Clinical

Join Us

Do you want to work with a progressive, diverse group of more than 70 Emergency Physicians? London Health Sciences Centre and St. Joseph’s Health Care London are recruiting  6 Full time Emergency Physicians to join our city-wide team in July 2019. Our Physician pool is "flush" but in order to maintain a group of this size and to keep up with growing volumes of patients we need to hire 6 Emergency Physicians every year!  CVs are always accepted from practicing Emergency Physicians with an FRCPC Emergency Medicine, CCFP-EM or equivalent.  Emergency Medicine Residents interested in starting in July 2019 should submit their CV by November 30th 2018 for consideration!

Workplace

The London Health Sciences Centre (LHSC) has 854 beds and 120,000 emergency visits (2016/2017), spread over 2 sites. LHSC provides the broadest range of services of any health care system in Ontario. We are also home to The Fowler Kennedy Sport Medicine Centre, Lawson Research Institute and the Children's Health Research Institute, and Canadian Surgical Technologies and Advanced Robotics (CSTAR), where our simulation programs are run. St. Joseph’s Health Care London (SJHC) has 21 geographic sites with 1397 beds. The SJHC Urgent Care Centre has 39,000 visits per year. LHSC and SJHC non-emergency physicians offer excellent rapid inpatient and outpatient consultation services for all of our patients. Diagnostic Imaging and Interventional Radiology are truly available 24/7.

Clinical Work and Remuneration

All members have an equitable distribution of shifts, based on partnership share. Full time members are scheduled for 10 shifts per month with an option to pick up more. We enjoy competitive remuneration, based on pooled AFA hourly rate with a factor for "unsociable hours".  Individual members keep their own shadow billings. 

NO NIGHT SHIFTS - Another attractive feature of our work life are the very popular 6 hour casino shifts for overnight coverage (2200-0400, 0400-1000). Victoria Hospital ED is triple covered for 19 hours per day and double covered throughout the night. University Hospital ED is triple covered for 15 hours, double covered for 3 hours and single covered for the remaining 6 hours.. SJHC UCC is an AFA with shadow billing environment. Most team members work about 20% of their total shift allotment at SJHC UCC. Current UCC hours are 0800-1800 on weekdays and 0800-1600 on weekends.  A group that is 70 members strong enables easy trades and last minute coverage for family / personal emergencies.

Living in London

London and its surrounding communities offer an excellent affordable place to live regardless of your age, life style or family situation. Current team members live in a variety of settings including Downtown London, established neighbourhoods (ex. “Old south” or “Old North”), new communities (ex. Sunningdale or Riverbend), small towns (ex. Komoka or Ilderton) and along the shores of Lake Erie (Port Stanley). All of these communities are less than a 30 minute drive to work. Please visit the Good Move London website for a great overview of London and surrounding area.

Our Members

The division members are a talented group with broad academic, professional and leisure interests.  We have full and part time partnership positions available, with the opportunity to teach in many settings, as well as pursue other passions, medical and nonmedical!

Some of the activities our current members are involved in include:

  • Critical Care
  • Trauma Team Leadership
  • Ultrasound Instruction
  • Medical Education & Research
  • Pre-Hospital Care (Home to the Southwest Ontario Regional Base Hospital)
  • Orng Transport Medicine Physicians
  • Professional Regulation (CPSO)
  • Sports Medicine (with a Team Physician for the National Women's Hockey team)
  • Evidence Based Medicine
  • Post-Graduate Education (both FRCP & CCFP-EM)
  • International and refugee health
  • Health Administration
  • Clinical Pharmacology, with an interest in optimal drug treament in the ED
  • UWO Human Ethics Review Board Member
  • Website Development & Medical Informatics

The division website was created and is managed by one of our partners, and is an excellent resource for schedules, teaching, rounds, clinical discussions, as well as billing information, and other clinical resources.

Education

Teaching at all levels is available, with Division participation in all years of undergrad, as well as post grad family medicine emerg seminars, and core content for both FRCP & CCFP-EM programs. ACLS courses occur regularly, under our direction, and there is ample opportunity to participate with the simulation learning at undergrad and post grad levels.   We have an active Simulation Program under the Direction of Dr. Karen Woolfrey. Our POCUS group is led by Dr. Drew Thompson, Dr. Bezhad Hassani, Dr. Heather Hames and Dr. Frank Myslik.  Many faculty and current trainees are actively involved in POCUS Education and research. 

