bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency department visits for children with acute asthma: discharge instructions, parental plans, and follow-through of care—a prospective study
Authors: Camp Pat G. , Norton Seamus P. , Goldman Ran D. , Shajari Salomeh , Smith M. Anne , Heathcote Susan , Carleton Bruce
Published: July 2016

Objective:

Communication between emergency department (ED) staff and parents of children with asthma may play a role in asthma exacerbation management. We investigated the extent to which parents of children with asthma implement recommendations provided by the ED staff. Method: We asked questions on asthma triggers, ED care (including education and discharge recommendations), and asthma management strategies used at home shortly after the ED visit and again at 6 months.

Results:

A total of 148 children with asthma were recruited. Thirty-two percent of children were not on inhaled corticosteroids prior to their ED visit. Eighty percent of parents identified upper respiratory tract infections (URTIs) as the primary trigger for their child’s asthma. No parent received or implemented any specific asthma strategies to reduce the impact of URTIs; 82% of parents did not receive any printed asthma education materials. Most (66%) parents received verbal instructions on how to manage their child’s future asthma exacerbations. Of those, one-third of families were told to return to the ED. Parents were rarely advised to bring their child to their family doctor in the event of a future exacerbation. At 6 months, parents continued to use the ED services for asthma exacerbations in their children, despite reporting feeling confident in managing their child’s asthma.

Conclusion:

Improvements are urgently needed in developing strategies to manage pediatric asthma exacerbations related to URTIs, communication with parents at discharge in acute care, and using alternate acute care services for parents who continue to rely on EDs for the initial care of mild asthma exacerbations.
An ultrasound program for the emergency department
Authors: Ip Urbain
Published: July 2016

In February 1997, a proposal to develop diagnostic ultrasound (U/S) skills for emergency physicians at Surrey Memorial Hospital was presented to the Diagnostic Imaging (DI) Department and subsequently to the Medical Advisory Committee. To our surprise, this was accepted in principle, with no resistance. With the support of DI, maternity and emergency medicine developed a joint proposal to purchase a $160,000 portable U/S machine. It happened so easily that I became convinced God is an emergency physician.
The pain in the sprain, is mostly in the …
Authors: Hollohan Kirk
Published: July 2016

A 21-year-old female presented to the emergency department complaining of wrist pain following a fall onto her outstretched (dominant) right hand. The injury occurred the previous night while the patient was riding her bike. She noticed some immediate wrist pain but believed it was only a “sprain.” The next morning she awoke with considerably more pain and was unable to move the affected wrist. She suffered no other injuries and was otherwise healthy.
Building a national organization of future emergency medicine physicians
Authors: Frank Jason R.
Published: July 2016

Resident interest in emergency medicine (EM) is on the rise. Each year, postgraduate matches add to the ranks of Canadian EM residents, and the Canadian Association of Emergency Physicians (CAEP) Residents’ Section (RS) continues to expand. The numbers are inspiring. This year, 16 residents accepted Royal College EM postgraduate year-1 (PGY-1) slots. Many more began their CCFP(EM) PGY-3 year, and this doesn’t include the residents who matched separately to EM training programs in Quebec. At the same time, the Canadian Resident Matching Service (CaRMS) matched about 433 new Family Medicine residents and 63 new Pediatrics residents. A significant number of these groups will also go on to develop interests and skills in EM.
Answer
Authors: Hollohan Kirk
Published: July 2016

The patient’s x-rays show 2 abnormalities. On the AP (anterior–posterior) view there is widening of the scapholunate space, which measures approximately 3 mm. On the lateral view, just dorsal to the lunate, a triquetral fracture is evident. The diagnosis of scapholunate dissociation with fractured triquetral was subsequently confirmed with an MRI (magnetic resonance imaging), and the patient underwent operative repair.
The case of the vanishing vim
Authors: Hollohan Kirk
Published: July 2016

A 39-year-old Asian male presented to the ED complaining of weakness that began gradually after eating a large meal. His legs were affected more than his arms and, over 3 to 4 hours, the weakness progressed to the point that he could no longer bear weight. He also noted palpitations and tingling in both legs, but there was no headache, dizziness, diplopia, dysphagia, dysarthria or shortness of breath. On further questioning, he reported a tremor, heat intolerance, diaphoresis and palpitations, and a loss of 20 pounds over a 2-month period.
CAEP/AMUQ 1999 scientific abstract competition: results and future directions
Authors: Rowe Brian H. , Sukhrani Nina , Sher Andy
Published: July 2016

Objectives:

To examine the 1999 CAEP/AMUQ research abstracts competition in a scientific fashion, and provide descriptive information about the present and future direction of Canadian emergency medicine (EM) research.

Methods:

Using a standard evaluation form, 3 volunteer CAEP reviewers rated each submitted abstract in blind fashion. The authors of this report then combined abstract review scores with the following data: research topic, province of origin, status of first author (resident or attending physician), number of authors, adherence to submission guidelines, and acceptance status.

