Emergency Medicine

 

Dr. Garth Meckler, Associate Professor and Division Head, Emergency Medicine

Dr. Garth Meckler, Division Head

The Division for Emergency Medicine at the BC Children’s Hospital provides 24/7 care to infants, children and youth with urgent and emergent care. We look after medical and surgical conditions as well as trauma. All patients are accepted in the emergency department from birth until their 17th birthday, for acute illness as well as chronic illness requiring pediatric emergency care.

The Emergency Department is staffed by subspecialists in Pediatric Emergency Medicine, including pediatricians who have completed a Pediatric Emergency Medicine Fellowship and physicians trained in Emergency Medicine. We pride ourselves in having an interdisciplinary approach to children in need of emergent care, and the physicians work closely with Divisional nurses, respiratory therapists, child-life specialists, social workers and administrative staff as well as hospital pediatricians and pediatric subspecialists.

As the only specialized Pediatric Emergency Department in the Province of British Columbia we serve almost 47,000 children every year, and are the only Pediatric Trauma Center in the Province.

Our international teaching program includes Medical Students, Residents and Fellows from the University of British Columbia and from Universities in other parts of Canada and other countries. Our Fellowship program allows sub-specialty training for Pediatric-Emergency Fellows that will shape the future of Pediatric Emergency Medicine in Canada. Our teaching program also includes a knowledge translation component, allowing us to provide hundreds of community practitioners further training and updates in pediatric acute care working with partners at Child Health BC and the Department of Emergency Medicine Network as well as national organizations such as Pediatric Emergency Research Canada.

The Pediatric Emergency Medicine Research Program focus on clinical research in the areas of pain and sedation, asthma, gastroenteritis and trauma as well as health services research. We work in collaboration with other pediatric centers in Canada and the US and allow each Fellow to explore clinical research during their training.

Following the theme “children are not small adults” we strive to develop and maintain the best clinical care for children and their families in our Emergency Department, but also for children all around British Columbia through Clinical Practice Guidelines and collaborations with Child Health BC, the Department of Emergency Medicine, and community health providers.

Dr. Garth Meckler
Associate Professor and Division Head

Mission and Vision

Research Themes

The young subspecialty of Pediatric Emergency Medicine has undergone tremendous and exciting changes in the last two decades. From a service that was provided by other specialists such as surgeons, general practitioners, or community pediatricians, PEM has evolved into a service provided by Pediatric Emergentologists, with a unique set of skills, knowledge, and aptitude. While in the past Emergency Rooms served as a triage and a referral system for children and their families, they have evolved into Emergency Departments, providing acute care, saving children’s lives 24/7/365, and in academic centers, additionally providing teaching and research.

Research in PEM has grown tremendously in the last decade despite the need to diagnose and treat almost immediately, as well as challenges in obtaining informed consent for research in the crowded and stressful ED. Networking between Canadian centers has paved the way for quality collaborative research in PEM. The Division of Emergency Medicine at BCCH is an active member of Pediatric Emergency Research Canada (PERC), a multi-site network of academic pediatric emergency departments and researchers across Canada. In addition, our Division is actively engaged in collaborative research with the Department of Emergency Medicine at the University of British Columbia, the Child and Family Research Institute, as well as several community hospitals in BC.

Mission and Vision

Our MISSION is to perform leading research in pediatric emergency medicine, disseminate the findings worldwide, and encourage evidence-based pediatric emergency practice through sound research.

Our VISION is to have a collaborative and vibrant locally-initiated research program, in pediatric emergency medicine, that will be Nationally and Internationally competitive with successful knowledge translation components through scientific publications, conference presentations, continuous medical education and clinical practice guidelines. We will be recognized worldwide as leaders in research in pediatric emergency medicine.

Research Themes

In order to excel in clinical research and provide cutting edge evidence that can be disseminated to patients and practitioners alike, research programs need to be relevant and focused.
The following are areas of great interest in Emergency Medicine and are likely to move forward a research program that will engage faculty, trainees and collaborators.

Pain and Sedation

Pain management during procedures is important because of the deleterious consequences of pain later in life. Analgesia in the ED setting, mostly in relation to procedures such as IV insertion, laceration repair and closed reduction of fractures, has been a focus of research around North America and beyond. The understanding of the short- and long-term consequences of pain has brought basic science, psychology and clinical research closer to the field of pain/analgesia research and in recent years substantial evidence was gathered and started finding its way to patient care.

Within this focus of research we may identify sub-themes:

Assessment of pain – conventionally used pain assessment tools may not be appropriate in the inimitable and intricate environment of the ED. New or revised measurement tools are clearly needed.

