About Fareen Zaver, MD

Chief Operating Officer, Chief Resident Incubator 2017-18
Lead Editor/Co-Founder of ALiEM Approved Instructional Resources - Professional (AIR-Pro)
Champion, 2016-17 ALiEM Chief Resident Incubator
Board Member, 2016-17 ALiEM Wellness Think Tank
Deputy Head - Education and Clinical Assistant Professor for Emergency Medicine
University of Calgary Emergency Department

How I Educate Series: Fareen Zaver, MD

This week’s How I Educate post features Dr. Fareen Zaver, the Deputy Head of Education in the Department of Emergency Medicine at the University of Calgary. Dr. Zaver spends approximately 30% of her shifts with learners at two tertiary care hospitals which include emergency medicine residents, off-service residents, and medical students.   Below she shares with us her approach to teaching learners on shift.

What is one thing (if nothing else) that you hope to instill in those you teach?

Take the time to give proper and SIMPLE discharge instructions for every patient you see. No medical jargon, clear follow-up instructions, and specific return instructions.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I truly give them the time and space to struggle on their own. Though they know I am here to support them, I will not give them the answers or deal with the difficult dispositions or difficult interactions, or bed block issues myself. I will always defer to their decisions and only if there is a risk to patient safety will I correct them in real-time. I will typically wait until they have managed the senior-level issues on their own to discuss my own approach or lessons learned from the decisions they have made.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Both – I always email learners before a shift to determine what their goals for a shift with me are so that I can be prepared (often I have to brush up on a specific topic they want to go over, create an oral board case for them, etc). I always discuss these objectives at the beginning of the shift so we are on the same page. I also check in halfway through the shift to see if we are meeting the objectives, if perhaps based on the types of patients we are seeing or the acuity or bed block of a shift if a certain objective is going to be unobtainable on the shift how to pivot or adjust a goal to something that will be more useful during that shift.

How do you boost morale amongst learners on shift?

With even the struggling learner there is ALWAYS something they do well. I start with those items first and really allow them to feel confident in that particular thing before moving on to any other feedback or teaching.

How do you provide learners feedback?

I provide learners feedback during a shift as well as at the end. The mid-shift feedback is to give them specific, actionable pointers after I have watched them either interact directly with a patient or nursing staff that they can implement immediately with the patients they look after for the rest of the shift. I also give them verbal feedback at the end of the shift. We are also required to give written feedback which I typically fill out either right after the shift or within a day or two as it is easy to forget exactly the feedback you wanted to share with them if I wait any longer than that for feedback.

What tips would you give a resident or student to excel on their shift?

The most important skill set is clear communication with patients as well as with nursing staff. Understanding why a patient has come to the emergency department, and what their fears are instead of judging them for what may seem like a primary care complaint. This often unearths the real reason they came and addressing it likely saves multiple investigations. A patient who doesn’t feel heard by their doctor leads to repeat visits for the same thing. This is the same for nursing staff, taking the time to answer nurses’ questions regarding choices in a workup, what the plan is for a patient, and closing the loop around the disposition of a patient allows for excellent teamwork. It also means they will always have your back!

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Read other How I Educate posts for more tips on how to approach on-shift teaching.

By |2022-07-29T07:23:47-07:00Aug 10, 2022|How I Educate, Medical Education|

ED Management of Cannabinoid Hyperemesis Syndrome: Breaking the Cycle

cannabis cannabinoid hyperemesis syndrome

What is cannabinoid hyperemesis syndrome?

Cannabinoid hyperemesis syndrome (CHS) is a condition in which patients who have been using cannabis or synthetic cannabinoids for a prolonged period of time develop a pattern of episodic, severe vomiting (usually accompanied by abdominal pain) interspersed with prolonged asymptomatic periods.

When should you consider cannabinoid hyperemesis syndrome as a diagnosis?