Results:

Of 86 abstracts submitted, 80 (93%) originated in Canada. The primary author was a resident in 34 cases (40%), a staff physician in 50 cases (58%) and unspecified in 2 cases (2%). Overall, 77 abstracts (90%) were selected for presentation: 26 (29%) oral, 40 (47%) poster, and 11 (13%) for the Resident Research Competition. The most common topics were clinical care (17%), prehospital care (15%), education/administration (14%), and decision rules (13%). The most common reason for rejection was failure to adhere to submission guidelines.

Conclusions:

Canadian EM research is growing rapidly, as witnessed by the interest in this competition, the publication of these abstracts, and the increased emphasis placed on research at the national meeting. Researchers must adhere to submission guidelines to increase their chances of abstract acceptance. Methods of promoting Canadian EM research are discussed.
The new ABCs: Airway, Breathing, and Court injunctions
Authors: Pauls Merril
Published: July 2016

Jusqu’à quel point la loi s’est-elle immiscée dans la pratique médicale? Les tribunaux peuvent-ils nous «obliger» à réanimer des patients lorsque nous jugeons l’intervention inutile? M. A.S., un homme âgé de 79 ans arrive difficilement à parler et à avaler à la suite de plusieurs AVC. Il a subi une trachéostomie et il ne peut exprimer ses propres souhaits. En 1998, lorsqu’il fut admis dans un hôpital de réadaptation, ses médecins rédigèrent un ordre de ne pas réanimer. Par la suite, comme l’ont rapporté les journaux, l’épouse de M. A.S. obtint une injonction «obligeant» le personnel de l’hôpital à administrer la réanimation dans le cas d’un arrêt cardiaque. Cette cause bien connue est présentement en litige devant les tribunaux du Manitoba. Qui a le dernier mot lorsque les médecins et les patients sont en désaccord? Quelles leçons doivent en tirer les médecins d’urgence? Le présent article discute des questions éthiques entourant la réanimation.
Bioterrorism: an emerging threat
Authors: Grafstein Eric , Innes Grant
Published: July 2016

Prior to the 1998 Vancouver Asian Pacific Economic Summit, emergency physicians were briefed on the possibility of terrorist-related biological or chemical weapons incidents. As part of a training exercise, the “victim” of a chemical weapon attack was brought to our ED. Because of confusion and ignorance, the “victim,” the physician, several members of the ED staff, and a number of other patients also became “casualties.”
Commentary: Bioterrorism: when politics make the best prevention
Authors: Schull Michael
Published: July 2016

The United States dominates academic emergency medicine. In other specialties, century-old medical traditions and international leaders balance the US influence. But emergency medicine was born in the US, the number of US trainees far out-number those of other countries combined, and our textbooks and journals are written primarily by US authors.
Safety of pediatric procedural sedation in a Canadian emergency department
Authors: Ip Urbain , Saincher Anurag
Published: July 2016

Objective:

To assess the safety of pediatric procedural sedation performed by emergency physicians working within a structured sedation protocol.

Methods:

A retrospective review of all children undergoing emergency department (ED) procedural sedation during a 2-year period after the institution of a structured sedation protocol.

Results:

167 children underwent procedural sedation, primarily for orthopedic manipulation, wound management and foreign body removal. Of these, 82% received ketamine, 17% received fentanyl and midazolam and 1% received midazolam alone. Sedation was adequate in all but 6 patients, who required supplemental ketamine for orthopedic manipulation. Vomiting after arousal occurred in 17 children (10%), but no episodes of clinical aspiration occurred. One child became agitated during recovery and another experienced a transient visual hallucination. There were no cases of laryngospasm, apnea or cardiorespiratory compromise, and no mortality or significant morbidity occurred.

Conclusion:

Emergency physicians using a structured sedation protocol can safely perform ED pediatric procedural sedation. Where intravenous access is not already present, intramuscular ketamine, administered in the doses described, is a safe and effective agent for pediatric sedation.
Data is power: resistance is futile
Authors: Ross John
Published: July 2016

Le mouvement d’ACQ (amélioration continue de la qualité), avec l’aide d’Intel et de Microsoft, fera de la prochaine décennie l’ère des données. Les départements d’urgence à travers le pays travaillent présentement à mettre sur pied des systèmes de collecte de données pour surveiller les profils de gravité des cas des patients, les temps d’attente, les durées de séjours à l’urgence, les habitudes de demandes d’épreuves, les pourcentages de demandes de consultation, l’utilisation des lits et les taux d’hospitalisation, et ce, pour chaque médecin. Mais ces données sont-elles fiables? Ou valables? Comment seront-elles utilisées pour juger le travail des médecins? Quelle sera la pénalité pour le médecin si sa surface sous la courbe tend à remonter? Peut-on quantifier les soins aux patients à l’aide d’un graphique? Et y a-t-il une corrélation directe ou une corrélation inverse entre la rapidité du médecin et la qualité des soins? L’ère de l’information est arrivée, mais les données feront-elles de nous de meilleurs médecins?
Reflections of a triage physician
Authors: Zeit Harry
Published: July 2016

Dans trop de milieux, les médecins d’urgence sont perçus comme des gestionnaires de traumatismes, des médecins de triage ou d’éternels internes. Cette image déplorable reflète un manque de compréhension de notre identité, de notre formation et de nos fonctions. Les médecins d’urgence ne se conforment pas à la conception traditionnelle des soins aux patients qui consistent à traiter un patient à la fois toutes les demi-heures, les patients étant à peu près tous également malades. Face à ce niveau d’incompréhension, il n’est pas surprenant que nous soyons attaqués par des gens qui n’arrivent même pas à nous définir.

