bluuebunny/crossref_metadata_2025 huggingface dataset:
Ultrasound in the emergency department: Emergency department ultrasound for the assessment of abdominal trauma: an overview
Authors: Ross John
Published: July 2016

Diagnostic ultrasound (U/S) has been used in medicine for over 40 years, and reports describing the use of abdominal U/S in trauma date back to 1971. Recently, however, trauma ultrasonography has become a controversial issue in Canada.

U/S provides the speed and accuracy we associate with diagnostic peritoneal lavage (DPL) in a noninvasive format. It is safe, inexpensive, repeatable, accessible at the bedside, and requires little patient preparation. U/S is now the initial test for the assessment of blunt abdominal trauma in most European and Australasian centres. More recently U/S has become common in US trauma centres.
Emergency department ultrasound — practical and political
Authors: Matthews Ron
Published: July 2016

Practically speaking, bedside ultrasound is well within the scope of emergency physicians (EPs) and is gaining acceptance. The literature supports the use of limited, goal-directed ultrasound in the diagnosis of many emergent conditions. EPs should use ultrasound as a tool to answer specific questions (e.g., Is there blood in the belly?); they should not surf the body for clues. ED ultrasound offers rapid evaluation of potentially life-threatening conditions
African hemorrhagic fever: Welcome to Marburg country
Authors: Dickinson Garth
Published: July 2016

African hemorrhagic fevers are lethal, incurable viral infections with a notorious propensity to afflict health care workers. Lassa and Ebola are the best-known culprits, and these killers spread fear well beyond their geographic range. Chances are your hospital has a plan to deal with febrile travellers returning from endemic regions of Africa. Such plans involve isolation, space suit technology and desperate calls to public health and tropical disease experts.
Answer
Authors: Hollohan Kirk
Published: July 2016

The correct diagnosis is D. In this case, a routine electrolyte screen revealed a serum potassium of 1.7 mmol/L (normal = 3.5−5.0) and a serum phosphate of 0.39 mmol/L (0.80–1.60). Calcium, magnesium, creatine kinase and ESR (erythrocyte sedimentation rate) were normal.
Acute gastric volvulus: case report and review of the literature
Authors: Sevcik William E. , Steiner Ivan P.
Published: July 2016

Gastric volvulus is a rare but potentially life-threatening cause of upper gastrointestinal obstruction. Emergency physicians must maintain a high index of suspicion in patients who present with signs and symptoms suggesting foregut occlusion. We report an illustrative case and review the pathogenesis, classification, diagnosis and treatment of this rare entity.
Out of Angola
Authors: Lockman Denis
Published: July 2016

Le Dr Denis Lockman présente un journal de son expérience comme bénévole pour Médecins Sans Frontières dans la région du nord de l’Angola déchirée par la guerre. Il décrit ses tentatives d’offrir un semblant de soins médicaux organisés au milieu du chaos. Son travail lui donnera l’occasion de rencontrer plusieurs personnages inoubliables, dont certains s’adaptent, d’autres non, chacun à sa façon. Face à la guerre et à la désintégration sociale où la corruption et la cupidité sont rampantes, l’aide des pays occidentaux bien intentionnés profite-t-elle aux pauvres et aux démunis, ou nourrit-elle tout simplement l’appétit prédateur insatiable des éléments criminels?
Emergency department utilization and success rates for intraosseous infusion in pediatric resuscitations
Authors: Nijssen-Jordan Cheri
Published: July 2016

Objective:

To determine the frequency of use and the success rates of intraosseous (IO) vascular access in the emergency department.

Design:

A retrospective chart review.

Setting:

A tertiary pediatric emergency department (ED) in a large urban centre.

Methods:

ED resuscitations (ICD-9 code 996) occurring between Oct. 1, 1989, and Sept. 30, 1995, were identified by searching the ED database, inpatient database, ICU admission log and provincial medical examiner’s database. From these, all cases involving IO access were selected and comprised the study sample. Demographics, diagnosis, number of IO attempts, success or failure of IO placement, relevant times and patient outcomes were recorded on standard data forms. Frequency of use, success rates and performance times were reported.

Results:

IO access was successful in 36 of 42 (86%) patients. In total, there were 68 attempts, or 1.6 attempts per child. All but one child were less than 3 years of age. The median time to successful IO placement was 8 minutes. Two complications, both fractures, occurred in one patient, a 10-day-old neonate.

