Link zur deutschen Version des Podcasts: SGEMGlobal#147: German

Link zur englischen Orginalversion des Podcasts: SGEM#147

Datum: 1. Juni 2016

Disclaimer: Im englischen Original des SGEM und hier in der deutschen Übersetzung wenden wir größte Sorgfalt an, um korrekte Informationen rund um die Notfallmedizin zu geben. Dieser Podcast ist nur an medizinisches Fachpersonal gerichtet. Allerdings sind wir nicht immun vor Fehlern und übernehmen keine Gewähr für den Inhalt des Podcasts und dessen klinischer Anwendung. Jeder ist für sein Handeln selbst verantwortlich und wir empfehlen, diesen Podcast nicht als einzige Grundlage für die Behandlung von Patienten zu verwenden!

Gast im Orginal: Dr. Robert Edmonds. Bob ist Assistent im dritten Jahr der Ausbildung zum Facharzt der Notfallmedizin an der Universität von Missouri in Kansas City. Vor dem Studium schloss er die Akademie der US Air Force ab. Wenn er seine Facharzt Ausbildung beendet hat wird er wieder zur US Air Force als Notfallmediziner zurückkehren.

Klinischer Fall: Eine 24-jährige Patientin kommt in die Notaufnahme mit Herzklopfen. Sie ist ängstlich, aber hämodynamisch stabil und in ihrem EKG zeigt sich eine supraventrikuläre Tachykardie. Mit diesen Symptomen kam sie schon mehrmals in die Notaufnahme und sie hasst die Medikamente, die sie normalerweise bekommt, weil es sich anfühlt, als ob sie stirbt.

Hintergrund: Patienten mit einer supraventikulären Tachykardie stellen sich häufig in der Notaufahme vor. Life in the Fast Lane hat einen guten Blogpost dazu geschrieben. Die Kardioversion in einen Sinusrhythmus kann auf mehrere Wege geschehen: nicht medikamentös, mit Medikamenten und mit Strom. Bei hämodynamisch instabilen Patienten ist die synchronisierte elektrische Kardioversion die erste Wahl.

Wenn die Patienten nicht hämodynamisch instabil sind, gibt es viele verschiedene Medikamente, um eine supraventrikuläre Tachykardie zu stoppen. Unter anderem Adenosin, Calcium-Kanal-Blocker und Betablocker. Adenosin empfinden die Patienten als sehr unangenehm und das ist wahrscheinlich auch der Grund, warum die Patientin in unserem Fall ängstlich ist.

Ein anderer Weg um die Patienten ohne Medikamente oder Strom zu konvertieren, ist der Tauchreflex. Dies wird mehr bei Kindern als bei Erwachsenen benutzt. Smith et al haben einen Review Artikel dazu geschrieben. Die Patienten tauchen ihr Gesicht in einen Eimer mit Eiswasser. Carotis Druck kann ebenfalls versucht werden, hat aber gerade bei älteren Patienten ernsthafte Komplikationsrisiken, wie eine Asystolie.

Das Valsalva Manöver ist ein nicht-invasives Verfahren, um die Patienten von einer supraventrikulären Tachykardie in einen Sinusrhythmus zu konvertieren. Dabei wird die myokardiale Refraktärzeit durch die Erhöhung des intrathorakalen Drucks verlängert, indem die Stimulation von Barozeptoren in Aortenbogen und Karotiden zu einer Verstärkung des Parasympathikus führen.

Die Effektivität des Valsalva-Manövers wurde in SGEM#67 besprochen. Das war ein systematisches Review von Smith et al, das drei Studien beinhaltet. Nur eine davon wurde in einer Notaufnahme durchgeführt und zeigte eine Konversionsrate von 19%.

Klinische Fragestellung: Kann ein modifiziertes Valsalva Manöver bei Patienten mit einer stabilen supraventrikulären Tachykardie in der Notaufnahme häufiger zu einer Konversion führen als mit dem Standard Valsalva Manöver?

Referenz:  Appelboam et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015.

Patientengruppe: Erwachsene mit einer supraventrikulären Tachykardie in der Notaufnahme (zehn Krankenhäuser in England: zwei Lehrkrankenhäuser, acht Kreiskrankenhäuser)

Einschlusskriterien: Über 18 Jahre alte Patienten mit einer Schmalkomplex Tachykardie (QRS Zeit kürzer als 0,12 Sekunden im EKG)

Ausschlusskriterien:

Instabile Patienten mit einem systolischen Blutdruck niedriger als 90 mmHg

Patienten mit einer [...]

