Emergency Care BC – Details, episodes & analysis

In this episode of End of Shift, Eric and Joe continue their discussion with Dr. Shannon Jackson, talking about blood types and donation as well as sickle cell disorders.

ONCE AGAIN, call 604-682-2344 (St. Paul’s Hospital) and you can reach a hematologist 24/7.

Most hospitals carry: pRBC, FFP, platelets and cryo. The Canadian Blood Services knows where all the products are, and the central transfusion registry in BC circulates products to areas of need and does so with minimal wastage. 

FFP is made from plasma which is separated from donor blood and frozen to minus 35°C to preserve it. Cryoprecipitate (cryo) is made from FFP which is frozen and repeatedly thawed in a laboratory to produce a source of concentrated clotting factors including Factor VIII, Factor XIII, von Willebrand factor and fibrinogen.

FFP can reverse the effect of warfarin because it contains substantial levels of vitamin K dependent clotting factors (II, VII, IX, X and protein C/S). FFP is indicated when a patient has MULTIPLE factor deficiencies and is BLEEDING.

Cryoprecipitate is indicated for the treatment of acquired fibrinogen deficiency or dysfibrinogenaemia, due to critical bleeding, an invasive procedure, trauma or disseminated intravascular coagulation (DIC). It’s not ideal for specific factor replacement.

If you have no factor available, you can use FFP/cryo.

DONATE DONATE DONATE!

There is never too much blood – donated blood can also be used for non-clinical research.
You can donate every 8 weeks! There are very few exclusions to donating.

Go to Canadian Blood Services - www.blood.ca - to book your donation.

Dr. Shannon Jackson is a clinical hematologist and the medical director of the Provincial Adult Bleeding Disorder program based out of St. Paul’s Hospital in Vancouver.

Related Clinical Resource:
Treatment of Persons with Inherited Bleeding Disorders (PwIBD) in the Emergency Room
by Dr. Shannon Jackson, Michelle Bech

The older ED crowd will remember this classic Supertramp track from the 1974 album, Crime of the Century. It's our springboard to talk about bleeding disorders.

Dr Shannon Jackson is a clinical hematologist and the medical director of the Provincial Adult Bleeding Disorder program based out of St. Paul’s Hospital in Vancouver.

The program deals primarily with inherited bleeding disorders: Factor (VIII and IX) deficiencies, von Willebrand disorder, platelet disorders and undefined bleeding disorders. 

This is episode 1 of 2 with Dr. Shannon Jackson.

Factor VIII or IX deficiency:

• VIII deficient: hemophilia A, 1 in 10,000 people and IX deficient: hemophilia B, 1 in 50,000 people
• X-linked recessive disorders, males have phenotypic disease, females can be obligate carriers from their fathers – but one third of emerging cases are NEW MUTATIONS
• 30% patients are SEVERE, with < 1% of normal factor
• 10 % are MODERATE, with 1 – 5 % of normal factor
• Rest are classed MILD, with < 40 % normal factor

Von Willebrand disorder:

• Autosomal inheritance on chromosome 12, 1 in 100 people
• Type 1: low antigen amount, so low activity – 70 % cases
• Type 2: defective antigen, so poor activity – 15% cases
• Type 3: no vWF

FEARED bleeds are intracranial, GIB, iliopsoas, vaginal, medial forearm, anterior calf

Patients are usually very well informed - perhaps more than you.

They carry Factor First cards, identifying their disease, appropriate doses of factor for treatment and thankfully – the contact information for the on-call hematologist.

Steps in the ED? Reverse order!

• Order factor first (or ddAVP if fVIII unavailable)
• Then imaging,
• Then history.

Tranexamic acid also a useful adjunct – UNLESS gross hematuria (can trigger renal and ureteric concretions)

Related Clinical Resource:

• Treatment of Persons with Inherited Bleeding Disorders (PwIBD) in the Emergency Room
  by Dr. Shannon Jackson, Michelle Bech

What are the most common disciplinary issues among physicians who practice emergency care? How are these issues handled, and how can YOU avoid getting into trouble? Bruce Campana walks us through the art of disciplining physicians. 

Bruce is currently the Medical Director of Enhanced Medical Staff Support (EMSS) at Vancouver Island Health Authority. EMSS supports medical leaders who are asked to attend to issues of medical staff professionalism. 

Bruce also describes his early career experience working under legends in emergency medicine, like the Dr. Rosen. From there, his career path led him to Saudi Arabia, where he was the Saudi King’s private physician and hacked into a plane’s oxygen supply to treat the Amir of Kuwait while in the air. 

His storied career led him to his current position at EMSS, where he emphasizes an empathic approach to bullying, challenging relationships, and mental health issues, among other disciplinary problems faced by emergency physicians. 

Bruce is an attending emergency physician at Victoria General Hospital, Clinical Associate Professor at the UBC Dept of Emergency Medicine, Medical Director for Enhanced Medical Staff Support for the Vancouver Island Health Authority. He also practices hyperbaric medicine at Vancouver General Hospital. 