Conclusions:

IO success rates were high despite infrequent use.
Creating a Trauma Fellowship for Canadian emergency physicians
Authors: Sookram Sunil
Published: July 2016

La spécialité de médecine d’urgence tout comme les soins aux polytraumatisés se sont développés au cours des dernières décennies. À mesure que les disciplines évoluent, les médecins souhaitent souvent recevoir une formation additionnelle dans des domaines sur-spécialisés qui les intéressent. Ce type d’intérêt et d’engagement améliore les soins aux patients et fait progresser la recherche dans ce champ spécifique. Dans le présent article, je passe en revue le raisonnement en faveur de d’une sur-spécialité de traumatologie en médecine d’urgence au Canada et je suggère des orientations pour sa création.
An unusual complication of chest tube thoracostomy
Authors: Poncia Hugo , Ryan John M.
Published: July 2016

This paper describes a previously unreported complication of chest tube thoracostomy: scalpel blade dislodgement within the pleural space. Techniques and complications of chest tube thoracostomy are then discussed.
Diagnosing urinary tract infections in febrile infants and children: when evidence-based medicine and clinical practice collide
Authors: Spence Julie , Ross John
Published: July 2016

The management of febrile pediatric patients is challenging, and the literature is replete with articles describing diverse diagnostic and therapeutic strategies. As many as 5% of infants and young children presenting with fever will be diagnosed with urinary tract infection. Many controversies exist concerning the management of these infections, the most important being: how to make the diagnosis. The financial and time costs of emergency department management must be balanced against the potential future costs of investigations and complications.
Tornado at Pine Lake, Alberta — July 14, 2000: Assessment of the emergency medicine response to a disaster
Authors: Sookram Sunil , Borkent Herman , Powell Greg , Hogarth Walter D. , Shepherd Lance
Published: July 2016

Les programmes de médecine et de résidence négligent souvent l’enseignement de la médecine de catastrophe, mais lorsqu’une catastrophe se produit, c’est le personnel de médecine d’urgence qui se retrouve au front. Les médecins d’urgence doivent se familiariser avec le plan de sinistre de leur hôpital et être prêts à participer à l’opération de sauvetage.
Anatomy of a disaster: one hospital’s experience and recommendations
Authors: Hogarth Walter D. , Neil Gordon F.
Published: July 2016

La prudence dicte que les hôpitaux aient un plan pour gérer les incidents à victimes multiples, mais peu d’entre nous croyons que nous aurons un jour à faire face à une véritable situation de catastrophe. Étant donné la myriade de problèmes de soins de santé plus pressants, les recommandations pour des exercices réguliers de planification en cas de sinistre sont souvent reléguées au bas de la liste des priorités. Or, lorsque l’hôpital régional de Red Deer a dû faire face récemment aux conséquences de la tornade de Pine Lake, la valeur d’une bonne planification en cas de sinistre a pris toute sa signification.
Déclaration de position conjointe sur l’encombrement des urgences
Authors:   Association canadienne des médecins d’urgence et la National Emergency Nurses Affiliation
Published: July 2016

L’encombrement des urgences est un problème national devenu chronique dans bien des départements. On peut définir l’encombrement comme suit : «Une situation où la demande de services dépasse la capacité à offrir des soins dans un délai raisonnable, rendant impossible l’administration de soins de qualité par les médecins et les infirmières.»
The trainee in difficulty
Authors: McGraw Robert , Verma Sarita
Published: July 2016

The trainee in difficulty is someone who is either marginal or at risk of failing in his or her clinical performance. Dealing effectively with these learners can pose problems even for seasoned medical educators. This article discusses some of the common mistakes made by educators in dealing with the trainee in difficulty and offers suggestions for a systematic approach. Further, the roles of faculty, including the program director and associate dean’s office, and some of the legal issues are described.
Methanol and ethylene glycol poisoning: a case study and review of current literature
Authors: Henderson William R. , Brubacher Jeffrey
Published: July 2016

Poisoning is an uncommon but potentially fatal outcome of toxic alcohol ingestion. The toxic alcohols methanol, ethylene glycol and isopropyl alcohol are commonly found in household and commercial products. Because the toxic effects are caused by the metabolites of methanol and ethylene glycol rather than the agents themselves, there is often a substantial delay between ingestion and onset of clinical toxicity. Anion and osmolar gaps are often used for the diagnosis and exclusion of these sometimes subtle overdoses. The pitfalls of using these tests to rule out alcohol ingestion are reviewed. Ethanol infusion is the traditional therapy for such overdoses. In addition to the pathophysiology and clinical findings in poisoning, recent evidence for the use of fomepizole and adjuvant therapies is reviewed.
Urethral catheter knotting: Be aware and minimize the risk
Authors: Arena Barbara , McGillivray David , Dougherty Geoffrey
Published: July 2016