Si nous parvenons à savoir ce que nos patients, nos collègues et les administrateurs pensent vraiment de nous, nous serons en mesure d’établir un inventaire de besoins, un outil d’élaboration d’un programme qui nous permettra d’entreprendre la lourde tâche d’éduquer notre entourage sur ce que nous sommes et ce que nous faisons. La crédibilité professionnelle est essentielle si nous voulons définir des normes cliniques et des programmes de recherche qui nous soient propres. Si, dans l’esprit des autres, nous sommes d’éternels internes ou des «médecins de triage», nous allons, au pire, voir disparaître la médecine d’urgence telle que nous la connaissons, et au mieux, perdre le pouvoir de lui donner sa véritable identité. La question cruciale est la suivante : Les médecins d’urgence réussiront-ils à établir leur identité propre ou seront-ils condamnés à demeurer confondus parmi les marginaux?
Rib fractures following minor trauma in older patients: a not-so-benign injury
Authors: Campbell Sam G. , Dingle Margaret A.
Published: July 2016

Two older adults presented to the emergency department with rib fractures following minor trauma. Both were discharged on oral analgesics and died within 2 days. Rib fractures more often lead to adverse outcomes in older adults. Emergency physicians should consider admitting any such patient who presents with two or more rib fractures.
Emergency medical services controversies in British Columbia
Authors: Wanger Karen
Published: July 2016

L’encombrement des salles d’urgence a atteint un niveau de crise et les retombées s’étendent au-delà des murs des hôpitaux. De plus en plus, le personnel des urgences surchargées utilise la tactique du «détournement des ambulances», obligeant les préposés aux SMU à se diriger vers le prochain établissement adéquat. Comme de plus en plus d’hôpitaux ont recours au détournement, les patients s’accumulent dans les établissements qui les acceptent jusqu’à ce que ceux-ci débordent également. Finalement, plus personne n’accepte de patients et les préposés aux SMU doivent attendre avec leurs patients dans les corridors de l’urgence qu’une civière se libère. En raison de cette situation, il y a moins d’ambulances disponibles pour répondre aux appels 911. Le principal mandat d’un service pré-hospitalier est de prodiguer des soins sur les lieux de l’incident et non dans les corridors d’une urgence et il est inacceptable qu’une pénurie de lits à l’urgence entraîne des retards de réponse au 911.

La plupart des gens sont d’accord pour dire qu’il est inacceptable que des patients malades aient à attendre dans les corridors de l’urgence pour des civières inexistantes; cependant, même si cette situation est dangereuse, elle l’est moins que le fait d’obliger ces mêmes patients à attendre indûment à la maison l’arrivée des SMU. Les hôpitaux devraient peut-être prendre un engagement moral d’accepter les patients peu importe la situation d’encombrement, puis d’assigner les ressources nécessaires pour les soigner; ou les services ambulanciers devraient peut-être embaucher et former du personnel pour traiter les patients dans les corridors des urgences. Quelle que soit l’approche adoptée, les hôpitaux et les préposés aux SMU doivent cesser de s’imputer mutuellement la responsabilité du problème et travailler à trouver des solutions.
Flu vaccine and the ED: Administering influenza vaccine in a Canadian emergency department: Is there a role?
Authors: Chiasson Ann Marie , Rowe Patrick
Published: July 2016

Objectives:

To determine the prevalence of influenza vaccination in patients who present to the emergency department (ED) who meet current guidelines for its use. To evaluate the feasibility of an ED-based program to provide influenza vaccine to at-risk patients.

Methods:

A survey of ED patients and their family physicians, using a convenience sample.

Participants and setting:

Consecutive patients presenting to the emergency department of Prince George Regional Hospital, Prince George, BC, a regional hospital in Northern British Columbia, during designated shifts between Nov. 6, 1997, and Dec. 10, 1997.

Outcome measures:

Age, gender, family physician (FP), eligibility for influenza vaccine, vaccination status, willingness to receive vaccine in the ED, and FP methods for ensuring use of influenza vaccine.

Results:

935 patients were interviewed; 816 met study eligibility criteria. Of 214 patients eligible for influenza vaccine, 113 (52.8%) had not been vaccinated. Fifty-three (46.9%) agreed to vaccination, and 49 were vaccinated in the ED. A survey of the patients’ FPs revealed that 85% used callback lists, but that only 49% of vaccine-eligible patients identified in the study were on a callback list. Positive associations were found between the presence of an FP and the likelihood of having been vaccinated (odds ratio [OR] = 8.8), being on a callback list and having been vaccinated (OR = 4.1), and age >64 and being on a callback list (OR = 2.1).