Bruce complete medical school training at McGill University, came out west to intern at St. Pauls’ Hospital in Vancouver and completed his medical residency in Denver, Colorado. He is a frequent keynote speaker at emergency medicine conferences.

Resources

Enhanced Medical Staff Support (EMSS), Vancouver Island Health Authority

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His non-medical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
End of Shift podcast discussions may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

In this episode, we cover all things POCUS (point-of-care-ultrasound) in emergency care. Guest Karine Badra-Quirion, an emergency physician at Lions Gate and St. Paul's Hospital, imparts her POCUS prowess.

We discuss BC's POCUS pioneers and the best studies for patient-oriented outcomes and ED flow. 

Karine shares image generation techniques, common errors, and her top POCUS tips. We explore ultrasounds VS CT scan and potential diagnoses, POCUS for trauma, and rural practitioner support. Plus, Karine takes the reappointment quiz!

Karine Badra-Quirion

Karine Badra-Quirion is an emergency physician at Lions Gate Hospital in North Vancouver and St. Paul’s Hospital in Vancouver,

Related Resources

• PoCUS Resources on BC Emergency Medicine Network 
• Real-Time Virtual Support in BC
  • Real-Time Virtual Support (RTVS) offers BC emergency care providers on-demand support for patient care. RTVS is delivered by video or phone, anywhere in BC.  Learn more.

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His nonmedical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

Show Notes

In this episode we talk to Louise Pick, an emergency bedside and charge nurse at Lions Gate Hospital in North Vancouver. We explore the dynamic between emergency physicians and nurses, and reflect on the unique challenges ED nurses face. Plus, Louise shares a harrowing story of being buried alive by an avalanche, and how her ED team mate saved her.

Louise Pick

Louise Pick is an emergency nurse with over a decade of experience in busy EDs. She skied competitively early on but stepped away from the podium to train in nursing at McGill University. She started practising at Montreal General Hospital, then moved out west to chase the mountains. She has worked at Lions Gate Hospital in North Vancouver ever since and recently became a Patient Care Coordinator.

Related Resources

• Understanding the factors which promote registered nurses’ intent to stay in emergency and critical care areas. Authored by EM Network Nursing Representation, Mary Van Osch. (Van Osch, et al. J Clin Nurs . 2018 Mar;27(5-6):1209-1215. doi: 10.1111/jocn.14167. Epub 2018 Jan 10.)
• EM Network Patient Information Sheets

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His nonmedical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network, or the Vancouver Coastal Health Authority.

In this episode, Eric and Joe speak to Dr. David Haughton, a life-long artist and leader in his field. David practiced pediatric emergency medicine at BC Children’s Hospital until 2017 and has been painting prolifically for over 40 years.

David shares the lessons learned from his storied career, including navigating medical politics and how to balance occupation, obligations, and the pursuit of happiness. He has now retired to pursue painting full time, but would Eric and Joe welcome him back into the fold? Find out if he passes the End of Shift locum quiz.

David Haughton

David Haughton received his undergraduate degree at Harvard University. He trained at Cornell Medical College in NYC, and Children’s Hospital of Los Angeles before moving to BC in 1991.

He worked at the BC Children’s Hospital for 25 years and headed the BC Section of Emergency Medicine for 11 years. In October 2017, David worked his last night shift and gave up his medical licensure to pursue painting full time.

David has been an artist for nearly all his life. He has been sketching and drawing, painting and scumbling for over 40 years. His home studio is in New Westminster, but he has travelled to Tuscany and Tofino to find inspiration for his creations. Visit https://www.haughton-art.ca to find out more about his work.

The BC Emergency Medicine Network is a community of physicians who practice emergency care in British Columbia, Canada. Visit http://bcemn.ca for clinical resources, real-time virtual support, continuing professional training, and EM innovation.

Podcast Hosts
The End of Shift Podcast is hosted by EM Network members Eric Angus and Joe Haegert.

Eric Angus

Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His non-medical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert

Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

In the emergency department, we see many injured and infected hands and need to be comfortable with initial diagnosis and treatment before considering downstream follow up with a hand surgeon. Hosts Eric and Joe discuss common hand presentations, workup, and treatment with Dr. James Saunders, Head of Plastic Surgery for the Sea to Sky Corridor. They review fractures, dislocations, amputations, infections, and injuries in the ED.

James advises on the best finger to get chopped off in a hostage-taking scenario, and Joe has two practice-changing, “a-ha” moments. Plus, three ways hand injuries are mismanaged in the ED.

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His nonmedical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

In this episode, Eric and Joe do a deep dive on sepsis with Dr. Rob Stenstrom, Sepsis and Infections Lead for the EM Network. They discuss the most practical definition of sepsis in the ED and which diagnostic score to use. They find the bottom line on serum lactate, fluid treatment, and blood cultures and antibiotic timing. Rob answers questions on which pressor to use, central access timing, and the status of novel therapies. Plus, is there a genetic predisposition to developing sepsis?

