The HEARTS ECG workshop: a novel approach to resident and student ECG education.

OBJECTIVES: ECG interpretation is a life-saving skill in emergency medicine (EM), and a core competency in undergraduate medical curricula; however, confidence for residents/students is low. We developed a novel educational intervention-the HEARTS ECG workshop-that provides a systematic approach to ECG interpretation, teaches EM residents through the process of teaching medical students and highlights emergency management. METHODS: We used the Kern Approach to Curriculum Development. A review of ECG education literature and a targeted needs assessment of local students/residents led to goals and objectives including systematic ECG interpretation with clinical relevance. ECGs were selected based on a national consensus of EM program directors and categorized into 5 common emergency presentations. The educational strategy included content based on HEARTS approach (Heart rate/rhythm, Electrical conduction, Axis, R-wave progression, Tall/small voltages, and ST/T changes), and methods including flipped classroom and near-peer teaching. Evaluation and feedback were based on the Kirkpatrick program evaluation. The workshop was piloted with 6 junior EM residents and 58 medical students, and repeated with nine residents and 68 students from four medical schools. RESULTS: Residents and students agreed or strongly agreed that the workshop improved their perceived ability (100% and 95%, respectively) and confidence (77% and 88%, respectively) in interpreting ECGs. Reports of ECG interpretation causing anxiety declined from pre-workshop (61% and 83% respectively) to post-workshop (38% and 37% respectively). Residents reported behavior change: 3 months after the workshop, 92.3% reported ongoing use of the HEARTS approach clinically and through teaching medical students on shifts. Reported workshop strengths included the pre-workshop material, the clinical application, facilitator-to-learner ratio, interactivity, the ease of remembering and applying the HEARTS mnemonic, and the iterative application of the approach. Suggested changes included longitudinal sessions with graded difficulty, and allocating more time for introductory material for ease of understanding. CONCLUSION: The HEARTS ECG workshop is an innovative pedagogical method that can be adapted for all levels of training. Future directions include integration in undergraduate medical and EM residency curricula, and workshops for physicians to update ECG interpretation skills.

An Active Shooter in Your Hospital: A Novel Method to Develop a Response Policy Using In Situ Simulation and Video Framework Analysis.

Hospital shootings (Code Silver) are events that pose extreme risk to staff, patients, and visitors. Hospitals are faced with unique challenges to train staff and develop protocols to manage these high-risk events. In situ simulation is an innovative technique that can evaluate institutional responses to emergent situations. This study highlights the design of an active shooter in situ simulation conducted at a Canadian level-1 trauma center to test a Code Silver active shooter protocol response. We further apply a modified framework analysis to extract latent safety threats (LSTs) from the simulation using ethnographic observation of the response by law enforcement, hospital security, logistics, and medical personnel.The video-based framework analysis identified 110 LSTs, which were assigned hazard scores, highlighting 3 high-risk LSTs that did not have effective control measures or were not easily discoverable. These included lack of security during patient transport, inadequate situational awareness outside the clinical area, and poor coordination of critical tasks among interprofessional team members. In situ simulation is a novel approach to support the design and implementation of similar events at other institutions. Findings from ethnographic observations and a video-based analysis form a structured framework to address safety, logistical, and medical response considerations.

Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents.

OBJECTIVE: Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents. METHODS: A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs. RESULTS: Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED). CONCLUSIONS: Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Creation of a national emergency medicine enhanced competency directory for residency training.

Canadian emergency medicine Royal College residency training allows for pursuing extra training in enhanced competency areas. A wealth of enhanced competency training opportunities exist nationally. However, the search for the right fit is a challenging one because there is no centralized resource that catalogues all of these opportunities. A working group of the Canadian Association of Emergency Physicians (CAEP) Resident Section was assembled in 2016 to create a freely accessible and comprehensive directory of Canadian enhanced competency areas. The working group used stakeholder surveys (of residents, recent graduates, and faculty members), social media engagement, and program website searches. Information was collated into the first edition of a national enhanced competency directory, which is available at no cost at http://caep.ca/sites/caep.ca/files/enhancedcompdoc.pdf. Limitations include the scope defined by the working group and survey responses. A biannual update is also incorporated into the CAEP Resident Section portfolio to ensure it remains up-to-date.

An environmental scan of academic pediatric emergency medicine at Canadian medical schools: Identifying variability across Canada.

OBJECTIVE: To complement our environmental scan of academic emergency medicine departments, we conducted a similar environmental scan of the academic pediatric emergency medicine programs offered by the Canadian medical schools. METHODS: We developed an 88-question form, which was distributed to pediatric academic leaders at each medical school. The responses were validated via email to ensure that the questions were answered completely and consistently. RESULTS: Fourteen of the 17 Canadian medical schools have some type of pediatric emergency medicine academic program. None of the pediatric emergency medicine units have full departmental status, while nine are divisions, two are sections, and three have no status. Canadian academic pediatric emergency medicine is practised at 13 major teaching hospitals and one specialized pediatric emergency department. There are 394 pediatric emergency medicine faculty members, including 13 full professors and 64 associate professors. Eight sites regularly take pediatric undergraduate clinical clerks, and all 14 provide resident education. Fellowship training is offered at 10 sites, with five offering advanced pediatric emergency medicine fellowship training. Half of the sites have at least one physician with a Master's degree in education, totalling 18 faculty members across Canada. There are 31 clinical researchers with salary support at nine universities. Eleven sites have published peer-reviewed papers (n=423) in the past five years, ranging from two to 102 per site. Annual academic budgets range from $10,000 to $2,607,515. CONCLUSIONS: This comprehensive review of academic activities in pediatric emergency medicine across Canada identifies the variability across the country, including the recognition of sites above and below the national average, which may prompt change at individual sites. Sharing these academic practices may inspire sites to provide more support to teachers, educators, and researchers.