Urethral catheterization is a technique frequently used in the pediatric emergency department. Intravesicular knotting of the catheter is a rare but potentially preventable complication that can involve significant morbidity. However, because of the relative rarity of this complication there remains a persistent lack of awareness in the pediatric clinical community. The risk of intravesicular catheter knotting can be reduced with proper technique and the correct choice of catheters. We present a case report and list recommendations to minimize the risk of occurrence.
Acute presentation of choriocarcinoma: a case study and review of the literature
Authors: Worster Andrew , Sharma Sangita , Mookadam Farouk , Opie John
Published: July 2016

We report an unusual case of a 27-year-old male with an acute presentation of choriocarcinoma. The patient presented with unstable vital signs, severe anemia and a widened arterial pulse pressure following a several day history of testicular pain. He was subsequently diagnosed as having testicular choriocarcinoma with multiple hepatic metastases and large hemorrhagic para-aortic lymph nodes. The widened pulse pressure persisted during fluid resuscitation and correction of both the anemia and hypotension, and only narrowed after the initiation of chemotherapy. A literature review indicates that metastatic testicular choriocarcinoma is a rare but aggressive malignancy that often presents with acute symptoms and signs that cause patients to seek emergency care. We summarize the reported cases of “acute” testicular choriocarcinoma presentation and briefly discuss its relationship to widened arterial pulse pressure.
Prehospital recognition of acute myocardial infarction
Authors: Bright Howie , Pocock Jeff
Published: July 2016

Introduction:

Paramedics often provide advance notice of patients with suspected acute myocardial infarction (AMI) so that emergency department (ED) staff can prepare for early aggressive management and expeditious thrombolysis, but the validity of this practice is unclear. Our objective was to determine the accuracy of prehospital AMI diagnosis by Paramedic Level III (ALS) attendants.

Methods:

ALS paramedics serving a busy community hospital were instructed regarding the clinical diagnosis of chest pain and the value of early thrombolysis. For all patients transported with a chief complaint of chest pain, they were asked to record an explicit diagnosis of “probable AMI” or “chest pain, other.” Prehospital diagnoses were subsequently compared to ED diagnoses. Sensitivity, specificity and predictive values of the prehospital diagnosis for AMI were determined.

Results:

During the 5-year study period, 1305 patients were studied. Based on clinical features alone, ALS paramedics were 77.8% sensitive and 82.2% specific for the diagnosis of AMI.

Conclusion:

ALS paramedics can accurately identify patients likely to benefit from early aggressive AMI management. These data have implications with respect to prehospital triage of chest pain patients, “early notification” protocols and future prehospital thrombolytic strategies.
Cardioversion of uncomplicated paroxysmal atrial fibrillation: a survey of practice by Canadian emergency physicians
Authors: Borgundvaag Bjug , Ovens Howard
Published: July 2016

Objective:

Paroxysmal atrial fibrillation (PAF) is the rhythm disturbance most commonly encountered by emergency physicians, yet the role played by emergency physicians in the management of this condition has not been well described. The purpose of this study was to describe the management of uncomplicated PAF by Canadian emergency physicians.

Methods:

All members of the Canadian Association of Emergency Physicians with a Canadian address (n= 1255) were mailed a 15-point questionnaire regarding training/certification, hospital demographics and practice patterns regarding the management of uncomplicated PAF. Chisquared analysis and Fisher’s Exact test were performed to identify significant differences in reported practice patterns in relation to demographic variables. Significant associations were tested for interaction using the Mantel–Haenszel test.

Results:

We received 663 responses, representing a 52.8% response rate. Six hundred and twenty-two (95%), 514 (78%) and 242 (38%) respondents reported routine performance of rate control, chemical cardioversion and electrical cardioversion respectively. Physicians working in high-volume emergency departments (>50 000 visits/yr) were significantly more likely to self-manage rate control and chemical/electrical cardioversion than those working in lower volume emergency departments. Residency training was associated with higher performance of electrical (44% v. 31%,p< 0.01) but not chemical cardioversion or rate control, although, amongst residency trained physicians, those with FRCP-level training were significantly more likely to perform both chemical (86% v. 76%,p< 0.05) and electrical (57% v. 37%,p< 0.01) cardioversion.