Research

The Division of Emergency Medicine at UWO has a fully supported research program, with Melanie Columbus and Kristine VanAarsen (clinical epidemiologists) as Research Coordinators and Dr. Jonathan Dreyer (Emergency Physician / Professor) as Medical Research Director. The Division also has part-time research assistants who help with prospective data collection, data analysis and interpretation. The faculty in the Division of Emergency Medicine has varied research interests which include:

  • Pre-hospital Care 
  • POCUS
  • Simulation
  • Sports Medicine
  • Medical Education
  • Sepsis
  • Toxicology
  • Clinical Decision Rules
  • Administrative Research
  • Trauma

A list of faculty members involved in research, their areas of interest, as well as current projects, publications and grants can be found here. To learn more about the Research program, please contact Melanie Columbus

More Information

Contact Dr. Adam Dukelow (City Wide Chair Chief of Emergency Medicine) via email or phone (519)-685-8500 ext. 57956 for more information about our recruitment package and working in our great city and group! We would love to have you visit London to learn more about your career opportunities with our team!

The New Pre-Hospital ECG Handover Process and the G313 pECG Billing Code

A new pre-hospital ECG (pECG) handover process has been in effect since September.  Paramedics must print a dedicated copy of any 12 lead pECG that they perform and give that copy to the nurse assuming care for the patient.  The RN or ward clerk will then stamp the pECG with the patient's blue card and attach the pECG to the back of the triage record.

A QA project is currently underway. Preliminary results are as follows:

 

When the pECG becomes a permanent part of the patient's chart, physicians can bill a "G313 pECG" after they interpret and document their findings on the ED chart.  Please be sure to write "pECG" beside the G313 code to differentiate it from the ED acquired ECGs.

In a retrospective study conducted at LHSC, nearly 20% of pECGs showed ischemic changes that were not captured on initial ED ECG.  A prospective study looking at the utility of the pECG in LHSC EDs and whether or not it has the ability to change ED management of patients will be starting in January.  This new handover process is one step in rolling out this project.  If you suspect that a patient may have had a pECG and do not find it attached to the triage record, or see pECGs that are not stapled to the triage record, please offer a friendly reminder to your colleagues about the new handover process.

New AHA CPR Guidelines

The American Heart Association has released its new 2010 guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The guidelines published in the November 2010 edition of Circulation are available for review here. Most notably is the replacement of the traditional Airway-Breathing-Compressions (ABC's) algorithm to the new Compressions-Airway-Breathing (CAB's) format. The new CPR sequence applies to adults, children and infants but does NOT include newborns.

Other important highlights include:

CPR

  • Rate of chest compressions should be at least 100 times a minute.
  • Rescuers should push deeper on the chest, resulting in compressions
    of at least 2 inches in adults and children and 1.5 inches in infants.
  • Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
  • Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
  • All 9-1-1 centers should assertively give telephone instructions to
    start chest compressions (Hands-Only CPR) when cardiac arrest is
    suspected in adults who are unresponsive, with no breathing or no normal
    breathing.
  • Dispatchers should provide instructions in conventional CPR for
    individuals who have presumably drowned or have had other likely
    asphyxial arrest.

 

Defibrillation

  • For attempted defibrillation with an automated external defibrillator of children 1 to 8 years old, the rescuer should use a pediatric dose-attenuator system if one is available, or a standard automated external defibrillator if the pediatric dose-attenuator system is not available.
  • A manual defibrillator is preferred for infants younger than 1 year.

ACLS algorithms

  • For management and treatment of pulseless electrical activity (asystole), atropine is no longer recommended for routine use.
  • For the initial diagnosis and treatment of stable, undifferentiated regular, monomorphic wide-complex tachycardia, adenosine is recommended.
  • To confirm intubation and monitor CPR quality, professional rescuers should use quantitative waveform capnography to measure and monitor carbon dioxide output.
  • The new guidelines do not recommend routine use of cricoid pressure in cardiac arrest.
  • Therapeutic hypothermia should be incorporated into the overall interdisciplinary system of care after resuscitation from cardiac arrest.

The highlights for the new 2010 guidelines can be downloaded here.

A chart comparing the old 2005 guidelines with the new 2010 guidelines can be viewed here.

Procedural Sedation Billing Guide

(Aug  2010 Revision)

Coding for Procedural Sedation

  1. Two doctors must be involved to be eligible to code for sedation.
    1.  Doctor 1 -  bills for the procedure
    2.  Doctor 2  - bills for the sedation
  2. Look up the procedural code (on cheat sheets, www.emlondon.ca, or SOB)
  3. Doctor 1 -  codes  with procedure code using the suffix 'A' (i.e. F032A)
  4. Doctor 2 - codes with the following:
    1. if the Procedure has a (6) listed behind it - use the same code but with suffix 'C'
    2. if no (6) or no procedure code listed, use E003C
    3. For BOTH scenarios document how many time units* you were in attendance
    4. Document and code any after hours anesthesia premiums**
    5. Document and code any Special Units*** -  NOTE: n/a if E003C is used

IF you provide sedation services for a CONSULTING SERVICE (ie Ortho) please document the CONSULTANT's name on the chart beside your billing codes