Conclusions:

Up to 50% of patients eligible for influenza vaccine are not adequately immunized. Administering influenza vaccine in the ED is acceptable to patients and should reduce influenza rates in at-risk populations. There is a role for administering influenza vaccine in the ED.
Do emergency physicians know the costs of medical care?
Authors: Innes Grant , Grafstein Eric , McGrogan Jonathan
Published: July 2016

Objectives:

To estimate the level of knowledge that Canadian emergency physicians have of the costs of common diagnostic tests and interventions in the emergency department (ED).

Methods:

In a cross-sectional survey, 75 emergency physicians from 7 community and academic EDs were asked to estimate the cost of 60 of the most commonly ordered imaging modalities, laboratory tests and pharmaceuticals. Their estimates were compared to actual costs obtained from hospital finance departments. For each test or pharmaceutical, physician error was calculated as a percentage of the actual value, using the formula [(actual – estimated) / actual] × 100. For each item, the proportion of responses that were underestimates, the proportion that were overestimates and the proportion that were accurate within 25% were reported.

Results:

Mean error of the physicians’ estimates was 40% (95% confidence interval [CI], 35%–45%) for imaging studies, 153% (95% CI, 128%–178%) for lab investigations, and 218% (95% CI, 179%–257%) for pharmaceutical costs. Rates of underestimation vs. overestimation were 68% vs. 16% for imaging modalities, 23% vs. 56% for laboratory tests, and 21% vs. 64% for pharmaceuticals.

Conclusions:

Emergency physicians have a limited knowledge of the costs of the tests and interventions they use on a daily basis. They tend to overestimate lab and pharmaceutical costs but underestimate imaging costs. Cost-awareness programs for emergency physicians are most likely to be beneficial if they focus on imaging modalities.
Infantile glaucoma presenting as a case of “red eye”
Authors: James David M.
Published: July 2016

Le glaucome infantile est une forme de glaucome congénital qui se manifeste au cours de la première année de vie. Les enfants, comme les adultes, peuvent développer une forme de glaucome aigu pouvant conduire à la cécité chez l’enfant. L’identification et le traitement rapides sont essentiels afin d’éviter ce dénouement tragique. L’enfant dont le cas est discuté dans le présent article présentait une rougeur à l’œil qui fut diagnostiquée par la suite comme étant un glaucome. Cet article passe en revue la physiopathologie du glaucome infantile, les techniques d’examen et les stratégies de traitement.
Pericardial tamponade presenting as abdominal pain in a patient with systemic lupus erythematosis
Authors: Muñiz Antonio E.
Published: July 2016

Abdominal pain is a common complaint in children presenting to the emergency department. Patients with systemic lupus erythematosus (SLE) are at increased risk of infection, bowel necrosis and perforation, especially if they are taking nonsteroidal anti-inflammatory drugs, corticosteroids or immunosuppresive agents, which may mask the signs and symptoms of the underlying condition, hence delay diagnosis and treatment. This article presents the case of an adolescent girl whose abdominal pain was related to cardiac tamponade and provides an overview of the cardiac and gastrointestinal manifestations of SLE.
Joint Position Statement on emergency department overcrowding
Authors:   Canadian Association of Emergency Physicians and National Emergency Nurses Affiliation
Published: July 2016

Emergency department (ED) overcrowding is a national problem and has become a chronic state in many departments. Overcrowding can be defined as “a situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care.”
Motivations for a career in emergency medicine: a profile of the 1996 US applicant pool
Authors: Kazzi Amin Antoine , Langdorf Mark I. , Ghadishah Delaram , Handly Neal
Published: July 2016

Introduction:

Although some studies have tried to assess the factors leading to choice of specialty, none have been specific to emergency medicine (EM). With a doubling of the number of EM residency programs in the past decade, an assessment of the career motivations of residents is in order.

Objectives:

To identify and rank the factors that lead candidates to choose EM as a career. Methods: Fifty-four participating EM programs returned a total of 393 anonymous surveys completed by their 1996 National Residency Matching Program (NRMP) interviewees. The survey asked respondents to rank 12 factors on a 5-point (0–4) Likert scale.

Results:

Respondents ranked the 12 motivating factors in the following descending order of importance: diversity in clinical pathology, emphasis on acute care, flexibility in choice of practice location, flexibility of EM work schedules, previous work experience in EM, greater availability of EM faculty for bedside teaching, strong influence of an EM faculty advisor or mentor, relatively shorter length of training, better salaries for EM than for primary care specialties, the presence of an EM residency at the student’s medical school, perception that EM residents have more time to moonlight and popularity of EM among medical students.

Conclusion:

US applicants appear to choose a career in EM largely because of clinical factors (diversity of clinical pathology and emphasis on acute care) and practice-related factors (flexibility in practice location and schedule).
Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life
Authors: Busse Jason W. , Bhandari Mohit , Schnittker Joseph B. , Reddy Kesava , Dunlop R. Brett
Published: July 2016

Objective:

Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES.

Methods:

Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire.

Results:

During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6–7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p= 0.03), social function (p= 0.03) and increased pain (p= 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size.