Conclusion:

Canadian emergency physicians surveyed in this study actively manage uncomplicated PAF. We found significant variations in practice, especially related to the use of electrical cardioversion. This may reflect different practice environments, levels of training, and lack of evidence to guide best practice. Further research is required to determine the optimal care of PAF in the emergency department setting.
Acute coronary syndromes: We must improve diagnostic efficiency in the emergency department
Authors: Christenson Jim
Published: July 2016

Chaque année, 100 000 Canadiens sont hospitalisés pour des syndromes coronariens aigus (SCA) (infarctus aigu du myocarde et angine instable); un aussi grand nombre de patients sont hospitalisés pour que soit finalement «écarté» le diagnostic de SCA. Le diagnostic de SCA doit être rapide et exact afin de réduire le taux de mortalité et de prévenir la progression de l’angine instable vers un infarctus du myocarde. En même temps, on doit limiter les coûts inutiles liés au traitement de ces patients. Malheureusement, aucune épreuve ou stratégie particulières ne permettent d’identifier de façon définitive tous les patients atteints de SCA. Les unités de douleur thoracique à l’urgence, de plus en plus populaires, permettent de réduire le nombre d’hospitalisations aux unités de soins critiques en appliquant des protocoles diagnostiques intensifs au département d’urgence. Mais ces unités diminuent-elles les coûts ou ne font-elles qu’augmenter la proportion de patients soumis à des épreuves? Plutôt que de soumettre tous les patients au même processus diagnostique, les urgentologues devraient classer les patients selon leur risque parmi l’une des trois catégories suivantes : ceux dont la probabilité de SCA est faible qui nécessitent un minimum d’épreuves à l’urgence; ceux qui présentent des signes évidents de SCA et qui doivent être hospitalisés; et ceux dont la probabilité de SCA est intermédiaire et qui doivent subir différentes épreuves.
Introduction
Authors: Bullard Michael , Rhine David
Published: July 2016

Our CJEM Journal Club consists of two sections. The first, “Critically Appraised Topics,” is devoted to evidence-based reviews of specific EM-related questions. Questions will be answered by using a focused literature review and presenting the results in a CAT (Critically Appraised Topic) format. The aims of this section are to address clinical or administrative questions, to demonstrate the application of evidence-based medicine methods in answering such questions, and to accumulate a CAT database for emergency physicians.
A new chest pain strategy in Thunder Bay
Authors: Mutrie David
Published: July 2016

Thunder Bay Regional Hospital (TBRH) developed a chest pain strategy (CPS) to support its emergency physicians in making the difficult clinical decisions required to properly evaluate and manage ED “chest pain” patients. This strategy was developed to ensure excellent patient care in a setting of diminished inpatient bed availability and increasing ED congestion. It focuses on rapid risk stratification, using history, electrocardiogram, physical examination and 3 new point-of-care cardiac markers: myoglobin, CK-MB mass, and cardiac troponin I.

Following the introduction of the CPS in 1997, TBRH realized significant ($500 000/yr) institutional resource savings through a 60% decrease in the admission rate of non-myocardial infarction, non-unstable angina chest pain patients, a 30% decrease in ED chest pain evaluation time, and improved ED availability of monitored stretchers. The CPS has allowed TBRH to simultaneously decrease costs and improve patient care.
Pilot intervention to improve the documentation of pediatric injuries in the emergency department
Authors: Voaklander Donald C. , Cummings Garnet E. , Borden Kim , Policicchio Carla , Vincenten Joanne
Published: July 2016

Objective:

Our goal was to determine the effectiveness of an intervention aimed at improving the emergency department (ED) documentation of pediatric injuries.

Methods:

All physicians and nursing staff in the ED of an urban teaching hospital and trauma centre underwent focused injury surveillance training and were instructed how to document 14 injuryspecific data elements. Pocket reminder cards were provided, and pediatric injury charts were flagged. Subsequently, random samples of pediatric injury charts were analyzed from a 3-month period prior to the intervention and from the corresponding months after the intervention. Postintervention documentation was compared to pre-intervention documentation for the 14 predefined data elements.

Results:

Six of the 14 data elements were charted more frequently, and 2 less frequently during the post-intervention phase. Odds ratios ranged from 4.59 (95%CI, 3.40 to 6.19) for charting “the presence of an adult observer” to 0.09 (95%CI, 0.01 to 0.76) for charting “sports equipment related to the injury.” The “flagging” of injury charts, as a visual reminder for clinicians to document injury data, seemed to be the most effective component of the intervention.

Conclusion:

A simple intervention, consisting of staff training, chart modification, and visual flagging of charts, can increase the amount of injury information documented by ED clinicians. Efforts to improve ED charting are most likely to succeed if they include visual prompts for clinicians.
Can a universal influenza immunization program reduce emergency department volume?
Authors: Groll Dianne , Henry Bonnie
Published: July 2016

Objectives:

In 2000 the Ontario Minister of Health and Long-Term Care announced a universal influenza immunization program for Ontario, Canada. The 2 objectives of this $38-million program were to decrease seasonal impact of influenza on emergency department (ED) visits and to decrease the number and severity of influenza cases. This paper examines the correlation between population influenza rates and ED visits in 5 tertiary care hospitals in Ontario over a 5-year period (1996–2001).

