A group of doctors based in Saint John are leading an international group of clinicians and researchers as part of the Sonography in Hypotension and Cardiac-Arrest in the Emergency Department (SHoC-ED) Network. The New Brunswick Health Research Foundation has named this group its Research Team of the Month for April, 2019.
“While we’re not based in a large academic centre, I think there’s certainly sufficient support when you look for it and you engage people. We have demonstrated that it is possible to complete high level multicentre, international, randomized controlled studies and projects with very minimal funding,” said Dr. Paul Atkinson, who heads the New Brunswick-based group leading a network of nearly 40 physicians internationally.
“What we have is collaboration. We have people willing to give their time in return for being part of the team and part of the network.”
Dr. Atkinson is an emergency physician, Director of Emergency Medicine Research at Saint John Regional Hospital and an Emergency Medicine Professor at Dalhousie University. He will also be awarded the Ian Stiell Researcher of the Year Award by the Canadian Association of Emergency Physicians later this month.
The SHoC-ED Investigator Group was launched in 2011 to provide high-level international research and best evidence about the use of Point of Care Ultrasound (PoCUS), or sonography, in critically ill patients admitted to the emergency department.
Atkinson came up with the idea and piloted the project with a small team in Saint John. James Milne, a medical student at Dalhousie Saint John at the time who became a key initial member, had suggested doing “something big.”
The group grew to involve physicians in the International Federation for Emergency Medicine (IFEM) Ultrasound Interest Group, for which Atkinson has been VP of research for many years, as well as physicians in Cape Town, South Africa. Once data from initial analysis of their study helped to form the basis of an international guideline, other physicians in Canada and the U.S. got interested and joined the network.
The network has so far completed eight studies, including a multicentre international randomized controlled trial. The team has also received national awards including the Grant Innes award for their research from CAEP in 2014.
From New Brunswick, Atkinson is helped by Jacqueline Fraser and Dr. David Lewis in leading the research. Fraser is the team research coordinator and Dr. Lewis is an emergency physician for Horizon Health Network in Saint John and emergency medicine professor at Dalhousie University.
The SHoC-ED group’s findings are not only important for diagnosing patients suffering from hypotension and cardiac arrest, but highlight how point of care ultrasound can also help make emergency physicians more efficient and effective in their work.
“At a high level, what we have found is, you need to be very targeted with your use of bedside ultrasound in clinically ill patients. There are certain conditions that ultrasound will provide extra info that may benefit patients. But there are also situations where it is not as likely to make much difference and therefore, it led us to totally change the approach to how we use ultrasound in critically ill patients,” Atkinson explained.
“Before the research, we were using ultrasound but i think it’s fair to say that the level of training for staff was not at the standard that it is now. And the areas that we were scanning, in terms of the types of patients and the modality – those would be whether you’re scanning the abdomen or the heart or the lungs – those have changed since the study,” Lewis said. “Now, we have better training and we are better at scanning those patients.”
A more targeted use of ultrasound to the heart, the lungs and inferior vena cava, for instance, and basing the overall diagnosis on other tests, the patient’s story and other factors, shortens the list of things doctors have to do. At the same time, this allows them to focus on what are really required.
“What we found from our study was that unless there was a high probability of there actually being one of those rare diagnoses, you can spend a lot of effort and not really come up with much benefit,” Atkinson said.
Ultrasound can pick up conditions that are very difficult to detect, such as tamponade – a collection of fluid around the heart. This condition is reversible and if fixed in time, can help the patient survive. Ultrasound can also detect bleeding in the abdomen, which helps a patient who may be too ill to go through a CT scan.
In South Africa, the studies also show that ultrasound could detect other conditions like tuberculosis and conditions that HIV patients often suffer from. While that doesn’t diagnose HIV specifically, Atkinson said it can help be a marker of how advanced the disease is.
For cardiac arrest patients, ultrasound also proves to be a reliable tool to predict the survival potential of a patient, Atkinson said.
“It’s not 100 per cent reliable, but reliable enough that it will help you target certain patients with extra effort and maybe extra resources and know that they have a better chance of survival,” he said. “The outcome of cardiac arrest is really poor in New Brunswick, with less than 5 per cent of people surviving. But with ultrasound you can definitely identify from the general group, which ones have a higher chance of survival, which ones have a lower chance. Which can be very useful in a critical setting.”
Because the research focuses on ultrasound used by the bedside by emergency physicians, and it shows when ultrasound can be helpful to identify key pathologies that need to be sorted out quickly, ultrasound can boost efficiency in small health centres like those in rural New Brunswick, where there’s often not a complete suite of tests.
“That’s one of the really important uses of ultrasound: to help people who may need a more urgent referral to a larger centre rather than waiting hours, and maybe also show patients who don’t need that and therefore, to reduce the use of ambulance transfers,” Atkinson said. “Especially in smaller rural centres, this type of work, this whole program of using ultrasound in emergency departments is cost effective and it’s going to help the flow of patients and hopefully speed up the diagnosis.”
The group is working on three more papers that are expected to be submitted for publication in the following months. Its members will meet in Halifax later this month to decide on what’s next as they’ve nearly concluded the initial two main topics, hypotension and cardiac arrest, and created a database for further ultrasound research. Many of the members are already looking into studying the use of sonography for conditions related to the lungs.
“We will look to see what further research needs to be done in this area and perhaps then start to branch out into other related areas around sonography in other conditions,” Atkinson said.
Lewis hopes the growing international network can continue its work.
“Just really to continue to grow, to really ensure that we focus on carrying out high quality research that is evidence based, that is supported by peer review, and looks at patient outcomes,” he said.
Thus far, the New Brunswick team has carried out its work with less than $30,000 in total funding from grants, but it relied on support from Horizon Health Network for statistical and research advice and nurse coordinator time, Dalhousie University provided support through its medical students, and the goodwill of the research team itself.
Dr. Atkinson said the success of the group not only raises the bar for research in New Brunswick, but it also puts the province on the map.
“We’re not necessarily well known as a world centre for research, but having said that I think we are well connected in many areas of research,” he said.
“We have high ethical standards yet we have a pragmatic team, and a very pragmatic research ethics board who acknowledge that you need to support research and not put barriers in the way. And so, strangely, I would say that New Brunswick is an ideal place to lead this study from at this time.”
Dr. Lewis agrees.
“It attracts learners and other physicians to come to Saint John to learn more about what we’re doing. I think it’s a great outcome and I think we’re extremely grateful to be recognized in this way,” he said.
This story was sponsored by the New Brunswick Health Research Foundation.