Conclusions:

Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters.
Accuracy and speed of urine pregnancy tests done in the emergency department: a prospective study
Authors: Lazarenko Gerald C. , Dobson Cathy , Enokson Rosemarie , Brant Rollin
Published: July 2016

Objectives:

Our primary objective was to assess the agreement between urine pregnancy tests done in the emergency department (ED) and those done by the Calgary Laboratory Services (CLS). Our secondary objective was to compare turnaround times for tests done in the ED and those done in the laboratory.

Methods:

This prospective study enrolled a convenience sample of ED patients who required a pregnancy test at 1 of 3 urban Calgary EDs. Using the same urine sample from each patient, testing was done in both the ED and by the CLS using the Abbott TestPak Plus (Abbott Laboratories, Mississauga, Ont.) urine pregnancy kit. The ED data included time of urine collection, β-hCG (human chorionic gonadotropin) result, urine specific gravity, and the time the ED nurse reported the result. The CLS data included the time sample was sent to the laboratory, time of laboratory reporting, time ED nurse was aware of the result, the urine β-hCG result and uring specific gravity. When the ED result and CLS result differed, a serum β-hCG assay was performed and used as the diagnostic “gold standard.”

Results:

There was a high level of agreement between the CLS and the ED, as indicated by a kappa value of 0.97 (95% confidence interval [CI], 0.95–0.98). The ED was significantly faster in time to initial report and time to availability on the chart, with mean differences of 25 minutes (95% CI, 22–27) and 60 minutes (95% CI, 56–64), respectively.

Conclusions:

ED nurses can perform urine pregnancy tests as accurately as laboratory technicians, and can provide results on which to base care much faster than the laboratory can. Point-of-care urine pregnancy testing may expedite the ED management of patients who require pregnancy tests.
Emergency patient transfers from rural hospitals: a regional study
Authors: Rourke James T.B. , Kennard MaryAnn
Published: July 2016

Objective:

To clarify case mix, mode of transport and reasons for interfacility transfer from rural emergency departments (EDs) and to make recommendations for improved emergency health care delivery in rural settings.

Methods:

This was a multi-centre descriptive study, based in 5 rural Ontario EDs. Over a 1-year period, all ED patients who required transfer to another hospital were studied. Data collection forms were completed prospectively by the most responsible nurse involved in the transfer. Main measurements included patient age, gender, place of residence, circumstances and reason for transfer, primary diagnosis, mode of transport and receiving hospital.

Results:

Of 53 796 patients who presented to the 5 participating EDs, 98.4% were managed locally and 836 (1.6%) were transferred to referral centres. Most patients (86%) were transferred because they required treatment beyond the scope of the local hospital. The need for orthopedic care, CT and pediatric care accounted for 23.6%, 14.1% and 8.7% of transfers respectively.

Conclusions:

These data suggest that rural family physicians may benefit from increased orthopedic and pediatric training and support. The study also identified a need for increased specialist availability in our rural setting. The high number of transfers for CT scans suggests that some rural health regions should consider acquiring a “regional” CT scanner. The development of a regional hospital, with a CT scanner and specialist resources, especially a general surgery on-call system, would reduce the need for transfer outside the region.
Food-dependent exercise-induced anaphylaxis
Authors: Woo Michael Y. , Cwinn A. Adam , Dickinson Garth , Yang William H.
Published: July 2016

Food-dependent exercise-induced anaphylaxis (FDEIA) is a specific variant of exercise-induced anaphylaxis that requires both vigorous physical activity and the ingestion of specific foods within the preceding several hours. When patients present to the emergency department (ED) with allergic reactions, careful history regarding these 2 factors is required to establish the correct diagnosis. Correct diagnosis of FDEIA will allow patients to take control of their lifestyles and avert repeated events and ED visits. Two cases of FDEIA are presented, and the diagnosis, pathophysiology and therapy of food-dependent exercise-induced anaphylaxis are reviewed.
Heat and dust in South Sudan
Authors: Cole Madeleine
Published: July 2016

Sudan is the biggest country in Africa and has been in the throes of a devastating civil war for over 30 years. In a great oversimplification, it is a war between the Muslim, Arabic north and the animist and Christian south. Access to resources, such as water and arable land, are also at stake. Specifically, exploitation of oil reserves has added real fuel to the fire, with Khartoum now spending US$1 million a day on the war.
Delayed recognition of esophageal intubation
Authors: Dittrich Kenneth C.
Published: July 2016

It is important for clinicians to be aware of the sensitivity and limitations of commonly used methods to confirm endotracheal tube placement. Overreliance on insensitive indicators can lead to delayed recognition of esophageal intubation. The case presented highlights this concern.
Ethics in the trenches: preparing for ethical challenges in the emergency department
Authors: Pauls Merril , LeBlanc Connie , Campbell Sam
Published: July 2016

Ethical issues can be more difficult to address in the emergency department than in other settings. We present two cases, with the goal of stimulating moral reflection and encouraging emergency physicians to gain a better understanding of two important ethical issues: advance directives and resource allocation decisions.