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Date: May 24th, 2016

Guest Skeptics:  Dr. Anthony Crocco is a Pediatric Emergency Physician and is the Medical Director & Division Head of the Division of Pediatric Emergency at McMaster’s Children’s Hospital. He is the creator of SketchyEBM.

Case: A 15-year-old female patient presents to your emergency department with a chief compliant of abdominal pain. A medical student picks up the chart and comes back to tell you about the case. His presentation includes that the abdominal pain has been going on for two days, has worsened over this time period, and is worse in the right lower quadrant from previously being around her umbilicus. She had a temperature this morning of 101 degrees Fahrenheit, vomited twice this morning (non-billious, non-bloody), says the bumps in the road travelling to your hospital hurt badly, and she doesn’t want to eat anything. The medical student also tells you that she doesn’t have dysuria, discharge, diarrhea, or constipation. She just finished her menstrual cycle and is not sexually active. The medical student tells you that he noticed pain over McBurney’s point. He wants to CT scan her. You start to tell him about trying to limit radiation in pediatric patients and the Pediatric Appendicitis Score (PAS) but can’t help to wonder, is this clinical prediction rule as helpful in this female adolescent as other pediatric patients?

Background: Abdominal pain is a common complaint in any emergency department, as is true in a pediatric emergency department. Appendicitis is usually on the differential in a pediatric patients presenting with abdominal pain and is a common surgical emergency.

Female adolescents pose a unique diagnostic dilemma due to having competing gynecologic diagnoses, such as urinary tract infections, sexually transmitted infections or ovarian cysts or torsion. Being accurate about diagnosis of appendicitis is important to avoid complications of missed appendicitis as well as complications of negative appendectomies.

The PAS is a clinical prediction tool which uses elements of the history and physical examination such as symptoms of right lower quadrant pain and fever and combines this with laboratory findings such as the white blood cell count (WBC) to predict the risk of acute appendicitis.

The PAS score was initially developed with a single cutoff, but validation studies showed better performance with two cutoffs: one at the low end to identify patients with a low risk of appendicitis who may not need further evaluation, and one at the high end to identify patients with a high risk of acute appendicitis on clinical grounds alone.

With a possible score of ten, scores at the lower cutoff, such as less than or equal to two are used to discharge a patient home without further work up due to low suspicion for appendicitis, thus making sensitivity important at this cutoff. Scores at the higher end, such as greater than or equal to seven or eight are used to predict high suspicion for appendicitis, thus making specificity important at this cutoff.

There are not any studies to our knowledge that compare the PAS performance at both different ages and genders which is an important consideration in caring for pediatric patients.

Clinical Question: How well does the Pediatric Appendicitis Score (PAS) perform for adolescent female patients?

Reference: Scheller et al. Utility of Pediatric Appendicitis Score in Female Adolescent Patients. This is Hot off the Press in AEM May 2016

* Population: Female patients 13-21 years old presenting with symptoms suggestive of appendicitis

* Intervention: Use of the Pediatric Appendicitis ...

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Date: May 12th, 2016

Guest Skeptics: Dr. Tony Seupaul and Dr. Marc Phan. Tony is the Chairman of the Department of Emergency Medicine, University of Arkansas. Marc is a PGY-3 resident in the Emergency Medicine program at the University of Arkansas.

Case: 48 year old man presents to the emergency department complaining of right flank pain radiating to his groin. He states the pain comes in “waves,” and he has associated nausea without vomiting. On exam, he is afebrile and appears very uncomfortable while grabbing his right flank.

Background: We have covered renal colic a number of times on the SGEM. The last time it was a systematic review on tamsulosin from 2012. The SGEM Bottom Line from that episode was: “Tamsulosin is useless in most ED patients with ureteral colic unless their stone size exceeds at least 4mm.”

* SGEM#71: Like a Rolling Kidney Stone

* SGEM#4: Getting Un-Stoned (Renal Colic and Alpha Blockers)

Clinical Question: Does medical expulsive therapy with tamsulosin or nifedipine increase the likelihood of spontaneous stone passage measured by the absence of need for further intervention?