The diagnostic criteria for CHS require evidence of relief of symptoms with sustained cessation from cannabis, which makes them of limited utility in the Emergency Department (ED) [1]. However, a number of ED-based diagnostic criteria have been proposed with overlapping features [1,2]. There are 3 key components to assess for when making a presumed diagnosis:

  1. An episodic pattern of vomiting
    • Episodes of vomiting should last < 7 consecutive days
    • Asymptomatic periods often last > 1 month between episodes
  2. Prolonged cannabis use
    • Criteria vary: normally >1 time per week (often daily) for at least 1 year
    • Importantly, this is not an intoxication effect from a single large ingestion
  3. Exclusion of alternative diagnoses
    • Look for atypical features on history & exam including abnormal vital signs, diarrhea, focal abdominal pain, peritonitis, and jaundice
    • It is important to exclude pregnancy in all female patients
    • If a patient has never had an esophagogastroduodenoscopy (EGD), it is reasonable to refer newly diagnosed patients to gastroenterology for a non-emergent EGD to assess for a structural cause of the patient’s symptoms

What causes cannabinoid hyperemesis syndrome?

There is no singular theory that fully explains CHS. Importantly, the pattern of illness does not correlate well with the amount of cannabis consumed acutely, suggesting it is not related to a direct effect of the delta-9-tetrahydrocannabinol (THC) or a withdrawal effect. There are two prevailing theories related to changes in neuro-signaling and receptor expression with chronic THC exposure:

Theory #1: Downregulation of the cannabinoid receptor type 1 (CB-1) receptor which occurs with chronic THC use causing dysregulation of the hypothalamic-pituitary-adrenal stress axis. This theory supports why medications that have sedative or anxiolytic properties, such as haloperidol and benzodiazepines, have reported efficacy.

Theory #2: Changes in central nervous system dopamine signaling pathways with chronic THC exposure leading to a hypersensitive emesis response to dopamine. This theory is less well supported but has been used to explain the beneficial effects of dopamine antagonists such as haloperidol, droperidol, and olanzapine.

How should we treat cannabinoid hyperemesis syndrome in the ED?

Ondansetron, Metoclopramide, and Antihistamines

Traditional antiemetics have had low rates of success in treating CHS based on reported cases (ondansetron = 1.75%, metoclopramide = 4.35%) [3]. Antihistamines such as dimenhydrinate, diphenhydramine, and meclizine have no studies supporting their use, and the limited case reports available suggest they are ineffective [3]. While cases of treatment failure are more likely to be published which contributes to a reporting bias, clinical experience supports that CHS often does not respond well to these antiemetics. These medications may still have a role as an adjunct for patients who are refractory to other treatments, but given the evidence available supporting other agents, they can no longer be recommended as first-line therapy. Drawbacks to using a “traditional antiemetics first” strategies include a delay to effective treatment, prolonged ED length of stay, and prolongation of the QT interval.


The HaVOC trial showed haloperidol was twice as effective as ondansetron at reducing nausea (change from baseline = -5.0 vs. -2.4) and abdominal pain (change from baseline = -4.3 vs. -2.1). Haloperidol also decreased rescue medication use (31% vs. 76%) and time from medication administration to ED discharge (3.1 hours vs. 5.6 hours) [4].

Lower doses of haloperidol were recommended (0.05 mg/kg) due to higher rates of adverse reactions with larger doses. Weight-band based dosing may be a more practical approach:

  • Haloperidol 2.5 mg IV for adults < 80 kg
  • Haloperidol 5 mg IV for adults > 80 kg


There is very limited evidence supporting olanzapine specifically in CHS (6 reported cases) [3]. However, olanzapine has strong evidence supporting its antiemetic properties in oncology literature [5,6]. Unlike haloperidol, olanzapine does not prolong the QT interval and it has much lower rates of extrapyramidal side effects. Therefore, olanzapine may be a reasonable substitution for haloperidol in the following cases: documented allergy to haloperidol, prolonged QT interval, or previous extrapyramidal effects with haloperidol.


While capsaicin is often discussed as a treatment [ALiEM trick of the trade], the evidence supporting its use is limited to a small case series and a small RCT with some significant limitations. The small RCT published in support of capsaicin had large baseline differences between the capsaicin and placebo groups. The placebo group was “more sick”, having higher baseline nausea which was not corrected for in the analysis [7].