Basic Time Units

  • 1 unit = 15 minutes = $14.54
  • Start time = begins when in 1st attendance with the patient with the purpose of initiating sedation
  • Stop time = time when physician is no longer needed and patient is safe to leave with RN

Time Premiums

  • Monday - Friday 17:00-24:00 hrs    E400C (increase Anes fee by 50%)
  • Sat/Sun/Holiday 07:00 - 24:00 hrs    E400C (increase Anes fee by 50%)
  • Nights 24:00 - 07:00 hrs    E401C (increase Anes fee by 75%)

Special Units (NOT eligible if used with E003C)

  • ASA III    E022C (+4 units)
  • ASA IV    E017C (+10 units)
  • BMI > 45    (BMI = wt(kg)/ht(m)2)    E010C (+ 2 units)

Example

37 y.o patient assessed for fall Saturday afternoon, requires reduction of ankle and 18 minutes of sedation for procedure

Doc # 1 - H153 + F075A + (typical ER charting)
Doc # 2 - F075C +  2 time units + E400C (documents anesthesia assessment and times on blue sheet)

** NO MORE SEDATION SHEETS - EVERYTHING IS CODED ON BLUE COPY OF CHART**
  

LHSC Surviving Sepsis Campaign

On March 1 we launched the sepsis campaign in the hospital emergency
departments. The processes and tools have been developed, and our plan
is to review and refine our processes throughout April and May, and
apply what we have learned to current models of care. On June 1 we will
then commence the sepsis campaign through our inpatient units.
Today we are launching our LHSC sepsis campaign website at

http://www.lhsc.on.ca/priv/sepsis/

 The website provides an overview of sepsis - from mortality rates,
incidence and costs to definitions, diagnosis and management - to help
educate healthcare professionals.

Specifically, the website also includes the following aids:
● Tools such as the Emergency Department screening form and checklist and the Inpatient screening form and checklist
● Severe sepsis first dose antibiotic guidelines  for both the ED and inpatients (Last updated February 2011)
● Sepsis recognition flow sheet with recommended actions
● Key articles of interest to healthcare workers regarding sepsis

 

Our
goal is to increase early recognition and to improve the care of
patients with sepsis. This will significantly improve the outcomes of
patients who experience sepsis in our hospital. Our target is to reduce
the mortality rate due to sepsis by 25 per cent within five years.

The Surviving Sepsis Campaign focuses on the following four initiatives:
● better recognition of sepsis,
● enhancing CCOT utilization,
● improving antibiotic stewardship, and
● improving palliative care recognition.

I
encourage you to review the website and the information it contains. If
you have any ideas or suggestions to improve the recognition and care
of patients with sepsis, please e-mail me at
christopher.fernandes@lhsc.on.ca

Acetominophen Toxicity Calculator

Hours After Ingestion  
Acetaminophen Level  
 
Notes
  • This calculator is based on data from Rumack and Matthew1. Treatment threshold levels are calculated to be 25% lower than the toxic drug level.
  • This calculator is only appropriate for patients who had a single ingestion of acetaminophen.
  • Drug levels done before the 4 hour point may not represent the true peak of absorption.

Rummack-Matthew Nomogram

 

Code modified from source at medcalc3000.

New Afterhours CT Guidelines

The following guideline applies to Emergency Department patients only during the hours of 1700 to 0800 Monday to Friday, or at any time on Saturday, Sunday or Statutory Holidays.
At University Hospital, a CT Technologist is not in-house Friday 2300-0800, Saturday 2300-0800 or on statutory holidays.

With this new guideline in place, CT Head, CT AAA and CT Trauma radiology orders can be placed without first consulting the radiology resident on call.  (If you do need to consult the radiology resident on call, follow normal procedure).

Implementation date:  December 15, 2009

We will be closely monitoring usage over the next three months.

Please feel free to contact Dr. Chris Fernandes or Glen Kearns office with any questions.

The provincial MRI and CT Expert Panel was established by the Ministry of Health and Long-Term Care to advise government on improving access to MRI and CT.  This panel developed the  'Ontario best practice guidelines for managing the flow of patients requiring an MRI or CT examination'.  The guidelines were developed after review by a broad range of expert clinical and administrative leaders.  The guidelines are supported with available evidence, and were informed by the work of Ontario's MRI and CT Expert Panel.

The full report is available here.

Standard Protocols

The panel recommended that hospitals develop policies to determine when a scan can be performed without therequisition being first reviewed by the radiologist (Best practice guidelines2.5).   The MRT(R) can use pre-approved standard CT protocols.