Pharmacology of pain – new routes of administration of analgesia, mostly in non-invasive ways (topical, trans-rectal, intranasal or buccal) are rapidly growing acceptance in the last. This is an exciting opportunity in order to work with Industry to identify effective and safe drugs and routes of administration.

Procedural sedation – while tens of thousands of sedations are done outside the operating room and without anesthetists, several key questions relating to drug preference, monitoring needs, NPO guidelines and discharge home queries are being explored.

Trauma and Resuscitation

Approximately 25-30% of all visits to Emergency Departments (ED) are of ill or injured children, and almost 85% of visits occur in general or community hospitals. Of all pediatric visits to EDs, 1% to 5% are critically ill children who require cardiopulmonary resuscitation. Unlike adults, children rarely present with cardiac arrhythmia or full cardiac arrest. Most critically ill children present in respiratory distress or in shock and impending cardiorespiratory arrest. A study from Philadelphia, of 80,000 children visiting the ED, only 200 needed resuscitation and while 58% needed endotracheal intubation, 30% needed resuscitation drugs, and only 2% needed defibrillation or cardioversion. Our ED is in a unique position to conduct insightful research in resuscitation and trauma.

One of the key components of such research will include multi-center trials due to the relative rare occurrence of these injuries and illnesses. BCCH ED can take a lead role in this endeavor.

Knowledge Translation

There is a gap between ‘evidence-based knowledge’, and implementation in current practice in many areas. Knowledge translation(KT) is imperative, but there is a lack of sufficient evidence for appropriate methodologies for implementation of these guidelines. Pediatric resuscitation presents many challenges; cases happen infrequently affording few opportunities for implementation of the new guidelines, and are highly stressful and filled with uncertainty. Some knowledge translation strategies have shown some success in causing a notable degree of change in behavior, but none a striking difference when used alone. Previous efforts to disseminate current guidelines centered on development of courses for health care providers, as well as preparing pediatric residents and pediatricians for circumstances they may encounter with pediatric acute illness. None of the studies assessing these techniques measured direct patient outcomes, and only few demonstrated some long-term knowledge acquisition among trainees.

Our team of experienced PEM physicians, with a Provincial mandate, can become leaders in KT of acute pediatrics and mostly in the field of resuscitation. Much of our work in this area is in conjunction with a Canada-wide project known as TREKK (Translating Research in Emergency Kare for Kids) – a partnership between children’s hospitals and community hospitals across the country to promote the uptake of best practices in pediatric emergency care through bottom-line recommendations for evidence-based treatment of common childhood emergencies. Resources for providers and parents can be found at WWW.TREKK.CA and our division leads the project’s implementation throughout BC in partnership with Child Health BC and the Department of Emergency Medicine Network.

Youth Mental Health
Youth mental health concerns are on the rise and challenges in the timely access of community mental health resources have resulted in increasing numbers of Emergency Department presentations youth and families in crisis. Our Division, in partnership with BCCH Mental Health has developed an innovative tool to help improve the evaluation of youth with mental health concerns and facilitate appropriate outpatient community referrals or acute crisis intervention. Our researcher team is currently training emergency providers across British Columbia to utilize this tool and has begun work together with youth and families to develop a version of the tool that will allow youth \to self-administer a mental health screening questionnaire to help identify concerns before they reach crisis and allow for more timely referral to community resources.

Emergency Care Services
Visits in Canadian Emergency Departments (ED) were documented to rise to over 5.1 million in 1999, up from 4.1 million in 1993 and 3.4 million in 1990. Most EDs reported they are "at" or "over" critical capacity. Population growth, and increase in the prevalence of severe chronic illness have constantly increased the demand on EDs. Widespread reports of ED overcrowding and ambulance diversion have cast doubt on the capacity of some emergency systems to provide consistent and rapid care. ED overcrowding has been around for decades and results in suboptimal functioning and inefficiencies. It has been shown to cause a high rate of violence in the ED, resulting in staff dissatisfaction and fear, and high staff turnover rate. While educational measures directed at health-care providers and patients alike help in the short term, they do not deal with the root causes.

Being the sole Pediatric ED in BC allows us to explore in an unprecedented way the impact of changes on the level of service provided to families. Within the field of health services management we would aim to explore the following sub-themes:

1. Leaving the ED without being seen – parents who bring their children to the ED but decide not to wait, and leave the ED prematurely. This phenomenon may impact patient care and further understanding of its impact is important.