Methods:

In this retrospective, observational study, we determined the total number of ED visits during the study period, by month, at 5 tertiary care hospitals in 3 Ontario cities Kingston, London and Ottawa). Detailed ED diagnoses were captured for Kingston, and provincial and national population-based influenza rates were obtained from Health Canada for the 5-year study period. Correlation and regression analyses were used to determine the relationship of influenza rates and ED volumes. “Influenza season” is defined in this study as November 1st to March 31st of each year.

Results:

There was no significant correlation between influenza rates and ED volumes, with Pearson correlation coefficients (r) of 0.22 (p= 0.72), 0.33 (p= 0.59) and 0.27 (p= 0.66) at the Kingston, London and Ottawa study sites, respectively. Data from the Kingston hospitals showed that, during influenza season, acute respiratory diagnoses accounted for only 4.4% of ED visits and influenza for only 0.34% of visits. Multiple linear regression analysis showed that the ED diagnosis of influenza was not significantly related to ED volume. During the influenza season after the universal immunization campaign, ED visits increased at all sites.

Conclusion:

Based on this study, a universal influenza immunization campaign is unlikely to affect ED volume.
Diagnostic testing: an emergency medicine perspective
Authors: Worster Andrew , Innes Grant , Abu-Laban Riyad B.
Published: July 2016

Emergency physicians use diagnostic tests extensively, and the ability to order and interpret test results appropriately is a critical skill. An understanding of sensitivity, specificity, predictive values and likelihood ratios, as well as an awareness of the importance of pre-test probability, is essential. The purpose of this article is to explain, in a straightforward and clinically applicable manner, the core concepts related to diagnostic testing.
Missed acute isolated peroneal compartment syndrome
Authors: Ebenezer Sudesh , Dust William
Published: July 2016

This paper outlines 3 cases of acute isolated peroneal (lateral) compartment syndrome following exertion, minor trauma or overuse. Compartment syndromes are usually associated with crush injuries or fractures; they are an uncommon development following minor trauma or overuse. In acute isolated peroneal compartment syndrome the diagnosis is often delayed, resulting in permanent impairment. Persistent or worsening pain following a minor injury or overuse is typical, and the initial physical findings are often nonspecific, although swelling and tenderness out of proportion to the described injury are common. Marked increase in pain with passive inversion and dorsiflexion of the ankle should suggest the diagnosis. In cases that present late or where the diagnosis is initially missed, there is often a common peroneal nerve palsy. As with all compartment syndromes, prompt diagnosis and surgical decompression is necessary to prevent permanent impairment.
The future of emergency medicine in Canada: submission from CAEP to the Romanow Commission. Part 1
Authors:   Canadian Association of Emergency Physicians Working Group on the Future of Emergency Medicine in Canada
Published: July 2016

In April 2001, the Commission on the Future of Health Care in Canada was established. The Honorable Roy Romanow was given the mandate to “inquire into and undertake dialogue with Canadians on the future of Canada’s public health care system” and “to develop recommendations that will ensure the long-term sustainability of a high quality, universally accessible, publicly administered health care system, for all Canadians.”

The Canadian Association of Emergency Physicians (CAEP) recognized an obligation to share in this public dialogue, to communicate the current state of emergency medicine, and to identify the components necessary to achieve excellence in emergency care. The CAEP Advocacy Committee was asked to develop a document that would educate and enlighten the Commissioner. Basic themes were identified, and authors from across the country were invited to write brief, factual essays with achievable recommendations. The resulting series of essays was presented on April 30, 2002, at the Health Care Commission’s open public hearing in Calgary, Alberta.

This article, part 1 of a 2-part series, includes discussions of Urban Emergency Care Delivery, Rural Emergency Care, Emergency Care for Children, Prehospital Care and Emergency Medical Services, and National Standards for Hospital Emergency Services.
Parental and health care provider understanding of childhood fever: a Canadian perspective
Authors: Karwowska Anna , Nijssen-Jordan Cheri , Johnson David , Davies H. Dele
Published: July 2016

Objectives:

Fever is common in children and causes misconceptions among parents. Many investigators have called for improved parental education to dispel “fever phobia.” Our objectives were to assess parental and health care provider understanding of fever, its treatment, and beliefs about its consequences, as well as to identify parental sources of information about fever.

Methods:

Self-administered surveys were distributed to 3 parent groups and 4 health care provider groups. Parent groups included parents of children with fever presenting to the emergency department (ED) (fever group,n= 209), parents of children with an injury presenting to ED (injury group,n= 160), and parents of healthy school children (school group,n= 141). Provider groups included pediatric ED physicians (n= 16), pediatric ED nurses (n= 39), general pediatricians (n= 26) and family physicians (n= 79).