Understanding the legal and ethical basis for advance directives allows emergency physicians to determine when the directives should be followed and when they should be questioned. Resource allocation decisions are among the toughest decisions emergency physicians make. Although patients or substitute decision-makers define the value of a treatment goal, emergency physicians must ensure that this goal does indeed represent the patient’s wishes, that it is achievable, and that competing claims for the same resource are considered.

Learning from others’ experiences and preparing for ethical problems in advance will help physicians feel more comfortable in dealing with ethical issues.
Urban emergency department overcrowding: defining the problem and eliminating misconceptions
Authors: Schull Michael J. , Slaughter Pamela M. , Redelmeier Donald A.
Published: July 2016

Study objective:

To develop an operational definition and a parsimonious list of postulated determinants for urban emergency department (ED) overcrowding.

Methods:

A panel was formed from clinical and administrative experts in pre-hospital, ED and hospital domains. Key studies and reports were reviewed in advance by panel members, an experienced health services researcher facilitated the panel’s discussions, and a formal content analysis of audiotaped recordings was conducted.

Results:

The panel considered community, patient, ED and hospital determinants of overcrowding. Of 46 factors postulated in the literature, 21 were not retained by the experts as potentially important determinants of overcrowding. Factors not retained included access to primary care services and seasonal influenza outbreaks. Key determinants retained included admitted patients awaiting beds and patient characteristics. Ambulance diversion was considered to be an appropriate operational definition and proxy measure of ED overcrowding.

Conclusion:

These results help to clarify the conceptual framework around ED overcrowding, and may provide a guide for future research. The relative importance of the determinants must be assessed by prospective studies.
Canadian C-Spine Rule study for alert and stable trauma patients: I. Background and rationale
Authors: Stiell Ian G. , Wells George A. , McKnight R. Douglas , Brison Robert , Lesiuk Howard , Clement Catherine M. , Eisenhauer Mary A. , Greenberg Gary H. , MacPhail Iain , Reardon Mark , Worthington James , Verbeek Richard , Dreyer Jonathan , Cass Daniel , Schull Michael , Morrison Laurie , Rowe Brian , Holroyd Brian , Bandiera Glen , Laupacis Andreas ,   Canadian CT Head and C-Spine (CCC) Study Group
Published: July 2016

This paper is Part I of a 2-part series to describe the background and methodology for the Canadian C-Spine Rule study to develop a clinical decision rule for rational imaging in alert and stable trauma patients. Current use of radiography is inefficient and variable, in part because there has been a lack of evidence-based guidelines to assist emergency physicians. Clinical decision rules are research-based decision-making tools that incorporate 3 or more variables from the history, physical examination or simple tests. The Canadian CT Head and C-Spine (CCC) Study is a large collaborative effort to develop clinical decision rules for the use of CT head in minor head injury and for the use of cervical spine radiography in alert and stable trauma victims. Part I details the background and rationale for the development of the Canadian C-Spine Rule. Part II will describe in detail the objectives and methods of the Canadian C-Spine Rule study.
Helping at Ground Zero: the experience of four Canadian emergency medicine residents and an emergency department nurse
Authors: Carvalho Anna-Maria , Delvin Marie-Elaine , Rosenczweig Carolyn , Sivarman Sujit , Venugopal Raghu
Published: July 2016

SOMMAIRE

Le 11 septembre 2001, le monde a été témoin d’une des pires attaques terroristes de l’histoire de l’humanité dirigée contre les deux Tours du World Trade Center à New York, et contre le Pentagone à Washington, DC. En tant que contingent canadien non officiel formé de quatre résidents en médecine d’urgence et d’une infirmière d’urgence, nous nous sommes joints au personnel médical américain pour offrir notre aide au cours de la phase de sauvetage à New York. Nous présentons un compte-rendu de notre expérience en tant que bénévoles au centre principal de triage de «Ground Zero.» Nous dressons le bilan des leçons que nous avons tirées de l’expérience et discutons du rôle du résident dans une situation de désastre.
Can nurses apply the Canadian C-Spine Rule? A pilot study
Authors: Kelly Anne-Maree , Bradshaw Luke , Kerr Debra
Published: July 2016

Objective:

The aim of this study was to determine the inter-rater agreement between physicians and nurses regarding eligibility for application of the Canadian C-Spine Rule (CCR) and assessment of the criteria of the CCR.

Methods:

In this observational study, nurses and physicians independently assessed the CCR criteria in a convenience sample of patients with potential C-spine injury. Data were entered onto separate data sheets. The outcomes of interest were the inter-rater agreement between nurse and physician regarding eligibility for application of the rule, for assessment of each component of the rule and for interpretation of the rule overall, assessed by kappa analysis.

Results:

In total, 88 cases were eligible for analysis. Physicians and nurses agreed on which patients were eligible for CCR application in 96.6% of cases. Inter-rater agreement for most CCR criteria was good (κ > 0.61), with the exception of midline tenderness (κ = 0.58) and range of motion, which most nurses did not test.

