EMOttawa Podcast: CaRMS Gone Wild!

EMOttawa Podcast: CaRMS Gone Wild!

So what if we’ve only had one ‘real episode’, it’s time for a bonus one! Dr. Rajiv Thavanathan sits down with FRCPC Program Director Dr. Lisa Thurgur, and Assistant PD Dr. Michael Ho to talk about the CaRMS process, and what they’re looking for in applicants. 

(Podcast Main Menu) 













What happens during the CaRMS file review process?

  • A deep dive into better understanding the applying medical students, applicants, and potential future residents.
  • Different programs use different scoring systems and data points.
  • For Ottawa, like many sites, reference letters make up a significant component of this score. That being said, given the Covid pandemic, there was no preference given to the writing physician’s specialty or home site. Rather, referees were asked to comment on whether a potential applicant would make an excellent emergency medicine resident and physician.

What about students who feel they decided late on emergency medicine as a career?

  • Not a red-flag, and not uncommon.
  • Can be addressed honestly in one’s personal letter and if it comes up during interviews.

How well should applicants know the specific details and nuances of each program?

  • Applicants will not be quizzed on the nuances on each program (i.e., how many weeks is our EMS block). They should have a general understanding, and perhaps even more importantly, know the city well as it’s where they’ll be living for the next five years.

How does a student decide which program is the best fit for them if they’re unable to visit?

  • Firstly: the good news for applicants is that you will get a great emergency medicine education in Canada no matter which city you match to.
  • Despite Covid-19, programs have been trying to give students a feel for what their program is like through virtual Q&A nights, 1-on-1 sessions, social media platform posts, and teaching days.

Remember: programs are interviewing you, but you’re also interviewing programs!

Think about what’s important to you: this can be program specific, i.e. what the teaching and half-day curriculum is like, or city specific, i.e. what do the residents like to do for fun.

Thoughts on residency programs use of social media?

  • Love it! In Ottawa we try our best to highlight our city and EM program.
  • Applicants should be aware that like all forms of social media, not all the challenging or difficulty times are reflected (i.e. long-call hours).

How can applicants come across genuine, enthusiastic about themselves and their accomplishments without coming across arrogant?

  • Consider practicing talking about yourself. It’s not something that comes naturally to most people. There’s nothing wrong with practicing questions and thinking about answers to common questions ahead of time.

Is there anything residents say they wish they knew before CaRMS?

  • Residency is a lot of work. Just as a lot of rewarding things in life are! You want a program that’s supportive, with a resident group, faculty and staff that has your back. Most of the things in your life that you don’t choose is what shapes you, and five years is a building block for the kind of future doctor you can be, but sometimes hard to realize when you’re in the thick of it.

To all of the medical students going through the CaRMS process this year:

You’re nearing the finish-line, try to enjoy the process, and best of luck!


Episode One Shownotes: GI Bleeds & TTM

Episode One Shownotes: GI Bleeds & TTM

Dr. Rajiv Thavanathan sits down with Dr. Jim Yang to talk about some of the best high impact trials in the last year in Emergency Medicine. Which patients with a GI bleed need urgent endoscopy, and which patients ACTUALLY need targeted temperature management (TTM) after cardiac arrest.

Acute Upper GI Bleeds– Does timing matter?

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding


  • Single centre, RCT performed in Hong Kong
  • 516 patients
  • Patients with overt UGIB, specifically with hematemesis or melena, with a Glasgow Blatchford Score (GBS) of >12

Rapid GBS Review

  • GBS > 1 suggests at risk for needing intervention
  • GBS > 6 traditionally predicted the need for intervention
  • GBS > 12 associated with increased mortality


Compared urgent endoscopy (endoscopy performed within 6-hours of GI consult) to early endoscopy (endoscopy performed within 6-24 hours of GI consult). Practically, speaking this means that people in the urgent endoscopy group were scoped overnight if they came in the evening.

All patients received standardized care, consisting of a high-dose PPI, and if concerns for variceal bleeding, vasoactive medications (i.e. octreotide) and antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis.  

Exclusion Criteria

  • Patients with hypotensive stock who failed to stabilize after initial resuscitation or patients moribund from terminal illness. 

Endoscopic Findings

  • Peptic ulcer disease (PUD) ~60% 
  • Variceal bleeding (7-9% of study)

Note: Epidemiologically, PUD is seen at much higher rates in Asian populations, so this prevalence was expected.  


No difference in all-cause mortality at thirty-days.
No difference in further bleeding, the amount of blood transfusions, the rates of surgery or embolization, or hospital or ICU length of stay. 