Results:

Parent groups considered a temperature of 37.9°C to be a fever, 39.1°C to be a high fever, and 39.9°C to be a dangerous fever. Parents were most concerned about discomfort, seizures and dehydration, and parents in the “fever group” worried more about dehydration (p= 0.01) and brain damage (p= 0.03) than other parents. Most physicians were concerned about dehydration and seizures, but family physicians were most likely to express concerns about brain damage (40.5%) and death (34.1%).

Conclusions:

Fever phobia exists among parents and health care providers and is most likely in parents of febrile children and family physicians. Health care providers varied in their knowledge of fever and its treatment. Greater education of health care workers is required in order to provide families with appropriate information.
Willingness of emergency department patients with musculoskeletal complaints to participate in complementary and alternative medicine research
Authors: Abu-Laban Riyad B. , van Beek Catherina A. , Quon Jeffrey A. , Wu Joseph
Published: July 2016

Background:

The emergency department (ED) is a unique potential location for recruitment into studies of complementary and alternative medicine (CAM) therapies. We sought to determine the stated willingness of ED patients with musculoskeletal complaints to participate in CAM research for their presenting problem, and to determine the characteristics of this population.

Methods:

The study was carried out in the ED of Vancouver General Hospital weekdays between 10 am and 6 pm from Oct. 16, 2000, to Nov. 21, 2000. All adults who presented with musculoskeletal complaints involving the spine, upper extremity or lower extremity, unless they had pain severe enough to impair their ability to answer questions or unless there was a language or other communication barrier, were approached by a research nurse. If it was learned that they had already been assessed by an emergency physician, they were eliminated as potential study participants. After being presented background information by the research nurse, consenting patients were asked a series of standardized questions during a 15-minute private interview prior to their assessment by an emergency physician.

Results:

Of 107 eligible patients, 93 participated (87%). Most symptoms began on the day of presentation (44%) or in the previous week (41%). The mean age of those studied was 38 years, and 56% were male. Most presenting problems involved the ankle/foot (29%), multiple sites (19%), the lumbosacral region (14%) or the wrist/hand (14%). Seventy-six percent of patients had utilized CAM previously during their lives, and 13% were currently using CAM for their presenting problem. The majority of patients stated an informed hypothetical willingness to enroll in a CAM study of the following therapies: traditional Chinese medicine 74% (69/93: 95% confidence interval [CI] 64.1%–82.7%); chiropractic 70% (65/93: 95%CI 59.5%–79.0%); and other CAM therapies 92% (86/93: 95%CI 85.1%–96.9%). Of patients asked, 99% stated they would comply with 4 to 6 weeks of outpatient follow-up, and 70% stated they would participate in a placebo-controlled study. Logistic regression modeling, performed for secondary purposes, indicated that willingness to participate in traditional Chinese medicine or chiropractic research was independent of age, sex, educational status, pain severity or prior exposure to the modality of interest.

Conclusions:

ED patients with musculoskeletal complaints have a high stated willingness to participate in CAM research, even if this involves outpatient follow-up or a placebo-controlled design. ED-based CAM research appears feasible and should be pursued.
The future of emergency medicine in Canada: submission from CAEP to the Romanow Commission. Part 2
Authors:   Canadian Association of Emergency Physicians Working Group on the Future of Emergency Medicine in Canada
Published: July 2016

In April 2001, the Commission on the Future of Health Care in Canada was established. The Honorable Roy Romanow was given the mandate to “inquire into and undertake dialogue with Canadians on the future of Canada’s public health care system” and “to develop recommendations that will ensure the long-term sustainability of a high quality, universally accessible, publicly administered health care system, for all Canadians.”

The Canadian Association of Emergency Physicians (CAEP) recognized an obligation to share in this public dialogue, to communicate the current state of emergency medicine, and to identify the components necessary to achieve excellence in emergency care. The CAEP Advocacy Committee was asked to develop a document that would educate and enlighten the Commissioner. Basic themes were identified, and authors from across the country were invited to write brief, factual essays with achievable recommendations. The resulting series of essays was presented on April 30, 2002, at the Health Care Commission’s open public hearing in Calgary, Alberta.

