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

Conventional medical school and residency curricula glossed over nutrition for patients and certainly made no mention of how to look after oneself on shift.

Eric and Karine discuss the roles that caffeine, hydration and nutrition play when working in emergency medicine. They look at some good and not-so-great strategies and provide some advice for shift performance enhancement.

Coffee:

Caffeine is the most widely consumed CNS stimulant, and coffee is the world's 3rd most popular beverage. If you drink coffee, you can probably do stupid things faster and with more energy but ... 

Seriously, caffeine has beneficial effects on reaction time, vigilance, and attention, but there is less to suggest that it improves decision making and problem solving.

• Caffeine is an ADENOSINE blocker. It counteracts the CNS depressant activity of adenosine.
• 2 to 3 cups are likely the ceiling of beneficial effect. Restrict caffeine the to the first half of your shift.
• Try a coffee nap:  have a cup or a shot some time prior to your shift, IMMEDIATELY lie down and rest/sleep/doze for 30 minutes. When you wake, the caffeine will be starting to have effect.

Hydration:

• Dehydration of 2% can affect decision making and cognitive performance.
• 1 to 1.5 litres of water over a shift is about right.
• Caffeine does NOT dehydrate you.
• PEE before you put on your PPE (prior to a procedure, critical care etc.)
• Urine colour is a reliable marker of hydration status, so if you are yellow, have a glass!

Nutrition:

• Shift working (especially night shift working) affects circadian rhythms which has detrimental metabolic effects.
• Night workers tend to choose sugary snacks, often out of convenience. Sleep deprivation makes you choose calorie dense carbs and salty snacks. 
• Aim for euglycemia, so avoid high glycemic foods (candy, donuts, fruit juice). Stick to balanced meals with roughage and high protein sources. Snack on fruits, vegetables, yoghurt and nuts.
• Avoid where possible processed foods.
• Eating at end of shift before sleeping? On one hand, you are less likely to wake up ravenous, but some data suggests that the increased body temperature generated after eating can impair sleep.
• Eric and Karine were unable to agree on the concept of comfort food at 0200 hrs being beneficial. You must decide whether a handful of jujubes will prevail over 4 carrot sticks.

End of Shift went on the road in late 2021 to catch up with Dr. David Pledger. David practiced in both Las Vegas and Vancouver before settling in Nevada. He fills us in on the interesting differences between US and Canadian emergency care and comments about how COVID impacted his adopted state and British Columbia.

In this episode of End of Shift, Eric and Joe talk with Dr. Carolyn Kelly-Smith about the practice of medicine (and sometimes not) in austere environments.

Dr. Kelly-Smith is an FRCP trained attending ED physician at the Royal Columbian and Eagle Ridge Hospitals. She is an Advanced Medical Provider for North Shore Rescue, a faculty member of the Canadian Society of Mountain Medicine and a ski patroller at Whistler/Blackcomb.

Why should you care about wilderness medicine? There are many reasons – from going where the action is (increasingly outdoors) to expanding your clinical horizons by stretching your comfort zone.

We examine the utility of having a physician involved in outdoor settings, be it reasonably controlled settings like a ski resort, or a complicated rescue operation with failing daylight and minimal clinical details.

It’s not all Mission: Impossible style heroics – sometimes the most useful clinical actions and decisions are simpler than you might think.

How to get involved? We’ll tell you. You’ll learn about the North Shore Rescue Society and the Canadian Society of Mountain Medicine – and maybe get fired up to get out there!

Resources:

• Documentary: Search and Rescue: North Shore
• Canadian Society of Mountain Medicine

Management of ED trauma cases has transformed over the past 20 years. Our guest, Dr. Hazel Park, discusses new and emerging pearls, trauma systems, training, and virtual support for BC trauma management.

Dr. Hazel Park

Dr. Hazel Park is an attending emergency physician and Trauma Team Leader at Lions Gate Hospital, Medical Director of the Regional Trauma Program for Vancouver Coastal Health and Providence Health Care. She is a Clinical Associate Professor at UBC. 

Dr. Park completed her training and family practice residency at the University of Toronto and worked at the emergency department of the Wellesley Hospital in Toronto. She currently volunteers as a ski patrol physician and is an advanced medical provider for the Vancouver North Shore Rescue.

Resources

• BC Emergency Medicine Network - Trauma Management Clinical Resources
• Real-Time Virtual Support in BC
• Information on Trauma Courses, including: 
  • Simulated Trauma Resuscitation Update Course (STRUC), Pediatric Advanced Trauma Simulation (PATS), and Advanced Trauma Life Support (ATLS)

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 quick review, Dr. Julian Marsden and Dr. Rob Stenstrom  discuss updates in sepsis management, research, and the latest diagnostic guidelines for the emergency department (ED). Dr. Stenstrom shares up-to-date guidance on the use of steroids, fluids, vasopressors, and antibiotics to treat sepsis in the ED.  

Dr. Rob Stenstrom

Rob Stenstrom is an emergency physician and senior researcher at St. Paul's Hospital in Vancouver, BC. He also holds a Ph.D. in Epidemiology and Biostatistics from McGill University. He is the Sepsis and Soft Tissue Infections Research Lead for the BC Emergency Medicine Network.  

Resources

• World Sepsis Day Events & Webinars (Sept 13, 2021)
• BC Emergency Medicine Network Sepsis Resources
• Emergency Department Surviving Sepsis Guidelines
• BC COVID-19 Therapeutics Committee Guidelines
• Rob Stenstrom, EM Network member and Sepsis and Soft Tissue Infections Research Lead
• David Sweet, EM Network member and clinical lead (sepsis) for Clinical Care Management initiated by the Ministry of Health, contact

Clinical Supports

• RUDi - Peer-to-peer Real-Time Virtual Support  for emergency care
• ROSe - Peer-to-peer Real-Time Virtual Support  for critical care
• BC Bedline  Patient Transfer

Host

Dr. Julian Marsden

Julian Marsden leads the development of the Clinical Resource Program for the BC Emergency Medicine Network. He has been an emergency physician for 27 years and currently works in the emergency departments of St Paul’s, Mount Saint Joseph’s, and Vancouver General Hospital. Julian has a strong interest in knowledge translation and quality improvement.  

Disclaimer: The views and opinions expressed in this podcast are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.

Learn more at bcemn.ca

In this in-depth review, Dr. Julian Marsden talks to EM Network member Dr. David Barbic, who gives an overview of his recently published article, Rapid Agitation Control with Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. The study was published in the Annals of Emergency Medicine online, on Aug. 2nd, 2021.

David walks through an in-depth look at the study setup and limitations, key take-home points, how the findings can be interpreted in rural EDs, and implications for emergency nurses and pre-hospital settings.

Dr. David Barbic
Dr. David Barbic is an emergency physician at St. Paul’s Hospital in Vancouver, BC. He is also a Clinician Scientist at the Centre for Health Evaluation & Outcome Sciences (CHÉOS). David’s particular clinical interest is in patients presenting to the ED with mental health and substances issues and traditionally underserved patient populations.  

Dr. Julian Marsden
Julian Marsden leads the development of the Clinical Resource Program for the BC Emergency Medicine Network. He has been an emergency physician for 27 years and currently works in the emergency departments of St Paul’s, Mount Saint Joseph’s, and Vancouver General Hospital. Julian has a strong interest in knowledge translation and quality improvement. 

Disclaimer: The views and opinions expressed in this podcast are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.