Conclusion:

This study shows that nurses have the potential to reliably apply the Canadian C-Spine Rule but require further training in the assessment of midline tenderness and range of motion.
Who should write admission orders?
Authors: Shuster Michael
Published: July 2016

The rural hospital environment differs from the urban hospital environment in that there are fewer physicians available to share the workload and to help out in an emergency. When a rural physician on call for emergency writes admission orders rather than disturb the patient’s family physician, that rural physician accepts full responsibility for the patient until the patient’s physician actually examines the patient and assumes care.
Chest pain? Again?
Authors: Hollohan Kirk
Published: July 2016

A 46-year-old man presented to the ED after the sudden onset of chest pain 45 minutes earlier. He had been straining (installing a fan) when the pain began. He described the pain as a severe pressure that radiated to his left shoulder and arm. No radiation to the neck or back was noted. He denied shortness of breath, nausea, diaphoresis, syncope or palpitations. He had not previously experienced similar symptoms and felt well until the moment the pain began. Past medical history included poorly controlled hypertension for 15 years and a 35 pack-year smoking history.
“The Future of Emergency Medicine” Inaugural address to the First Canadian EM Residents Workshop
Authors: Dubinsky Isser
Published: July 2016

On June 10 to 11 this year, the Residents’ Section of the Canadian Association of Emergency Physicians (CAEP-RS) held its first official national forum for future emergency physicians — the First Canadian EM Residents Workshop, in conjunction with CAEP 2000. To celebrate the event, the RS decided to invite a nationally recognized emergency medicine leader, advocate, and teacher to be the first to address the Annual Residents’ Dinner. We were grateful for the privilege of having Dr. Isser Dubinsky be that person. Dr. Dubinsky, currently Chief of Emergency Services at the University Health Network in Toronto, was asked to speak about “The Future of Emergency Medicine.” Dr. Dubinsky's speech, filled with warmth, wisdom, and humanity, is transcribed below. — Jason Frank, MD, Chair CAEP-RS
Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation
Authors: Shuster Michael , Abu-Laban Riyad B. , Boyd Jeff , Gauthier Charles , Shepherd Lance , Turner Chris
Published: July 2016

Objective:

Research has demonstrated that experienced emergency physicians can identify a subgroup of patients with shoulder dislocation for whom pre-reduction radiographs do not alter patient management. Based on that research, a treatment guideline for the selective elimination of pre-reduction radiographs in clinically evident cases of anterior shoulder dislocation was developed and implemented. The primary objective of this study was to prospectively determine whether the treatment guideline safely eliminates unnecessary radiographs.

Methods:

We enrolled a convenience sample of patients who presented to our rural emergency department with possible shoulder dislocation between November 2000 and April 2001. Physicians scored their level of clinical diagnostic certainty on a 10-cm visual analogue scale prior to viewing pre-reduction radiographs (if obtained). Data were collected on clinical scoring and evaluation, compliance with the guideline, and outcomes.

Results:

A total of 63 patients were enrolled, ranging in age from 17 to 79 years (mean = 33); 87.3% were male. Emergency physicians were certain of shoulder dislocation in 59 (93.7%) patients (95% CI, 84.5%–98.2%) and complied with the treatment guideline in 52 patients (82.5%). Most deviations from the treatment guideline involved the elimination of post-reduction radiographs (which the guideline recommends for all patients). The treatment guideline eliminated 56 (88.9%, 95% CI, 78.4%–95.4%) pre-reduction radiographs, as compared to the standard practice of obtaining pre-reduction films for all cases of suspected shoulder dislocation (p < 0.0001)

Conclusions:

Experienced emergency physicians are frequently certain of the diagnosis of anterior shoulder dislocation on clinical grounds alone and can comfortably and safely use this guideline for the selective elimination of pre-reduction radiographs. Compliance with the guideline substantially decreases pre-reduction radiographs. Validation of the guideline in other settings is warranted.
Intravenous amiodarone for acute pharmacological conversion of atrial fibrillation in the emergency department
Authors: Slavik Richard S.
Published: July 2016

Atrial fibrillation (AF) is the most common arrhythmia seen in patients presenting to the emergency department (ED). Pharmacological conversion of atrial fibrillation to normal sinus rhythm (NSR) may be a feasible management strategy in selected patients. Recent guidelines have recommended intravenous amiodarone, a class III antiarrhythmic agent, for the conversion of AF to NSR. The purpose of this review is to examine the published evidence for the efficacy of IV amiodarone for the acute conversion of AF to NSR in the ED. Currently available data from 11 randomized, controlled trials and 3 meta analyses do not support the use of conventional doses of IV amiodarone for acute conversion in the ED. High dose IV or combined IV and oral administration may be effective as early as 8 hours in patients with recent-onset AF of ≤48 hour duration in patients without contraindications to these high dose regimens. There are no data to support the use of IV amiodarone for acute conversion in patients with an ejection fraction of <40% or clinical heart failure, so its use in these scenarios should be limited to symptomatic patients who are refractory to electrical conversion. More well-designed studies are required to determine the role of IV amiodarone for the acute conversion of AF in the ED.
Antidote stocking in British Columbia hospitals
Authors: Gorman Sean K. , Zed Peter J. , Purssell Roy A. , Brubacher Jeffrey , Willis Gillian A.
Published: July 2016

Introduction:

Previous studies have demonstrated that antidotes are insufficiently stocked in Canadian and US health care facilities. The purpose of this study was to determine the adequacy of antidote stocking in British Columbia hospitals based on the current guidelines.

