Introduction: Online educational resources (OERs) are increasingly available for emergency medicine (EM) education. This study describes and compares the use of free OERs by the Royal College of Physicians and Surgeons of Canada (RCPSC) EM residents and program directors (PDs) and investigates the relationship between the use of OERs and peer-reviewed literature. Methods: A bilingual, online survey was distributed to RCPSC-EM residents and PDs using a modified Dillman method. The chi-square test and Fisher's exact test were used to compare the responses of residents and PDs. Results: The survey was completed by 214/350 (61%) residents and 11/14 (79%) PDs. Free OERs were used by residents most frequently for general EM education (99.5%), procedural skills training (96%), and learning to interpret diagnostic tests (92%). OER modalities used most frequently included wikis (95%), file-sharing websites (95%), e-textbooks (94%), and podcasts (91%). Residents used wikis, podcasts, vodcasts, and file-sharing websites significantly more frequently than PDs. Relative to PDs, residents found entertainment value to be more important for choosing OERs (p < 0.01). Some residents (23%) did not feel that literature references were important, whereas all PDs did. Both groups reported that OERs increased the amount of peer-reviewed literature (75% and 60%, respectively) that they read. Conclusions: EM residents make extensive use of OERs and differ from their PDs in the importance that they place on their entertainment value and incorporation of peer-reviewed references. OERs may increase the use of peer-reviewed literature in both groups. Given the prevalence of OER use for core educational goals among RCPSC-EM trainees, future efforts to facilitate critical appraisal and appropriate resource selection are warranted.

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BackgroundRecent surveys suggest few emergency medicine (EM) training programs have formal evidence-based medicine (EBM) or journal club curricula. Our primary objective was to describe the methods of EBM training in Royal College of Physicians and Surgeons of Canada (RCPSC) EM residencies. Secondary objectives were to explore attitudes regarding current educational practices including e-learning, investigate barriers to journal club and EBM education, and assess the desire for national collaboration.MethodsA 16-question survey containing binary, open-ended, and 5-pt Likert scale questions was distributed to the 14 RCPSC-EM program directors. Proportions of respondents (%), median, and IQR are reported.ResultsThe response rate was 93% (13/14). Most programs (85%) had established EBM curricula. Curricula content was delivered most frequently via journal club, with 62% of programs having 10 or more sessions annually. Less than half of journal clubs (46%) were led consistently by EBM experts. Four programs did not use a critical appraisal tool in their sessions (31%). Additional teaching formats included didactic and small group sessions, self-directed e-learning, EBM workshops, and library tutorials. 54% of programs operated educational websites with EBM resources. Program directors attributed highest importance to two core goals in EBM training curricula: critical appraisal of medical literature, and application of literature to patient care (85% rating 5 - “most importance”, respectively). Podcasts, blogs, and online journal clubs were valued for EBM teaching roles including creating exposure to literature (4, IQR 1.5) and linking literature to clinical practice experience (4, IQR 1.5) (1-no merit, 5-strong merit). Five of thirteen respondents rated lack of expert leadership and trained faculty educators as potential limitations to EBM education. The majority of respondents supported the creation of a national unified EBM educational resource (4, IQR 1) (1-no support, 5- strongly support).ConclusionsRCPSC-EM programs have established EBM teaching curricula and deliver content most frequently via journal club. A lack of EBM expert educators may limit content delivery at certain sites. Program directors supported the nationalization of EBM educational resources. A growing usage of electronic resources may represent an avenue to link national EBM educational expertise, facilitating future collaborative educational efforts.

This report describes the successful application of ECMO as rescue therapy in aid of four patients with refractory blastomycosis-associated ARDS. In addition to early appropriate antimicrobial therapy, transfer to an institution experienced with ECMO should be considered when caring for patients from endemic areas with rapidly progressive respiratory failure.

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Pulmonary hypertension (PH) and right ventricular (RV) dysfunction are common and potentially devastating conditions in patients undergoing cardiac surgery. The prevalence of PH and elevated pulmonary vascular resistance (PVR) in patients with aortic stenosis and regurgitation is 15-30% and C 25%, respectively, and at least 40% in patients with mitral stenosis.1 In certain patients with pulmonary venous hypertension due to valvular cardiac disease, the elevated PVR persists or is slow to regress after valve replacement/repair as a result of remodelling of the pulmonary circulation.2 Preoperative PH is associated with prolonged mechanical ventilation, greater duration of hospital stay, and increased operative and long-term mortality.3 This is likely a consequence of the relationship between PH and the development of perioperative RV failure, a condition that, even with early recognition and treatment, has high morbidity and greater than 30% mortality. 4,5 Despite the critical importance of perioperative PH and RV dysfunction, there is a paucity of high-quality clinical trials addressing the perioperative management of these conditions.Milrinone, a phosphodiesterase-3 inhibitor, acts by augmenting cyclic adenosine monophosphate signalling to induce pulmonary and systemic vasodilation and to increase cardiac contractility -i.e., an inodilator.2,6 Inhaled milrinone (iMil) has attracted attention in view of the preferred route of administration in the setting of PH and RV dysfunction. There is a reduction in systemic vasodilation with this approach when compared with the intravenous route, and there is evidence to suggest that iMil has superior ability to mitigate pulmonary endothelial dysfunction during cardiopulmonary bypass (CPB). 7Lamarche et al. published retrospective data suggesting that the incidence of difficult weaning from CPB was reduced when iMil was administered before vs after CPB. 6 Until now, however, there has been a lack of prospective randomized-controlled trials evaluating the utility of iMil in this setting.In this issue of the Journal, Denault et al. present an important multicentre randomized-controlled trial examining a unique strategy for the management of perioperative PH and RV dysfunction.8 They posed the question: does prophylactic treatment with iMil before CPB facilitate separation from CPB in patients with preoperative PH? The authors studied 124 well-matched adult patients undergoing elective high-risk cardiac surgery with baseline mean pulmonary artery (PA) pressure [ 30 mmHg or a PA systolic pressure [ 40 mmHg. Patients were randomized to receive a single dose of either iMil (5 mg) or placebo through an in-line ultrasonic mesh nebulizer after induction of anesthesia. Detailed hemodynamic measurements and echocardiographic data were collected.