This article, part 2 of a 2-part series, includes discussions on Emergency Department Overcrowding, Human Resources Issues in Emergency Medicine, Standardization of Care and Clinical Practice Guidelines, Informatics and the Electronic Health Record, and Research in Emergency Medicine.
Canadian emergency department preparedness for a nuclear, biological or chemical event
Authors: Kollek Daniel
Published: July 2016

Since the terror attacks of September 11th, emergency departments across North America have become more aware of the need to be prepared to deal with a mass casualty terror event, particularly one involving nuclear, biological or chemical contaminants. The effects of such an attack could also be mimicked by accidental release of toxic chemicals, radioactive substances or biological agents unrelated to terrorist activity.

The purpose of this study was to review the risks and characteristics of these events and to assess the preparedness of Canadian emergency departments to respond. This was done by means of a survey, which showed a significant risk of a mass casualty event (most likely chemical) coupled with a deficiency in preparedness — most notably in the availability of appropriate equipment, antidotal therapy and decontamination capability. There were also significant deficiencies in the ability to respond to a major biologic or nuclear event.
Posterior myocardial infarction with isolated ST elevations in V8 and V9: Is this an “ST elevation MI”?
Authors: Brown Lance , Sims Jessica , Conforto Alessandra
Published: July 2016

We report a case of a 53-year-old man whose first manifestation of coronary artery disease was an acute isolated posterior myocardial infarction (IPMI). Acute IPMI is relatively uncommon and predominantly due to occlusion of the left circumflex coronary artery. IPMI is challenging to diagnose due to the absence of ST segment elevation on a standard 12-lead electrocardiogram (ECG) even in the setting of total coronary artery occlusion and transmural (Q-wave) infarct. We discuss the diagnostic implications of the absence of tall R waves in leads V1 and V2 on this patient’s ECG. The utility of posterior leads (V7 through V9) is demonstrated. The controversy surrounding the use of thrombolytic therapy or primary angioplasty in the setting of acute IPMI without ST segment elevation on a standard 12-lead ECG is reviewed.
War on SARS: a Singapore experience
Authors: Marcus Ong E.H.
Published: July 2016

On Mar. 12, 2003, the World Health Organization issued a global alert regarding cases of a severe atypical pneumonia termed “severe acute respiratory syndrome” (or SARS). In Singapore alone, there have been 238 SARS cases and 33 deaths, including 5 health care workers. With modern global inter-connectivity, SARS rapidly spread to become a worldwide phenomenon. This article describes the Singapore “war on SARS” from an emergency physician’s perspective, focusing on the “prevent, detect and isolate” strategy. Notable innovations include the use of home quarantine orders, mass temperature screening using thermal imaging, modular systems of hospital staffing, “virtual” hospital visits, and innovations in emergency department design. Most emergency departments, hospitals and health care systems appear to be psychologically and logistically unprepared for a massive infectious disease outbreak. In light of recent natural and terrorism-related threats, emergency care providers around the world must adopt a new paradigm. The current SARS outbreak may be merely a taste of things to come.
Potential error in the use of an automated external defibrillator during an in-flight medical emergency
Authors: Katis Peter G. , Dias Solange M.
Published: July 2016

In-flight medical emergencies are uncommon, generally non-lethal events. In fatal cases, the most common cause of death is a sudden cardiac event. This fact, and the awareness that early defibrillation is the most important determinant of successful cardiac resuscitation, have led to the increasing availability of automated external defibrillators (AEDs) aboard commercial airplanes. AEDs are sophisticated and extremely reliable devices that are designed to be used by trained laypersons in the hope of minimizing the crucial time to defibrillation. Although designed to be foolproof, both machine- and operator-dependant usage errors have been recognized. In this case study we report a unique operator-dependent error involving the misreading of an AED instruction window, briefly review the history of AED use in the airline industry, and underscore the need for a sound knowledge of basic life support skills when working with these devices. We conclude by making recommendations to prevent similar errors from occurring in the future.
Utility of follow-up recommendations for patients discharged with community-acquired pneumonia
Authors: Campbell Sam G. , Murray Daphne D. , Urquhart David G. , Maxwell David M. , Ackroyd-Stolarz Stacey Ann , Varley-Doyle Suzanne M. , Ells Mabel D. , Hawass Ammar
Published: July 2016

Introduction:

The joint Canadian Infectious Diseases Society and Canadian Thoracic Society guidelines for community-acquired pneumonia (CAP) recommend 48–72 hour telephone follow-up of patients discharged from the emergency department (ED). The guidelines provide no evidence supporting this practice, and neither the clinical utility nor the effectiveness of such recommendations has been assessed. Our objective was to assess the utility of a 48–72 hour telephone follow-up protocol for patients discharged from the ED with CAP.