Reference: Pickard et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015

* Population: Patients between the age 18-65 undergoing expectant management for single ureteric stone 10mm or less identified by CT

* Excluded: Patients with suspected sepsis, GFR<30, stones >10mm and age >65yrs

* Intervention: Tamsulosin 400µg daily x 4 weeks or nifedipine 30mg daily x 4 weeks

* Comparison: placebo and each other

* Outcome:

* Primary: Need for further treatment to achieve stone clearance in 4 weeks.

* Secondary: Number of days for analgesic use, time to stone passage, and health status between the groups

Author’s Conclusions: “Tamsulosin 400 μg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic.”

Quality Checklist for Randomized Clinical Trials:

* The study population included or focused on those in the ED. Probably

* The patients were adequately randomized. Yes

* The randomization process was concealed. Yes

* The patients were analyzed in the groups to which they were randomized. Yes

* The study patients were recruited consecutively (i.e. no selection bias). Yes

* The patients in both groups were similar with respect to prognostic factors. Yes

* All participants (patients, clinicians, outcome assessors) were unaware of group allocation. Yes

* All groups were treated equally except for the intervention. Yes

* Follow-up was complete (i.e. at least 80% for both groups). Yes

* All patient-important outcomes were considered. Yes

* The treatment effect was large enough and precise enough to be clinically significant. No. 

Key Results: 1136 patients were enrolled (378 in the tamsulosin group, 379 in the nifedipine group and 379 in the control group). Mean age was in the low 40’s, 20% women, one-third of patients had a history of stones, two-thirds of stones were in the lower ureter and 75% were <5mm.

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Date: May 2nd, 2016

Reference: Olszynski et al. Ultrasound during Critical Care Simulation: A Randomized Crossover Study. CJEM 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlight educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: An emergency medicine resident in your institution has learned some basics of ultrasound training, but feels uncomfortable performing ultrasound in a crashing patient. They come to ask you how they can learn to use their ultrasound skills in critically ill patients, other than doing it in real time.

Background: Point of care ultrasound (PoCUS) can be broken down into two main categories – diagnostic applications and procedural applications. There are simulators and trainers for both types.

* Diagnostic Applications: When it comes to diagnostic ultrasound simulation the case is most compelling for the more invasive applications. These include things like transesophageal echo in shock and arrest states or transvaginal ultrasound in first trimester bleeding.

* Procedural Applications: The procedural side of ultrasound simulation is where we find the most compelling evidence. In one study by Barsuk et al, trainees who were trained to mastery on Central Venous Line trainers with the use of ultrasound and performed far better on real patients than those trained with the more traditional approach of “go read about it, then see one – do one.”

There is now a movement towards hybridized simulation experiences where either diagnostic or procedural trainers are introduced into broader simulation environments. This type of “bridging” from simple task training to clinical integration (in a simulated setting) is now being explored more and more, especially as we move towards competency based training.

Assessing competency is not a one-time event. Seeing a trainee perform a skill like PoCUS in one instance is insufficient to say they have achieved competence. Assessment of competence requires thoughtful assessment of several instances spaced over time and ranging in complexity. It is here where these types of hybrid simulation offer a window for assessment.

Seeing when the trainee decides to reach for the transducer, how they hold it, how long they allow themselves to scan, how they interpret and then integrate the findings into care. This can serve as one of many touch points making the case for that trainee’s PoCUS competence. Eventually, with multiple assessment points over the duration of their training with the formative feedback that is associated with it, they will achieve competence in PoCUS.

Resuscitative PoCUS can be divided into three parts:

* Firm Grasp of Indications – Knowing when and where to scan

* Image Generation with Interpretation – Generating the images and knowing when the image is adequate for interpretation and data extraction

* Integration into Clinical Care – Making decisions based on the all the data (history, physical and PoCUS images).

High-fidelity simulation (HFS) can then be combined with PoCUS to teach residents.

* The purpose of this study was to evaluate two comparable ultrasound simulation interventions as used during HFS. Comparing two somewhat similar but distinct interventions allowed the study team to assess and isolate for the potential value ...

