• • Know and identify clinical presentations of toxic alcohols.

• • Understand the differential diagnosis of high anion gap metabolic acidosis.

• • Appreciate the importance of history and clinical findings in establishing methanol toxicity diagnoses, especially in centres where laboratory testing is unavailable.

• • Recognize the value of provincial poison centres in supporting emergency physicians in the diagnosis and management of poisonings and overdoses.

A common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days.

This was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound.

Of the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram.

Next-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.

Studies show that First Nations patients have worse health outcomes than non-First Nations patients, raising concerns that treatment within the healthcare system, including emergency care, is inequitable.

We performed a retrospective chart review of Status First Nations and non-First Nations patients presenting to two emergency departments in Saskatoon, Saskatchewan with abdominal pain and a Canadian Triage and Acuity Scale score of 3. From 190 charts (95 Status First Nations and 95 non-First Nations), data extracted included time to doctor, time to analgesia, length of stay, specialist consult, bloodwork, imaging, physical exam and history, and disposition. Univariate comparisons and multiple regression modelling were performed to compare care outcomes between patient groups. Equivalence testing comparing time intervals was also undertaken.

No statistically significant differences in presentation characteristics were observed, although Status First Nations subjects showed a greater tendency towards weekend presentation and younger age. Care parameters were similar, although a marginally significant difference was observed in Status First Nations versus non-First Nations subjects for imaging (46% versus 60%, p=0.06), which resolved on adjustment for age and weekend presentation. Time to physician was found to be similar among First Nations patients on equivalence testing within a 15-minute margin.

In this study, First Nations patients presenting with abdominal pain did not receive delayed care. There were no detectable differences in the time-related care parameters/variables that were provided relative to non-First Nations patients. Meaningful and important qualitative factors need to be examined in the future.

Sepsis, a common, time-sensitive condition, is sometimes not identified at emergency department (ED) triage. The use of early warning scores has been shown to improve sepsis-related screening in other settings.

Our objective was to elucidate nurse and physician perceptions with the Hamilton Early Warning Score (HEWS) in combination with the Canadian Triage Acuity Scale.

Semi-structured interviews were conducted with nurses, resident physicians and attending physicians to explore perceived feasibility, utility, comfort, barriers, successes, opportunities and accuracy. A constructivist grounded theory approach was used. Transcripts were coded into thematic coding trees.

The twelve participants did not value the HEWS in the ED because they felt it was not helpful in identifying critically ill patients. We identified five themes; knowledge of sepsis and HEWS, utility of HEWS in emergency triage, utility of HEWS at the bedside, utility in communicating acuity and deterioration, and feasibility and accuracy of data collection. We also found 9 barriers and 7 enablers to the use of early warning score in the ED.

In our emergency departments, we identified potential barriers to implementation of an early warning score. A pre-existing expertise and lexicon related to critically ill patients lessens the perceived utility of an EWS in the ED. Understanding these cultural barriers needs to be addressed through change theory and implementation science.

The purpose of this qualitative study was to explore the experiences and perceptions of care of women treated for early pregnancy complications in a Canadian emergency department (ED) and early pregnancy clinic (EPC).

We conducted a descriptive qualitative study to understand the perceptions, meanings, and perspectives of women of 18 years and older who presented to the ED or EPC of an urban, tertiary care hospital with early pregnancy complications or loss. Using a semi-structured interview guide, a 45- to 60-minute telephone interview was conducted by a trained qualitative interviewer at 4 to 6 weeks after the ED visit. All interviews were digitally recorded and transcribed verbatim for analysis. Data analysis occurred in conjunction with data collection in order to continuously monitor emerging themes and general areas for further exploration. Interviews were conducted until thematic saturation had occurred.

Interviews were completed with 30 women between June and August 2018. Three key themes arose: disconnect of the ED's role in the provision of care, normalization of a chaotic healthcare experience, and finding connection through the institution's EPC.

Perspectives of women with early pregnancy complications highlight the ways in which ED care often does not meet the expectations or needs of patients and their families. The emotional complexity of this medical situation is often overlooked by ED staff and can produce encounters that are distressing. However, negative experiences were often mitigated by follow-up care in the institution's EPC.

Enhanced skills training in emergency medicine through the Canadian College of Family Physicians, CCFP(EM), has existed since the 1980s. Accreditation standards define what every program “must” and “should” have, yet little is known on what is currently done across Canada. Our objectives were to 1) describe major components of CCFP(EM) programs and 2) determine how curricular components are taught.

After a rigorous development process (expert content development, cognitive reviews, and pilot testing), a survey questionnaire was administered to all 17 CCFP(EM) program directors using a modified Dillman technique.

All (17/17) program directors responded. Programs are similar in core clinical rotations conducted and provide ultrasound courses for basic skills (trauma, abdominal aortic aneurysm, intrauterine pregnancy). Variation exists for offering independent ultrasound certification (77%), advanced scanning (18%), and protected time for scanning (53%). All programs utilize high fidelity simulation. Some programs use in situ simulation (18%) and carry out a simulation boot camp (41%). Most centres require an academic project, which is a quality assurance project (53%) and/or a critical appraisal of the literature (59%). Publication or national conference presentations are required by 12% of programs. Competency-based curricula include simulation for rare procedures (88%), direct observations (65%), and a “transition to practice” curriculum (24%). All programs maintain strong connections to family medicine.

This study demonstrates the diverse structures of CCFP(EM) programs across Canada. Programs have similar clinical rotations, ultrasound, and simulation requirements. Variation exists in administrative structure and financial resources of programs, academic project requirements, and programs’ competency-based curricula.

This study sought to assess the effectiveness of ultrasound simulation as a component of high-fidelity trauma simulation, in training diagnostic capabilities of resident and attending physicians participating in simulated trauma scenarios.

Twelve residents and 20 attending physicians participated in 114 trauma simulations. Participants generated a ranked differential diagnosis list after a physical exam and subsequently after a simulated extended focused assessment with sonography for trauma (E-FAST) ultrasound scan. We compared reports to determine whether the addition of ultrasound improved diagnostic performance.

The primary diagnosis accuracy improved significantly with the addition of simulated ultrasound (p<0.0001). Median diagnostic ranking scores also improved (p<0.0001). Further, participants reported a higher confidence in their diagnoses (p<0.0001) and narrowed their differential diagnosis list (p<0.0001).

We demonstrated that a low-cost ultrasound simulator can be successfully integrated into trauma simulations, resulting in an associated improvement in measures of diagnostic accuracy, confidence, and precision for participating resident and attending physicians.