Advanced EKG
By Wade Kean MD  

Purpose:
Is this a wide complex supra ventricular tachycardia or is it VT? Lets go beyond determining if there is an indication of cardiac ischemia to more challenging cases. This course prepares people for common and not so common cardiac rhythms and events.

Back Pain
By David Howe MD

1. Recognize 'red flags' that indicate it is a symptom of something serious, especially cord compression.
2. In the absence of red flags treat it as simple back pain.
3. Consider 'orange flags' that indicate recovery may be delayed for reasons not connected with the back condition.
4. Do not X-Ray routinely. There is no correlation between X-Ray and CT images and severity of pain. If the history and examination do not suggest a red flag, X-Ray will not either.
5. Encourage early return to normal activity, even if it hurts.
6. Try and avoid referring to a specialist because the ensuing wait will in itself prolong the disability.
7. May treat with NSAID's, muscle relaxants, manipulation, physiotherapy and in some cases caudal epidural injection.

There are many reasons that make hemodynamic monitoring not only possible but sometimes mandatory in rural hospitals: the ease of operation that new technologies have brought, the difficulty sometimes encounteredin getting moderately or severely ill patients into tertiary care ICUs, the need for more invasive monitoring that certain fairly common treatments demand (e.g. Dopamine or Nitroprusside), and the inability to provide a fail-safe, 24 hour, all weather transport system to all regions of Canada.

Cervical Spine Injuries
by Karl Stobbe MD and Peter Hutten-Czapski, MD

Purpose:
Is this C-spine film normal?  Having an abnormal c-spine film is uncommon in rural practice but having to read a c-spine film is not.  After taking this course participants will have learned an approach to ordering and reading c-spine films and through repetition with case based learning, develop greater comfort in correctly managing neck injuries and reading the X-rays.

Purpose:
Once you have decompressed the tension pneumo, or diagnosed a haemothorax you know that you need to place a chest tube.  The same goes for the simple pneumothorax that you are going to fly out.  If you are not used to doing chest tubes the sledinger technique that you know can be used to introduce a large caliber chest tube with minimal fuss or risk.  This workshop will help you regain confidence in providing this service.

Hand injuries are a common cause of presentation to emergency departments. These injuries are as likely to show up in a rural ER as in an urban one and the rural MD needs some confidence in his/her approach to the management of these problems, as the RMD substitutes for the Plastic, Orthopaedic and Trauma specialists in this setting.

The initial assessment and management of these injuries has a direct determinant effect on the final outcome for the patient. Regardless as to where the injuries are first seen and who first evaluates them, the approach to management should be the same

Head Injuries
Sylvain Simard,MD Peter Hutten-Czapski, MD and Keith MacLellan, MD
Introduction
 

The purpose of the workshop is to help rural practitioners to evaluate head trauma patients (as part of ATLS/ABCDE protocol) and initiate patient management since a neurosurgeon will not be available prior to transfer.
Adequate oxygenation and maintenance of sufficient blood pressure to perfuse the brain and to avoid secondary brain damage are of paramount importance to the patient's outcome. We will review basic information on head trauma and practise your skills on:

1) Occasional burr hole
2) Mr. Hurt
3) Helmet removal
4) Scenario
5) Principles of spine immobilization and log rolling
6) Radiography

Hemodynamic Monitoring
by Keith MacLellan, MD
 
Introduction

Hemodynamic monitoring has usually been the preserve of the tertiary care intensive care unit (ICU), staffed by trained intensivists and nurses. There are many reasons that make this type of monitoring not only possible but sometimes mandatory in rural hospitals: the ease of operation that new technologies have brought, the difficulty sometimes encountered in getting moderately or severely ill patients into tertiary care ICUs, the need for more invasive monitoring that certain fairly common treatments demand (e.g. Dopamine or Nitroprusside), and the inability to provide a fail-safe, 24 hour, all weather transport system to all regions of Canada.

No course or booklet will replace time spent in a tertiary care ICU learning indications, mechanics, and problems of hemodynamic monitoring. Nevertheless, it seems that the main stumbling block in acquiring invasive capabilities is often an unfamiliarity with the procedures themselves. This workstation takes the view that if registrants become more comfortable with the actual mechanics of the procedures, they might more easily learn how to use them wisely.

Four basic techniques will be taught:

1) Arterial Lines - We have reprinted our nursing protocols for withdrawing blood from arterial lines.
2) Central Venous Access - useful for a variety of conditions, and probably mandatory for infusing dopamine in cases of shock.
3) Central Venous Catheters - for safer rapid fluid insertion, and when no peripheral veins are available.
4) Temporary Transvenous Pacemakers - much more comfortable for the patient and more reliable in cases of severe bradycardias than transcutaneous pacers.