The trial reported a significant reduction in nausea scores with capsaicin (60-minute nausea score: Placebo = 6.4 vs. Capsaicin = 3.2, p = 0.007) which looks impressive, but the change in nausea from baseline was much less substantial (change in nausea: Placebo = -2.1 vs. Capsaicin = -2.8). Overall, the evidence supporting capsaicin is limited, so its use should be a shared decision.


Lorazepam has no studies assessing its utility in CHS, but a summary of case reports suggests an efficacy of 58.3% in 19 patients [3]. Despite the lack of evidence, clinical experience has led to lorazepam being recommended as an adjunct in recent cyclic vomiting syndrome guidelines for patients who have an anxiety component to their presentation [8]. Since 40-50% of traditional cyclic vomiting syndrome patients were chronic cannabis users, it is reasonable to extrapolate these guidelines to CHS until more specific literature is published.

Overall Approach to Treatment

Based on the currently available research outlined above and clinical experience, the following is a reasonable approach to acute symptomatic management of CHS in the ED:

What should we be considering at the time of discharge?

Like other chronic episodic illnesses (eg. migraines) the long-term management of CHS can be conceptualized to have three components: avoidance of triggers, management of acute episodes, and episode prevention (prophylaxis).

Avoidance of Triggers

  • The only cure for CHS is the prolonged cessation of cannabis. It is important to emphasize that it may take 6 months of cannabis cessation before symptoms improve, and to recognize that the challenges in stopping cannabis use are often underestimated. Professional addictions support is encouraged.

Management of Acute Episodes

  • Medications at home to abort acute episodes are a logical management strategy and may be a safe option to reduce recurrent ED visits in some patients. This will depend on which medications work for the patient, their comorbidities, and the patient’s access to reliable follow-up.
  • There is no current evidence to guide outpatient treatment. Traditionally, many gastroenterologists have used a combination of sublingual lorazepam and ondansetron which may be reasonable if a patient has responded to these medications in the ED.
  • The use of oral haloperidol at home is currently being studied, but there are no good protocols published to guide practice.

Episode Prevention

  • There have been no studies on using medications to reduce the frequency of CHS episodes. However, amitriptyline is recommended as a first-line prophylactic treatment for adults with cyclic vomiting syndrome as it reduces subjective symptoms scores, episode frequency, and ED utilization [9,10].
  • Using amitriptyline for CHS would be considered experimental and amitriptyline has several well-recognized side effects, requires slow up-titrated, and necessitates close follow-up. It may be reasonable for a patient to discuss with their primary care provider.



  1. Venkatesan T, Levinthal DJ, Li BUK, et al. Role of chronic cannabis use: cyclic vomiting syndrome vs cannabinoid hyperemesis syndrome. Neurogastroenterology & Motility. 2019 Jun;31(Suppl 2):e13606.
  2. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT. Cannabinoid hyperemesis syndrome: diagnosis, pathophysiology, and treatment – a systematic review. Journal of Medical Toxicology. 2017;13:71-87.
  3. Richards JR, Gordon BK, Danielson AR, Moulin AK. Pharmacologic treatment of cannabinoid hyperemesis syndrome: a systematic review. Pharmacotherapy. 2017;37(6):725-34.
  4. Ruberto AJ, Sivilotti ML, Forrester S, et al. Intravenous haloperidol versus ondansetron for cannabis hyperemesis syndrome (HaVOC): a randomized, controlled trial. Annals of Emergency Medicine. 202 Nov;S0196-0644(20)30666-1.
  5. Hashimoto H, Abe M, Tokuyama O, Mizutani H, Uchitomi Y, Yamaguchi T, Hoshina Y, Sakata Y, Takahashi TY, Nakashima K, Nakao M, et al. Olanzapine 5 mg plus standard antiemetic therapy for the prevention of chemotherapy-induced nausea and vomiting (J-FORCE): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncology. 2020;21:242-49.
  6. Naravi RM, Qin R, Ruddy KJ, et al. Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. New England Journal of Medicine. 2016 Jul;375(2):134-42.
  7. Dean DJ, Sabagha N, Rose K, et al. A pilot trial of topical capsaicin cream for treatment of cannabinoid hyperemesis syndrome. Academic Emergency Medicine. 2020;27:1166-72.
  8. Venkatesan T, Levinthal DJ, Tarbell SE, et al. Guidelines on management of cyclic vomiting syndrome in adults by the American neurogastroenterology and motility society and the cyclic vomiting syndrome association. Neurogastroenterology & Motility. 2019;31(Supp 2):e13604.
  9. Hejazi RA, Reddymasu SC, Namin F, et al. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two year follow up study. Journal of Clinical Gastroenterology. 2010;44:18-21.
  10. Namin F, Patel J, Lin Z, et al. Clinical, psychiatric and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterology & Motility. 2007;19:196-202.
By |2021-09-29T09:38:58-07:00Sep 27, 2021|Academic, Emergency Medicine, Tox & Medications|

