Thunder Bay Regional Hospital (TBRH) developed a chest pain strategy (CPS) to support its emergency physicians in making the difficult clinical decisions required to properly evaluate and manage ED “chest pain” patients. This strategy was developed to ensure excellent patient care in a setting of diminished inpatient bed availability and increasing ED congestion. It focuses on rapid risk stratification, using history, electrocardiogram, physical examination and 3 new point-of-care cardiac markers: myoglobin, CK-MB mass, and cardiac troponin I.

Following the introduction of the CPS in 1997, TBRH realized significant ($500 000/yr) institutional resource savings through a 60% decrease in the admission rate of non-myocardial infarction, non-unstable angina chest pain patients, a 30% decrease in ED chest pain evaluation time, and improved ED availability of monitored stretchers. The CPS has allowed TBRH to simultaneously decrease costs and improve patient care.

The United States dominates academic emergency medicine. In other specialties, century-old medical traditions and international leaders balance the US influence. But emergency medicine was born in the US, the number of US trainees far out-number those of other countries combined, and our textbooks and journals are written primarily by US authors.

In February 1997, a proposal to develop diagnostic ultrasound (U/S) skills for emergency physicians at Surrey Memorial Hospital was presented to the Diagnostic Imaging (DI) Department and subsequently to the Medical Advisory Committee. To our surprise, this was accepted in principle, with no resistance. With the support of DI, maternity and emergency medicine developed a joint proposal to purchase a $160,000 portable U/S machine. It happened so easily that I became convinced God is an emergency physician.

In this issue, Dr. David Mutrie illustrates both the utility of departmental care protocols and the caution we must take in drawing conclusions from them. The latter point is particularly important if one wishes to apply these conclusions to other institutions.

The Thunder Bay Regional Hospital (TBRH), in Ontario, established simple guidelines for the management of patients with chest pain. Following the implementation of these guidelines, Mutrie reports shorter chest pain assessment times and reduced admission rates for non-myocardial infarction and non-unstable angina patients, without any obvious increase in inappropriate discharge of patients with ischemic disease. Can we therefore conclude that the guidelines were responsible for these improvements and that this set of guidelines would similarly improve performance in other emergency departments? The answer, unfortunately, is No. The fact is, the establishment of any organized approach to a clinical problem tends to improve performance. This is perhaps a sad reflection on “individual” practice patterns, but it is true nonetheless.

Focused abdominal sonography in trauma (FAST) has in many centres replaced the diagnostic peritoneal lavage (DPL) for the early assessment of acute blunt abdominal trauma. In many cases a negative FAST obviates the need for further imaging and intervention. In well-trained hands, it is a very specific and relatively sensitive test for the detection of hemoperitoneum and has the advantage over DPL of being noninvasive. However, the introduction of this exam has raised many contentious issues around indications for the study, as well as who should perform and interpret the study. Ironically, the question of who should perform the test has in many ways overshadowed the issue of whether it should be performed at all.

Le Dr Denis Lockman présente un journal de son expérience comme bénévole pour Médecins Sans Frontières dans la région du nord de l’Angola déchirée par la guerre. Il décrit ses tentatives d’offrir un semblant de soins médicaux organisés au milieu du chaos. Son travail lui donnera l’occasion de rencontrer plusieurs personnages inoubliables, dont certains s’adaptent, d’autres non, chacun à sa façon. Face à la guerre et à la désintégration sociale où la corruption et la cupidité sont rampantes, l’aide des pays occidentaux bien intentionnés profite-t-elle aux pauvres et aux démunis, ou nourrit-elle tout simplement l’appétit prédateur insatiable des éléments criminels?

A 46-year-old man presented to the ED after the sudden onset of chest pain 45 minutes earlier. He had been straining (installing a fan) when the pain began. He described the pain as a severe pressure that radiated to his left shoulder and arm. No radiation to the neck or back was noted. He denied shortness of breath, nausea, diaphoresis, syncope or palpitations. He had not previously experienced similar symptoms and felt well until the moment the pain began. Past medical history included poorly controlled hypertension for 15 years and a 35 pack-year smoking history.

You’ll start in the ER!” the Chief of Staff informs his prize new surgical fellow, Robert Yeats, played by Hollywood heartthrob Eric Stoltz. This is TV land, Chicago Hope to be exact, and a great set-up for a hard-hitting personality clash.

“I don’t want him,” the ER director and trauma surgeon, Dr. Keith Wilks, complains ineffectually. “I’m ‘way too busy today.”

A 21-year-old female presented to the emergency department complaining of wrist pain following a fall onto her outstretched (dominant) right hand. The injury occurred the previous night while the patient was riding her bike. She noticed some immediate wrist pain but believed it was only a “sprain.” The next morning she awoke with considerably more pain and was unable to move the affected wrist. She suffered no other injuries and was otherwise healthy.

The Royal Flying Doctor Service, or RFDS, is close to every rural Australian’s heart. Five aircraft in Alice Springs cover central Australia, an area of desert the size of Spain. People in need call the flying doctor, hundreds of miles away, by telephone or radio. These aircraft, really airborne ICUs, can be wherever help is needed in 45 minutes.

I love my job. I truly enjoy going to work and being part of the controlled pandemonium. The IVDA in 12 that was given Narcan by EHS and arrived awake enough to grab his full syringe and start injecting again. The sound of swear words wafting through the department and the sights and smells of human waste products exuding through all body orifices. Sometimes it is overwhelming: the noise, the demands, and the sadness of the conditions that people end up in.

The most likely answer in this case is D, but the correct answer is B. Because of diagnostic uncertainty, this man underwent urgent cardiac catheterization. Angiography revealed 80% occlusion of the left main coronary artery resulting from the false lumen created by an ascending aortic dissection. An immediate transesophageal echocardiogram showed mild aortic insufficiency, a left ventricular ejection fraction of 40%, and diffuse anterior hypokinesis. The patient underwent emergency surgery to repair both aortic dissection and the aortic valve, and to perform bypass grafting to the left main coronary artery.

African hemorrhagic fevers are lethal, incurable viral infections with a notorious propensity to afflict health care workers. Lassa and Ebola are the best-known culprits, and these killers spread fear well beyond their geographic range. Chances are your hospital has a plan to deal with febrile travellers returning from endemic regions of Africa. Such plans involve isolation, space suit technology and desperate calls to public health and tropical disease experts.

Resident interest in emergency medicine (EM) is on the rise. Each year, postgraduate matches add to the ranks of Canadian EM residents, and the Canadian Association of Emergency Physicians (CAEP) Residents’ Section (RS) continues to expand. The numbers are inspiring. This year, 16 residents accepted Royal College EM postgraduate year-1 (PGY-1) slots. Many more began their CCFP(EM) PGY-3 year, and this doesn’t include the residents who matched separately to EM training programs in Quebec. At the same time, the Canadian Resident Matching Service (CaRMS) matched about 433 new Family Medicine residents and 63 new Pediatrics residents. A significant number of these groups will also go on to develop interests and skills in EM.