%). The primary outcome was the PoCUS rate in the ED. The main secondary outcome was the formal ultrasound rate. The literature recommends PoCUS in all early pregnancy bleeding in the ED, with a target of 100% of patients receiving PoCUS. Additional data recorded included the live birth rate, pelvic and speculum examination rate and lab tests. There is no clearly defined ideal practice for the additional data so these rates will be recorded without comparison. Results: Records of 168 patients were screened for inclusion. 65 cases were excluded because they were not pregnant or had confirmed miscarriage or other, leaving a total of 103 patients included in the analysis. The PoCUS rate was 51.5% (95% CI 42%-61%), lower than previously reported PoCUS rates of 73% (67.8 – 77.6%). The formal ultrasound rate was 67% (57%-75%). Both approaches were significantly lower than the recommended rate of 100% (95.7 – 100%). Rates for other key markers of care will also be presented. Conclusion: Fewer PoCUS exams were performed at our centre compared with reported and recommended rates for ultrasound. Further results will explore our current practice in the management of first trimester pregnancy complications. We plan to use this information to suggest improvements in the management of this patient population.