Diagnosis of a Strangulated Laparoscopic Incisional Hernia with Point-of-Care Ultrasonography.

The use of point-of-care ultrasound for the diagnosis of bowel obstructions and hernias is becoming increasingly common in the emergency department (ED). Using a relatively rare case of an incisional port hernia, we demonstrate the ultrasound findings of a strangulated hernia causing a partial small bowel obstruction. A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements. There was a palpable mass in the left lower quadrant under the 12mm trocar port incision. ED point-of-care ultrasound revealed herniated akinetic loops of bowel through her laparoscopy incision. This is the first case report to describe the use of point-of-care ultrasound for the diagnosis of a strangulated incisional port hernia at the bedside.

A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults in three Canadian cities.

BACKGROUND: Homeless persons experience a high burden of health problems; yet, they face significant barriers in accessing health care. Less is known about unmet needs for care among vulnerably housed persons who live in poor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were to examine the prevalence of and factors associated with unmet needs for health care in a population-based sample of homeless and vulnerably housed adults in three major cities within a universal health insurance system. METHODS: Participants were recruited at shelters, meal programs, community health centers, drop-in centers, rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009. Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regression was used to identify factors associated with self-reported unmet needs for health care in the past 12 months. RESULTS: Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses, factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months (AOR = 1.40, 95% CI = 1.03-1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24-3.79). Having higher health-related quality of life (AOR = 0.21, 95% CI = 0.09-0.53), improved mental (AOR = 0.97, 95% CI = 0.96-0.98) or physical health (AOR = 0.98, 95% CI = 0.96-0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46-0.85) decreased the odds of reporting unmet needs. CONCLUSIONS: Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health care needs. Strategies to improve access to primary care and reduce barriers to accessing care in these populations are needed.

Role of AP-2alpha transcription factor in the regulation of synapsin II gene expression by dopamine D1 and D2 receptors.

Synapsins are a family of neuron-specific phosphoproteins involved in synaptic vesicle docking, synaptogenesis, and synaptic plasticity. Previous studies have reported an increase in synapsin II protein by dopaminergic agents in the striatum, medial prefrontal cortex, and nucleus accumbens. This study investigated the mechanistic pathway involved in synapsin II regulation by dopaminergic drugs using primary midbrain neurons to determine which of several transcription factors regulates synapsin II expression. Protein kinase A (PKA) participation in the signaling pathway was examined using selective PKA inhibitors, which reduced synapsin II expression in cell cultures while dopaminergic agents were unable to increase synapsin II in the presence of the PKA inhibitor. Transcription factor involvement was further investigated using separate cultures treated with antisense deoxyoligonucleotides (ADONs) against the following transcription factors: activating protein 2 alpha (AP-2alpha), early growth response factor 1 (EGR-1), or polyoma enhancer activator-3 (PEA-3). Selective knockdown of AP-2alpha by ADONs reduced synapsin II levels, whereas treatment with EGR-1 and PEA-3 ADONs did not affect synapsin II expression. Furthermore, dopaminergic agents were no longer able to influence synapsin II concentrations following AP-2alpha knockdown. Collectively, these results indicate that a cyclic adenosine-3',5'-monophosphate/PKA-dependent mechanism involving the AP-2alpha transcription factor is likely responsible for the increase in neuronal synapsin II following dopamine D1 receptor stimulation or dopamine D2 receptor inhibition.

Allosteric modulation of the dopamine D2 receptor by Pro-Leu-Gly-NH2 peptidomimetics constrained in either a polyproline II helix or a type II beta-turn conformation.

Type II beta-turn mimics and polyproline II helix mimics based upon diastereoisomeric 5.6.5 spiro bicyclic scaffolds have provided two pairs of Pro-Leu-Gly-NH(2) (PLG) peptidomimetics with contrasting dopamine receptor modulating activities. Compounds 1a and 3a were found to be positive allosteric modulators of the dopamine receptor, while the corresponding diastereoisomeric compounds 1b and 3b provided the first PLG peptidomimetics with the ability to decrease the binding of agonists to the dopamine receptor. The positive allosteric modulating activity of 3a supported the hypothesis that a polyproline II helix conformation is the bioactive conformation for the PLG analogue Pro-Pro-Pro-NH(2). The results also show that a change in the bridgehead chirality of the 5.6.5 scaffold brings about opposite effects in terms of the modulation of the dopamine receptor.