Sepsis Stats

• 1 in 18 deaths in Canada involve Sepsis
• 30% of Canadians hospitalized with sepsis die within 1 month.

Related links

• Sepsis and Septic Shock – Diagnosis
• Sepsis with Hypotension and Septic Shock – Treatment
• Sepsis without Hypotension – Treatment
• Pediatric Septic Shock Management
• EM Network Sepsis and Soft Tissue Infections Research Program

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His nonmedical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

Daniel Kalla - danielkalla.com

Additional reading
Daniel Kalla

• Pandemic (2005)
• Resistance (2006)
• Blood Lies (2007)
• We All Fall Down (2019)
• The Last High (2020)

Stephen King 

• On Writing: A Memoir of the Craft (2000)

Michael Crichton 

• michaelcrichton.com

Resources for Emergency Care Practitioners 

• Oral Opioid Analgesic Conversion Table (McMaster University)
• Buprenorphine (Suboxone) Initiation for Opioid Use Disorder Patients  (BC EM Network)
• Opioid Overdoses – Management (BC EM Network)
• Suboxone Take Home (Buprenorphine-Naloxone) Patient Information Sheet (BC EM Network)

Conflict of Interest Statements

• Adam Lund is an emergency physician and Clinical Associate Professor at UBC, with no conflicts related to this interview.  He is the Communications Liaison for the BC Emergency Medicine Network.
• Daniel Kalla is the author of the book reviewed in this interview, as well as an emergency physician and Clinical Associate Professor at UBC.
• Neither participant received any additional/direct funding from the publisher by participating in this voluntary interview.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

In this episode of the End of Shift podcast, recorded on Jan. 7, 2020, Eric and Joe talk to Jim Christenson, Executive Lead of the BC Emergency Medicine Network. They discuss highlights from Jim's 40-year career practicing emergency medicine and talk about why he started the BC Emergency Medicine Network. Jim shares his lessons on how to stay well and avoid burn out. Plus, find out whether Eric would hire him as locum!

Jim Christenson

Jim is an emergency physician, and professor and head of the Academic Department of Emergency Medicine at UBC. Jim’s primary research interest is in resuscitation. He is a co-principal investigator for the Canadian Resuscitation Outcomes Consortium (CanROC) and has been involved in various aspects of cardiac arrest and trauma research for 25 years. Currently, he is leading a groundbreaking prehospital stroke study. Committed to improving emergency care across BC, Jim is proud to provide leadership to the BC Emergency Medicine Network that is solely focused on supporting physicians in emergency departments.

Two EM Network projects mentioned in the interview have progressed significantly since the date of the recording on Jan. 7, 2020. Find out more by clicking the links below:

Kwiis hen nep: project to improve emergency care for remote Indigenous communities in BC

• View the December 2019 UBC Emergency Medicine Rounds.
• The EM Network received 1.17M in April 2020 to improve emergency care for remote Indigenous communities.
• The project continues despite the challenges posed by the COVID-19 pandemic.

Real-Time Virtual Support Project

• The way we provide emergency care in BC has rapidly evolved. The EM community is leading provincial health system transformation through new real-time virtual support platforms. The services below are playing a pivotal role in providing exceptional emergency care, everywhere.
• The BC EM Network is involved in the implementation and evaluation of the virtual services listed above. This broad Real-Time Virtual Support program is only possible through collaboration between the Rural Coordination Centre of BC, BC Emergency Medicine Network, BC Section of Emergency Medicine, First Nations Health Authority, Providence Health Care, and HealthlinkBC.
• The are several services for physicians practicing EM care, including RUDi (Rural Urgent Doctors in-aid), and ROSe (Rural Outreach Support). Visit our Real-Time Virtual Support page for more information.

End of Shift Hosts

Eric Angus
Eric Angus is an emergency physician and trauma team leader at Lions Gate Hospital. He is married with 15-year-old twins. His nonmedical interests include origami, meditation, mountain biking, skiing, rock climbing, just generally being outside, and drinking wine. He has a diploma in mountain medicine and volunteers for ski patrol and the North Shore Rescue team. He is an ATLS instructor. He dabbles in stoicism and Buddhist philosophies.

Joe Haegert
Joe Haegert practices emergency and trauma medicine at the Royal Columbian Hospital in New Westminster, British Columbia. He is a talented teacher, engaging speaker, and devoted clinician. He lives in South Surrey with his wife Sandy and managed to raise three children without much incident. Known for his unflagging enthusiasm, Joe enjoys all aspects of the outdoors and recently has taken to turning wooden burls into all manner of bowls and tables.

Disclaimer
The discussion within the End of Shift podcast may be graphic, and some listeners may find the language and content disturbing. The views and opinions expressed in this podcast are those of the participants and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.