Methods:

A written survey was mailed to hospital pharmacy directors at all 93 acute care facilities in BC. Availability of 14 essential antidotes was classified as sufficient or insufficient based on the current guidelines. Facilities were stratified into small (<50 beds), medium (50–250 beds) or large (>250 beds); teaching or non-teaching; trauma or non-trauma, urban or rural, and isolated or non-isolated.

Results:

Complete responses were received from 75 (81%) of 93 hospitals. No hospital had adequate stock of all 14 antidotes. Overall, the average number (± standard deviation) of antidotes adequately stocked was 4.2 ± 2.9 per hospital. Urban hospitals had adequate stocks of 6.5 ± 2.6 antidotes while rural centres had adequate stocks of 2.6 ± 1.8 (p < 0.001). Corresponding figures were 9.0 ± 1.8 for teaching hospitals vs. 3.7 ± 2.4 for non-teaching hospitals (p < 0.001), 8.9 ± 2.0 for trauma centres vs. 3.8 ± 2.5 non-trauma centres (p < 0.001), and 2.5 ± 2.1 for isolated hospitals vs. 4.6 ± 2.9 for non-isolated hospitals (p = 0.018). Small, medium, and large hospitals adequately stocked 2.3 ± 1.7, 5.7 ± 2.2, and 7.7 ± 3.0 antidotes, respectively (p < 0.001). The 4 antidotes most adequately stocked were sodium bicarbonate (77%), N-acetylcysteine (64%), ethanol (49%) and naloxone (47%). Digoxin immune Fab fragments, glucagon, pyridoxine and rattlesnake antivenin were poorly stocked with sufficient supplies of 5%, 7%, 7% and 13%, respectively.

Conclusion:

BC hospitals do not have adequate antidote stocks. Provincial stocking guidelines and coordination of antidote purchasing and stocking are necessary to correct these deficiencies.
Neurologically normal survival after fibrinolysis during prolonged cardiac arrest: case report and discussion
Authors: Clark Kevin , Abu-Laban Riyad B. , Zed Peter J. , Graham Lois
Published: July 2016

Cardiac arrest secondary to pulmonary embolism is a devastating condition with a high mortality rate. It is currently unclear whether fibrinolysis (thrombolysis) is beneficial in this setting. We report the case of a 28-year-old woman with a pulmonary embolism who developed return of pulses following the administration of tissue plasminogen activator after 38 minutes of pulseless electrical activity cardiac arrest. She went on to make a full neurologic and cardiopulmonary recovery. This case is discussed with reference to the current literature on the subject.
Wrist buckle fractures: a survey of current practice patterns and attitudes toward immobilization
Authors: Plint Amy , Clifford Tammy , Perry Jeff , Bulloch Blake , Pusic Martin , Lalani Amina , Ali Samina , Nguyen Bich Hong , Joubert Gary , Millar Kelly
Published: July 2016

Objectives:

Buckle fractures are the most common wrist fractures in children, yet there is little literature regarding their management. This study examined the management of these fractures and attitudes toward their immobilization by pediatric emergency department (ED) physicians and pediatric orthopedic surgeons.

Methods:

A standardized survey was mailed to all pediatric orthopedic surgeons and pediatric ED physicians at 8 Canadian children’s hospitals.

Results:

Eighty-seven percent of physicians responded, including 33 of 39 pediatric orthopedic surgeons and 84 of 96 pediatric ED physicians. Sixty-four percent of respondents believe that wrist buckle fractures always need to be immobilized; pain control was most frequently cited for this belief. Physicians who did not believe that all buckle fractures need to be immobilized indicated that these fractures are inherently stable and have a low risk of refracture. Forty-eight percent of the orthopedic surgeons prefer below-elbow casts, 30% prefer a combination (splint and cast) and 12% prefer backslabs. Sixty percent of ED physicians “usually or always” use casts and 31% “usually or always” use backslabs. Although there was variation among the orthopedic surgeons regarding the recommended length of immobilization, most (70%) recommended 2 to 4 weeks, although some (12%) treated only until pain free. ED physicians showed greater diversity regarding length of immobilization.

Conclusions:

Although many physicians believe that wrist buckle fractures need to be immobilized, a significant number do not. There is substantial variability in the type and length of immobilization used. This variability suggests that the optimal management strategy for wrist buckle fractures is unclear and should be determined in future prospective studies.
Medical myth: Bimanual pelvic examination is a reliable decision aid in the investigation of acute abdominal pain or vaginal bleeding
Authors: Brown Todd , Herbert Mel E.
Published: July 2016

Reliance on the accuracy of the pelvic examination is upheld in many medical textbooks, but review of the literature does not support the accuracy or reproducibility of this examination. That this “test” is useful for ruling out serious disease will be exposed for the myth that it is.