SGEM#147: This is a SVT and I’m Gonna REVERT It – Using […]

Link zur deutschen Version des Podcasts: SGEMGlobal: German: #150

Link zur englischen Orginalversion des Podcasts: SGEM#150

Datum: 1. Mai 2016

Disclaimer: Im englischen Original des SGEM und hier in der deutschen Übersetzung wenden wir größte Sorgfalt an, um korrekte Informationen rund um die Notfallmedizin zu geben. Dieser Podcast ist nur an medizinisches Fachpersonal gerichtet. Allerdings sind wir nicht immun vor Fehlern und übernehmen keine Gewähr für den Inhalt des Podcasts und dessen klinischer Anwendung. Jeder ist für sein Handeln selbst verantwortlich und wir empfehlen, diesen Podcast nicht als einzige Grundlage für die Behandlung von Patienten zu verwenden!

Gast im Orginal: Dr. Chris Bond. Chris ist Notfallmediziner der Universität von Calgary. Er ist ebenfalls der Gastgeber der CAEP Casts, ein Programm, das besondere Errungenschaften in der Wissensvermittlung der notfallmedizinischen Weiterbildung in Kanada hervorhebt. Er hat ebenfalls einen eigenen FOAMed Blog namens “Standing on the Corner minding my own business” was soviel heist wie “ich stehe nichts Böses ahnend an der Ecke”.

Klinischer Fall: Ein 21 jähriger Mann steht an der Ecke, nichts Böses ahnend, als er einen Schlag auf den Kopf bekommt und ein schweres Schädel-Hirn-Trauma erleidet. Er wird in ein Traumazentrum gebracht und es scheint, als ob er ein isoliertes SHT hat. Er öffnet seine Augen nicht, er spricht nicht und er zeigt keine Reaktion auf Schmerzreize. Sein Glasgow Coma Score beträgt 6 und nach der Intubation reagiert seine linke Pupille nur träge auf Licht und ist 5 mm weit, während seine rechte Pupille 3 mm ist und prompt auf Licht reagiert. Du entscheidest Dich eine hyperosmolare Lösung gegen seinen vermutlich erhöhten intrakranialen Druck zu geben, während er zum CT transportiert wird. Du orderst Mannitol, aber jemand fragt, ob für diesen Patienten nicht hypertones NaCl  besser wäre.

Hintergrund: Das schwere Schädel-Hirn-Trauma (SHT) ist mit einer hohen Morbidität und Mortalität verbunden und ist eine häufige Verletzung in Kanada (Turgeon et al and Zygun et al). In schweren Fällen kann ein erhöhter intrakranialer Druck (ICP) auftreten und durch die herabgesetzte Hirndurchblutung und Ischämie einen sekundären Hirnschaden verursachen. Ein erhöhter Hirndruck ist stark mit einer hohen Mortalität und ungünstigem neurologischen Überleben vergesellschaftet (Giulioni and Ursino).

Es gibt einige gängige Interventionen, um den erhöhten ICP zu therapieren:

Abfluss von Liquor (Bullock et al): Das bedeutet vereinfacht, dass eine externe Ventrikel-Drainage in einen Hirnventrikel eingelegt wird, um  Liquor abzulassen, wenn der ICP ansteigt.

Entlastungskraniotomie (Bullock et al): Dabei wird ein Teil der Schädeldecke entfernt, um dem Gehirn mehr Platz zu geben und so den ICP zu senken.

Barbiturat Koma (Guidelines): Das wird als letzte Möglichkeit angesehen, wenn alle anderen medizinischen und chirurgischen Möglichkeiten erschöpft sind. Barbiturate sollen den ICP senken, indem sie über verschiedene Mechanismen den Gefäßtonus und den cerebralen Metabolismus senken. Leider sind die Studien zu Barbituraten in den 1980er Jahren durchgeführt worden. In dieser Zeit bestand die Standardtherapie allerdings aus einer massiven Hyperventilation, Flüssgkeitsrestriktion und Kortison.

Eine weitere therapeutische Möglichkeit um den erhöhten ICP zu behandeln ist die Therapie mit hyperosmolaren Lösungen. Mannitol ist die am häufigsten verwendete Lösung und wird als der Goldstandard für hyperosmolare Lösungen bei erhöhten Hirndruck angesehen (Guidelines,Brown et al and Sakowitz et al).