Obstetrical Emergencies
By Peter Hutten-Czapski MD, and Caroline Knight MD

Purpose:
The night nurse calls you "Mrs Smith is in emergency and I think she is going to deliver!"  The rural doctor doesn't have obstetrical housestaff to call down to take care of this situation.  This course prepares people for common and not so common obstetrical emergencies.  After taking the course participants will have an approach to several obstetrical emergencies and some increased comfort in doing the proceedures. 

Shoulder Dystocia

Even the experienced rural GP-OB gets gray hair with stuck babies.  Training in manouvers to get you out of this common problem quickly will be discussed and demonstrated on a manequin.

Breech

The vaginal delivery of a breech is becoming a lost art in the developed world.  A rural doctor may not be able to arrange for a caesarean in time so knowledge of breech remains important in our settings.  Training in manouvers to get you out of this problem will be discussed and demonstrated on a manequin.

Post Partum Haemorage

Post Partum Haemorage is an easily treated condition.  However not everything responds to Ergotamine!  Learn the various causes of PPH and how to recognise and treat them.

Pregnancy Induced Hypertension

Hypertension in pregnancy often is just a simple complication. Choice of appropriate medications and foetal monitoring may be all that is required. However it can also go wrong and require stabilisation prior to urgent delivery. Learn current management of this common complication.

• Supracondylar fractures

• true lateral view?
• anterior humeral line intersects 1/3 of capitellum
• radius points to the capitellum in all views
• posterior fat pad sign .... always pathological, plaster, pulse

• Dislocation

• medial epicondyle commonly avulsed and migrates distally; if present will require K wire fixation

• Clinical issues:

• supracondylar fractures have a risk of Volkman's contracture
• document radial pulse before and after manipulation
• tense elbow swelling may inhibit 90 degree casting initially
• short term imobilization for reduced dislocations

Epiglottitis is an infectious inflammation of the epiglottis usually caused by hemophilus influenza but other organisms, on rare occasions, might cause it. It can happen at any age but its prevalence tends to peak between the ages of 2 and 5 years.

A child with epiglottitis usually presents with characteristic signs and symptoms such as dysphagia, stridor, drooling, sitting in a sniffing position, fever, toxic appearance, sore throat, muffled voice, not coughing and rapid onset of the disease. The patient will not drink if offered water. However, the classic signs and symptoms may not be present.

Laryngotraheobronchitis (Croup)
Introduction

Croup is an inflammation of the larynx and subglottic area mostly caused by viral infection. The most common microorganisms causing laryngotracheobronchitis are parainfluenza, influenza A and B, adenovirus, RSV and measles. Mycoplasma pneumonia can also be responsible. Bacterial infections are usually secondary and the most common entity is bacterial tracheitis. Pneumonia can also result from bacterial infection. The most common pneumonias are caused by S. Aureus, S. Pneumonia, or H. influenza. They may cause accumulation of pus with plug formation leading to airway obstruction. Croup affects mostly children between 6 months and 3 years of age and is more common in fall and winter.

Status Epilepticus
Introduction

Convulsions consist of a variety of events representing abnormal electrical activity in the neurons. This disturbance can result in motor, sensory, autonomic or psychological dysfunction. About 5% of the pediatric population has had one or more seizures by the time they have reached puberty. Status epilepticus is not a common condition. In this section, grand?mal seizure will be discussed. Status epilepticus is a repeated seizure without recovery for a prolonged period of time ( 20 minutes). It usually suggests an underlying disorder.

Numerous causes of epilepsy exist. One can narrow down the differential diagnosis by the age of onset (see table 5). An infant or a child frequently presents with a first seizure episode in the presence of fever. This may suggest an infection of the central nervous system, an underlying seizure disorder or simple febrile seizure. Febrile seizure is the most common of these.

• The Differential Diagnosis of the Agitated Patient
• Useful Behavioural and Non-behavioural Management techniques
• Drug Management
• Rural Hospital adaptations and Facilities needed to manage these patients

Learn how to meet the patients needs for care and ensure your safety as well as that of staff. 

Rapid Sequence Induction And The Difficult Airway
By Dr. Thomas C. O'Neill and Dr. Gord Edwards
Purpose:

¨ describe the indications for R.S.I. In the Emergency
¨ discuss the equipment and drugs we should have available
¨ review examples from our hospital
¨ demonstrate the use of:
¨ intubation techniques
¨ combi-tube
¨ laryngeal mask airway
¨ lighted stylet
¨ crico-thyroidotomy
¨ describe a practical approach to difficult airway scenarios for the ER physician.

Rapid sequence induction Is becoming the standard of care in many Emergency Rooms. It provides a smooth, atraumatic means of intubating a patient. It involves the use of drugs which, until recently, have been used only by anaesthetists.