Teaching in the age of COVID-19: The learning management system

learning management systemGiven the epidemiological data from China and Italy, educators should be prepared for the likelihood that online learning will continue to be the norm for many weeks to months. Simply running disconnected weekly educational sessions without an overall organization will hinder educational success for learners. Learning Management Systems (LMS) are a tool that can support educational leaders with the delivery, assessment, and organization of learning.


By |2020-04-02T13:55:37-07:00Mar 19, 2020|Academic, Administrative, COVID19, Medical Education|

Teaching in the age of COVID-19: Enhancing discussion with digital asynchronous chats


asynchronousA significant portion of the technology industry is built around social media and asynchronous chat platforms that seek to connect people. Modern tools are designed with the intention to maximize engagement with push notifications, engagements, and emoji/like integrations that maximize the “dopamine rush” for users; “social media addiction” is a known phenomenon. These tools, when repurposed for learning, provide an easy and user-friendly platform for learners to discuss educational objectives. Chats are the quickest communication form, occurring in real-time and encouraging spontaneity and adaptation. There is a sense of forgiveness, and oftentimes if the chat is anonymous, a high degree of confidence for participation among learners. Use of a moderator is a KEY factor in keeping the discussion professional (and alive!) [1].


By |2020-04-02T13:56:10-07:00Mar 18, 2020|Academic, Administrative, COVID19, Medical Education|

Teaching in the age of COVID-19: Real-time video conferencing

video conferencing

As programs face unprecedented pressure to protect learners via social distancing, many will turn to video as their preferred method to continue delivering educational content. The need to do this in “real-time” makes conferencing applications an obvious choice for content delivery. Programs may already be familiar with this technology for conference calls, further lowering the bar for early adoption. Studies demonstrate the educational content via live video is at least as effective as a live lecture [1]. Further, they have been used to deliver additional content, such as small groups and simulation [2]. With current technology, these tools are widely available and easy to use for educators.


By |2020-04-02T13:56:51-07:00Mar 17, 2020|Academic, Administrative, COVID19, Medical Education|

Teaching in the age of COVID-19: Teaching with tech while socially distancing

social distancing

With the arrival of SARS-CoV2 (COVID-19) in North America, programs are facing the need to reconsider how they deliver didactic education to their learners. The ACGME only allows for 20% of the curriculum to be delivered in an asynchronous fashion. The remainder is delivered through traditional didactic means, including “small-group sessions, such as break-out groups, serially repeated conference sessions, practicum sessions, or large-group planned educational activities.” With mandatory social distancing likely to become standard practice, we present multiple solutions to bridge the gap between live, in-person conferences and asynchronous materials.


By |2020-04-02T13:57:06-07:00Mar 17, 2020|Academic, Administrative, COVID19, Medical Education|

Peer Accountability: A Strategy for Maintaining Commitment to Personal and Professional Obligations

There are a number of personal attributes characterizing the professional identity of “physician.” We are dedicated to patients, committed to lifelong learning, and responsible for a variety of other professional obligations. Each requires physicians to be highly accountable – obligated or willing to accept responsibility for one’s actions. In this post we present examples of how we’ve adopted peer accountability as a strategy to help us with the myriad responsibilities and obligations at the heart of our profession. Just in time for the New Year – we challenge each of our readers to consider finding an “accountability partner” in 2020!


By |2020-01-06T18:09:21-08:00Jan 10, 2020|Professional Development, Wellness|
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