In letzter Zeit wurden, wegen ihrer Volumen-Expander Eigenschaften und des osmotischen Effektes mehr und mehr hypertone NaCl-Lösungen für die Behandlung des erhöhten Hirndrucks verwendet (Mattox et al).

Klinische Fragestellung: Was sind die klinischen Vorteile und Nebenwirkungen von hypertonen NaCl-Lösungen im Gegensatz zu jeder anderen Lösung bei dem schweren Schädel[...]

SGEM#136: CPR: Man or Machine? Podcast:SGEMGlobal-136-E […]

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Date: April 22nd, 2016

Guest Skeptic: Jay Loosley. Jay is a Registered Nurse, Paramedic and Research Assistant. He was a Professor at Fanshawe College but is currently the Superintendent of Education for Middlesex-London Emergency Medical Services.

Case: A 43 male patient calls with chest pain from 14th floor of a downtown high-rise apartment building. After the 911 dispatcher gets the address and details of the chest pain, the patient stops responding and the dispatcher can hear no voice. The paramedic response time is 4 minutes with lights and sirens to the apartment. The paramedics enter the controlled access area and buzz the apartment number. Of course the patient doesn’t answer because he is vital signs absent. The paramedics look on the control panel for a building superintendent, and attempt to buzz them. Of course he isn’t in his apartment at the time, so it goes to voicemail. The paramedics start picking random names on the list to buzz. “Hi this is the paramedics, could you please let us in?” Click, they hang up. They try another name, and another name until someone buzzes them in. Upon entering the lobby, the first elevator that opens won’t fit the stretcher, so they have to send it up, and wait for the second one. After it comes down, they take it to the 14th floor, where of course the apartment door is locked. One medic goes back down to the lobby to get the superintendent’s number and after a few minutes, they arrive at the 14th floor to open the patient’s door and allow us access to the building. Ten to fifteen minutes after the arrival of the Paramedics, they gain access and meet their patient, a 43-year-old male, vital signs absent, with the phone in his hand.

Background: Recent data from the AHA estimates about 350,000 EMS-assessed OHCA happen in the United States each year. The median age is 65 years. Half of these arrests are witnessed (bystander 38% and EMS provider 12%) with the other half being unwitnessed. The majority of these cardiac arrests happen at a home or residence (70%). Of those EMS-treated patients with OHCA about ¼ have an initial shockable rhythm. Survival to discharge from hospital for adults with OHCA assessed by EMS is around 6% (AHA Statistical Update 2016).

The American Heart Association came out with updated CPR & ECC Guidelines in 2015 that included its “Chain-of-Survival”. There are five steps in the Chain-of-Survival for OHCA:

* Step One – Recognition and activation of the emergency response system

* Step Two – Immediate high-quality CPR

* Step Three – Rapid defibrillation

* Step Four – Basic and advanced emergency medical services

* Step Five – Advanced life support and post arrest care

Clinical Question: Is there an association between floor of patient contact and survival of out of hospital cardiac arrest?

Reference: Drennan et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. CMAJ 2016.

* Population: Adults with OHCA of not obvious cause at private locations

* Excluded: Children, witnessed arrests by first responders, traumatic arrests or with another obvious cause, or in a public location

* Intervention (prognostic factor): On or above the 3rd floor

* Comparison: Below the 3rd floor

* Outcome:

* Primary Outcome: Survival to hospital discharge

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Date: April 10th, 2016

Guest Skeptic: Dr. Salim Rezaie. Salim is an Associate Clinical Professor of Emergency Medicine Internal Medicine University of Texas Health Science Center at San Antonio and the creator/founder of REBEL EM @srrezaie. Salim is also part of The Teaching Course.

Case: A 40 year-old male arrives to the emergency department via EMS with substernal chest pain that has lasted for three days without any relief. He denies shortness of breath, radiation, nausea/vomiting, diaphoresis, or palpitations. He has no past medical history, does not smoke, but states his father died of a myocardial infarction at the age of 70, which is why this chest pain concerned him. He runs four times a week without any difficulty, but has had some increased stress at his work place. Your evaluation in the emergency department shows an ECG with normal sinus rhythm without any other abnormalities and cardiac troponin testing was negative both at arrival and at three hours after arrival. You go to speak to your patient about objective/provocative testing. What will your conversation be?