Procedure

After reviewing the on line order, the MRT will protocol and prioritize the patient according to the approved guidelines and protocols.  The protocol needs to be initialed by the technologist.  If they are unsure of the protocol or priority, the MRT will contact the Radiology Resident or Radiologist for clarification. The following non contrast procedures may be protocoled by the MRT: AAA,non contrast head and non-contrast trauma cases at University Hospital.  Contrast examinations for multiple trauma at Victoria hospital may be performed and protocoled by the MRT if there is an order for contrast from the trauma team physician or emergency physician as per attached and below guidelines.

This guideline applies to Emergency Department patients only during the hours of 1700 to 0800 Monday to Friday, or at any time on Saturday, Sunday or Statutory Holidays.

At University Hospital,a CT Technologist is not in-house Friday 2300-0800, Saturday 2300-0800 or on statutory holidays.  During these times all AAA and trauma requests for a CT must be approved and organized by the Radiology Resident.  A CT Technologist can only be called in by the Radiologist or Radiology Resident.

Area

History

CT Guideline

Non Contrast Head

Trauma (R/O bleed)

Trauma on warfarin (R/O bleed)

Altered level of consciousness (R/Obleed)

? TIA

? stroke

Std non contrast Head

AAA

R/O AAA

Std non contrast

Trauma

Multi-system trauma (being managed bytrauma team leader or emergency physician)

Std contrast CT

(order for contrast written by physicianattending patient)

Head or spine trauma

Std non contrast head and/or spine

 

This document is available as a PDF here.

H1N1: Vaccination Update

As flu season is firing up, the MLHU will be receiving an additional 24,000 doses of vaccine and setting up additional community clinics between Tuesday October 27 and Tuesday November 3 for all high risk groups, including health care workers. A list of community vaccination clinics within the Middlesex-London health unit can be found here. There are also vaccination clinics within the Emergency Department:

        UH-ED, consultant's room: Oct 28 (7-9, 12-13) Oct 29 (7-9, 12-13) and Oct 30 (7-9, 12-13)

        Victoria-ED, classroom: Oct 28 (7-9, 12-13) Oct 29 (7-9, 12-13) and Oct 30 (7-9, 12-13).

Information about the vaccine can be read here.

And for those who absolutely cannot live without twitter, the latest information can be found here.

H1N1: To Swab or Not to Swab

It seems there has been some confusion about who requires a nasopharyngeal swab for influenza, and people are still testing people who are discharged home.  I spoke with Dr.R. Lannigan (Chief of Medical Microbiology @ LHSC) to clarify.  Below is an excerpt from one of Dr. Warshawsky's email from 2 days ago:

Testing for influenza is not recommended for surveillance purposes any
longer
. It is only recommended to assist with clinical management.
Since there are delays in receiving results, testing is only
recommended for hospitalized, severe or worsening patients
. Treatment
with antiviral drugs should be offered on spec according to the
criteria identified in this document. Treated patients do not need to be tested (unless hospitalized,
severe or worsening), and treatment (when indicated) should not wait
for test results.

I believe that some of the confusion revolves around the "severe or worsening patients".  Basically, this means patients who had suspected H1N1, received Tamiflu, and come back to the ED with worsening symptoms.  In the future, this could also encompass patients who have been vaccinated, but meet the clinical criteria for influenza (as described earlier).

I thought I'd include the indications for oseltamvir while I'm at it, as it seems as though everyone and their dog is getting it (although almost certainly not  through the ED).

Early empiric treatment with oseltamivir should be considered for persons with suspected or confirmed influenza who are at higher risk for complications including:

  • Children younger than 2 years old
  • Persons aged 65 years or older
  • Pregnant women and women up to 2 weeks postpartum (including following pregnancy loss)
  • Persons of any age with certain chronic medical or immunosuppressive conditions
              • Chronic pulmonary (including
                asthma), cardiovascular (except hypertension), renal, hepatic,
                hematological (including sickle cell disease), or metabolic disorders
                (including diabetes mellitus
              • Disorders that
                that can compromise respiratory function or the handling of respiratory
                secretions or that can increase the risk for aspiration (e.g.,
                cognitive dysfunction, spinal cord injuries, seizure disorders, or
                other neuromuscular disorders)
              • Immunosuppression, including that caused by medications or by HIV

  • Persons younger than 19 years of age who are receiving long-term aspirin therapy.

STEMI Bypass Protocol

At last week's Grand Rounds Dr. D. Peterson and Dr. M. Lewell presented the new STEMI bypass protocol that has been implemented in the Middlesex county. EMS can now diagnose STEMIs in the field, speak directly to the interventional cardiologist on call and bring STEMI patients directly to the cardiac cath lab, which is now available 24/7. This was all made possible thanks to the tireless efforts of Dr. Lewell, Dr. Adam Dukelow, Dr. Karl Theakston, Dr. Trevor Gilkinson, Dr. Jon Dreyer, Dr. Kumar Sridhar, Dr. Patrick Teefy and Marlene Allegretti!

For further details, refer to Dr. Peterson's presentation.