2. Return visits to the ED – parents who decide to return for an unscheduled care to the ED within 48-72 hours of discharge. This phenomenon increases congestion on the ED and increases waiting time. Studies to explore the reasons and ways to reduce return-visits have failed to provide sufficient answers.

3. Educational interventions - parental knowledge translation and teaching during the ED visit and its effect on future health care utilization in the community.

4. Caregiver decision-making around bringing their children to the ED to seek care NERD (Novel Education in Research and Design)NERD (Novel Education in Research and Design)

The Division continues to be involved in the education of many different trainees from a variety of backgrounds. These include 3rd year medical students, elective 4th year students, residents from various surgical and medical sub-specialties, as well as residents from our own pediatric residency program.

All trainees participate weekly in Pediatric Emergency Medicine academic half-day (Thursdays 8-12). These rounds cover a core curriculum in PEM and provide a forum to discuss new developments in the field. In addition, the Division holds weekly simulation sessions Thursday afternoons which junior and senior trainees participate in.

In addition to educational rounds for physicians in training, the Division is committed to maintaining the skills and knowledge of its staff physicians with monthly full-day sessions devoted to the latest emerging evidence and hands-on training using high-fidelity simulation and labs to hone critical procedural skills.

PEM ORIENTATION BROCHURE FOR RESIDENTS

Our Fellowship program in Pediatric Emergency Medicine has grown significantly in recent years.

The Division of Emergency Medicine offers a 2 or 3 year academic fellowship in Pediatric Emergency Medicine. The academic curriculum has been designed to address the requirements of the Royal College of Physicians and Surgeons of Canada, as well as the American Board of Pediatrics, for certification in Pediatric Emergency Medicine. Fellows in the program are offered a wide variety of clinical opportunities, with rotations in Pediatric Emergency, Toxicology, Intensive Care, Transport Medicine, Orthopedics and others. In addition to clinical work, fellows are engaged in a comprehensive educational curriculum including core pediatric emergency topics, administrative topics, research methods, critical appraisal and hands on technical skills and teamwork training at the pediatric simulation center.

For more information, please see the PEM Fellowship Brochure, or contact Rhea Ignacio, Education Program Assistant, at  Rhea.Ignacio@cw.bc.ca

DOWNLOAD A BROCHURE ABOUT OUR FELLOWSHIP

DOWNLOAD OUR FELLOWSHIP APPLICATION PACKAGE

The Pediatric Emergency Medicine Fellowship Training program accepts applications from both Canadian and International applicants.
Canadian applicants must adhere to the deadlines of the national subspecialty matching process and must submit their applications directly to the match website/CaRMS.

Canadian Applicant Deadlines (for July 2018 start date)

Canadian Applicants (CaRMS)
Application website open: February 1, 2017
Application website closed: March14, 2017
Interviews: TBD

International applicants should submit their application package directly to the program. International applicants are highly encouraged to obtain funding support from their local
Hospital or government as this will greatly increase their chances of getting accepted into the program. Please note that all international applicants must show proof of English proficiency meeting the requirements of the College of Physicians and Surgeons of BC before their application can be considered.

International Applicant Deadlines (for July 2018 start date)

International Applicants (TOEFL)
Applications accepted until position is filled

The division is also active in continuing medical education (CME) activities through a unique and Provincial Knowledge Translation Program. The Pediatric Emergency Medicine Update is our flag-ship knowledge translation course. This cutting-edge course held in April each year, entails presentations of recent innovation in PEM themes combined with practical procedure-oriented workshops and a practice-altering literature review session. Participants also have an opportunity to participate in a PALS course.

 

Faculty:

Dr. Jasmine Allaire (maternity leave January-November 2017)
Dr. Karen Black
Dr. Michelle Clarke
Dr. Dr. Joseph Copeland
Dr. Carolyn Davies
Dr. Navid Dehghani
Dr. Quynh Doan
Dr. Paul Enarson
Dr. Ran Goldman
Dr. Sim Grewal
Dr. David Haughton
Dr. Pavan Judge
Dr. Simi Khangura
Dr. Celine Kim
Dr. Paul Korn
Dr. Zoe Leatherbarrow
Dr. Fran Lockie
Dr. Garth Meckler
Dr. Christine Perreault
Dr. Bruce Phillips
Dr. Vikram Sabhaney

Clinical Fellows:
Hathami Almubarak
Najeeb Alqarni

Subspecialty Residents:
Benetta Chin
Fahad Mansouri
Alison Lee

Staff:
Christina Tou
Rhea Ignacio