Background: There are approximately 8 to 10 million patients complaining of chest pain coming to emergency departments in the United States annually. In the US, a very liberal testing strategy is used in order to avoid missing acute coronary syndrome (ACS) in patients with chest pain. This results in over 50% of emergency department patients with acute chest pain receiving serial cardiac biomarkers, stress testing, and/or cardiac angiography at an estimated cost of $10 to $13 billion annually and yet fewer than 10% of these patients are diagnosed with ACS.

To add further angst to emergency department providers the American College of Cardiology/American Heart Association (ACC/AHA) recommends that chest pain patients with concern for ACS should receive serial cardiac markers followed by some sort of provocative/objective cardiac testing.

Using this strategy amongst a low-risk chest pain population unnecessarily uses resources on those least likely to benefit. Low risk chest pain patients have ACS rates of <2%. Provocative/objective cardiac testing is associated with a significant amount of “downstream” testing (i.e. cardiac catheterization) due to false positive tests. These false positives expose patients to potential harms from the testing and treatment.

The value of chest pain characteristics to predict ACS has been studied. None of these individual elements have been shown to have +LR>10 or –LR <0.1 to help us rule-in or out ACS.

Cardiac risk factors like the Framingham Criteria can predict future risk but do not help in the emergency department whether or not the patient is having ACS.

Combining various aspects like: the risk factors, history, physical, labs and ECG findings into a score like the TIMI Score or GRACE Score have been used. A problem with TIMI and GRACE scores is they were not designed to assess whether patients presenting to the emergency department with chest pain are due to ACS. They were designed to risk stratify patients once the diagnosis of ACS had already been made.

A new score has recently been developed in the emergency department to help risk-stratify patients who present with chest pain into who will have a Major Adverse Cardiac Event (MACE) in the next 6 weeks and who will not have a MACE. This new score is called the HEART Score and has five different elements.

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Date: March 23rd, 2016

Guest Skeptic: Dr. Brent Thoma. Brent is an emergency physician, trauma team leader, Clinical Assistant Professor and the Director of EM research at the University of Saskatoon in Saskatchewan. As of July 1st, he will become the EM Program Director.

Brent was last on SGEM#56: BEEM Me Up (Impact Factor in the Age of Social Media). He was discussing the new idea of social media, impact factor and medical education with Dr. Chris Carpenter. Chris had just published a new study in AEM looking at how the BEEM rater score correlated with traditional journal impact metrics.

This is a SGEMXtra so there will be no critical review. We will instead be discussing the following three things:

* Healthy Skepticism

* Free Open Access to Medical Education (FOAMed)

* METRIQ Study.

Healthy Skepticism:

People often think skeptics are close minded, cynical and don’t believe anything. However, Wikipedia defines Skepticism as a “questioning attitude towards unempirical knowledge or opinions/beliefs stated as facts, or doubt regarding claims that are taken for granted elsewhere.” To me it means I want to see some good evidence before I believe something is true.

It is an especially good idea to be skeptical of the medical literature. There was an amazing paper by Dr. John Ioannidis titled Why Most Published Research Findings Are False published over ten years ago in PLoS.

However, we need to avoid nihilism and not conclude that nothing works. What we are trying to achieve is healthy skepticism. To remain open minded. We need to be ready to reject the null hypothesis when presented with convincing evidence to the contrary.

Free Open Access to Medical Education (FOAMed):

The term FOAMed was coined over a pint of beer in Dublin Ireland at ICEM back in 2012.  It was to be medical education for anyone, anywhere, anytime.

The creators of FOAMed define it not as a “teaching philosophy or strategy but as a globally accessible crowd-sourced educational adjunct providing inline (contextual) and offline (asynchronous) content to augment traditional educational principles.”

FOAMed movement has just one objective; to make the world a better place. This reminds me of Bill Nye the Science Guy. He encouraged us in science and made us believe that we could change the world. Another example could be Steve Jobs from Apple and his famous ‘Think Different” commercial.

Brent started in the FOAMed world as a resident with his blog BoringEM.org. He has now launched a new site with a team of individuals called CanadiEM.org on January 1st, 2016. The mission of this new national site is “to improve emergency care in Canada by building an online community of practice for healthcare practitioners and providing them with high quality, freely available educational resources.”

One of the most popular posting on CanadiEM has been the info graphic of the