Urgent endoscopy is more technically challenging. Waiting gives the medications more times to act, which improves visibility, resulting in less and more-targeted interventions. 


Given the study’s low prevalence of variceal bleeds, we can’t apply this to variceal bleeds, a known higher-risk population. This study also excluded patients in shock, so clinical judgement and early involvement of endoscopists is still warranted in these very sick patients. 

Additionally, this only applies to larger centers where you have quick access to endoscopists. Particularly in the community, it’s prudent to still discuss these cases with gastroenterology early, as we know these patients can quickly decompensate.

Case application

60 y/o M, known PUD, CC’ melena & presyncope.
Vitals: HR = 115, BP = 90/60 mmHg
Labs: Hgb = 52 g/L

As per our trial, this is indeed a patient who could be delayed until the next morning for early endoscopy. However, if that patients develops any hemodynamic instability, or signs of ongoing bleeding, Dr. Jim Yang would advocate for an earlier endoscopy.

Therapeutic Hypothermia after ROSC

Is therapeutic hypothermia post ROSC always a good thing?
Or does this depend on the underlying etiology (cardiac vs non-cardiac) and the pre-post ECG rhythm? What temperature should we aim for? 

Pathophysiology Summary:

Anoxic brain injury is associated with increased mortality and morbidity. Fevers are bad and can worsen ischemic brain injury. The theory behind therapeutic hypothermia is that it reduces free radicals, cerebral oxygen consumption, and ultimately reduces ischemic injury.

The initial trials (early 2000s) were small RCTs showing a huge difference in favorable neurologic outcomes for hypothermia post shockable rhythms (post VF and pVT arrest).  

But in 2013 the TTM trial was published: Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest

The TTM Trial by Nielsen et al. (2013) was a large RCT of 939 patients. It showed that unconscious survivors of out-of-hospital (OOH) cardiac arrest, of presumed cardiac cause (but of all rhythms, shockable and non-shockable) there were no difference in outcomes between a temperature target of 33° C vs. 36° C. 

Flash-forward to the HYPERION Trial this past year: Therapeutic Hypothermia After Cardiac Arrest With Non-Shockable Rhythm


  • Multi-center, RCT performed in 25 ICUs in France
  • 581 adult patients


  • ROSC following in hospital (IH) or out of hospital (OOH) cardiac arrest with non-shockable rhythm due to any cause
  • Patients had to be comatose post (GCS <8)


  • Patients with poor prognostic indicators. 
    • More than 10-minutes from collapse to initiation of CPR.
    • More than 60-minutes from initiation of CPR to ROSC
    • Those in refractory shock despite vasopressors


  • Randomized to either period of hypothermia (targeted temp 33°) vs normothermia (targeted temp 37°)
  • Hypothermia group was cooled after randomization and maintained at 33° for 24-hours, then slowly rewarmed with fever avoided over the subsequent 24-hours.
  • Normothermia group cooled if need (avoidance of fever) for up to 48-hours


  • Primary outcome: Survival with favorable neurologic outcome
  • Secondary outcomes: mortality, length of mechanical ventilation, length of ICU stay, adverse events


Hypothermia was associated with improved survival with favourable neurologic outcome. 10% in hypothermia group vs. 6% in normothermia group. However: No difference in overall mortality, no difference in duration of mechanical ventilation, ICU length of stay, or adverse events. 

Note: hypothermia group had TTM for a longer duration than the normothermia group. 

The normothermia had avoidance of fever for 48-hours, whereas the hypothermia group had induction of hypothermia & maintenance for 24 hours, a period of rewarming, and then maintenance of rewarming for an additional 24 hours. In total, between 56-64 hours of TTM. 

Also, a substantial number of patients in the normothermic group were not normothermic! Although target was 37° C, Patients randomized to this group developed fevers > 38° C throughout the TTM period. 

Bottom Line

  1. Fever is bad.
  2. All patients who are comatose following ROSC should be cooled to prevent fever. 
  3. Temperature you end up at isn’t as important as long as you avoid fever. 

For Dr. Jim Yang, the next patient he sees post ROSC, regardless of shockable vs non-shockable rhythm, he’ll be targeting a temperature of 32-36^C, keeping with the American Heart Association and European Resuscitation Counsel.

We should be initiating cooling for all ROSC patients in the ED.

This can be as simply as

  • Inserting a bladder temperature probe
  • Placing ice packs on the patients groin and axilla

 Any regarding rates of adverse events?  

There has never been any document increase in rates of adverse events between hypothermia and normothermia in ANY of published RCT to-date. 

Show notes compiled by Dr. James Gilbertson

Original music by Eusang