Methods:

This was a retrospective chart audit covering a 2-year period (Jan. 3, 1999 to Jan. 3, 2001) after the introduction of a clinical practice guideline (CPG) that included routine 48–72 hour telephone follow-up of patients discharged from the ED with CAP. Eligible patients were identified in the ED database, rates of referral for telephone follow-up were recorded, and 30-day outcomes (death and readmission) for patients referred versus not referred were compared.

Results:

During the study period, 867 patients were identified as being eligible for the study. The mean age was 55.7 years (range 16–98 yr), and mean pneumonia severity index (PSI) was 68.9 (range 6–187). Despite the CPG, only 148 patients (17.1%) were referred for telephone follow-up. Age, demographics, comorbidity, clinical status and pneumonia severity were similar for referred and non-referred patients. Thirty-day death (2.5%) and readmission rates (3%) were strongly related to PSI score, but did not differ significantly in the 2 comparison groups.

Conclusions:

In this setting, physicians were poorly compliant with a routine telephone follow-up protocol. The likelihood of referral for follow-up did not correlate with pneumonia severity, and follow-up referral did not appear to affect patient outcome. These findings do not support recommendations for routine early follow-up mechanisms beyond those already existing in the community.
Attitude of emergency department patients with minor problems to being treated by a nurse practitioner
Authors: Moser Meite S. , Abu-Laban Riyad B. , van Beek Catherina A.
Published: July 2016

Introduction:

It may be appropriate for nurse practitioners (NPs) to provide care for a subset of emergency department (ED) patients with non-urgent problems. Our objective was to determine the attitude of ED patients with minor problems to being treated by an NP.

Methods:

Consecutive adults who presented to this tertiary ED on weekdays between 8 am and 4 pm were eligible for the study if they had 1 of the following 18 complaints: minor abrasions or lacerations, minor bites, minor burns, minor extremity trauma, cast check, earache, superficial foreign body, lice or pinworms, morning-after pill request, needlestick injury or body-fluid exposure, prescription refill, puncture wound, sore throat, subconjunctival hemorrhage, suture removal or wound check, tetanus immunization request, toothache, or urinary tract infection (women). Unless pain or a language barrier precluded study involvement, a triage nurse gave each patient a brief survey to be completed prior to physician assessment.

Results:

Of 728 eligible patients during the study period, 246 (34%) were invited to participate and 213 (87%) were enrolled. The mean age was 34.5 years, and 58% were men. When asked about their willingness to be treated by an NP, 72.5% said “yes” (95% confidence interval [CI], 65.8%–78.4%), 15.5% were “uncertain” (95% CI, 10.8%–21.1%) and 12.1% said “no” (95% CI, 8.0%–17.3%). Of those who said “yes,” 21% expected to also see an emergency physician during their ED visit and 67% did not. Willingness to be treated by an NP was independent of age, gender or educational status.

Conclusions:

A majority of ED patients with minor problems accepted being treated by an NP, often without additional physician assessment. Several factors, including impact on ED staffing and patient flow, logistics, cost and quality of care should be evaluated before implementing such strategies.
Survival rates for adult trauma patients who require cardiopulmonary resuscitation
Authors: Alanezi Khaled , Alanzi Farhan , Faidi Samir , Sprague Sheila , Cadeddu Margeritta , Baillie Frank , Bowser Daniel , McCallum Andy , Bhandari Mohit
Published: July 2016

Objectives:

To determine survival rates in adult trauma patients requiring cardiopulmonary resuscitation (CPR).

Methods:

We used 1992–2002 trauma registry data to identify all adult trauma patients over the age of 16 who required CPR in the pre-hospital setting or within 24 hours of arriving at the hospital. Demographic information, mechanism of injury, injury severity score (ISS), vital signs at the scene and in the hospital, and mortality were obtained from patient charts. Patients were stratified into 2 groups: those with absent vital signs in the field who required prehospital CPR, and those who lost vital signs within 24 hours of arriving at the trauma suite.

Results:

Of 50 eligible patients, 28 (58%) were male and 46 (92%) sustained blunt trauma. Mean age was 44.8 ± 20 years and mean ISS was 38 ± 18. Overall mortality was 96% (48/50), and all patients who required prehospital CPR died. The only 2 survivors were patients who arrived with vital signs and developed pulseless electrical activity while in the trauma suite.

Conclusion:

In this consecutive series of trauma victims with cardiopulmonary arrest there were no survivors among those who lost vital signs and required CPR prior to arriving at the hospital.
Focused abdominal ultrasound for blunt trauma in an emergency department without advanced imaging or on-site surgical capability
Authors: Shuster Michael , Abu-Laban Riyad B. , Boyd Jeff , Gauthier Charles , Mergler Sandra , Shepherd Lance , Turner Chris
Published: July 2016

Objectives:

To determine whether focused abdominal sonogram for trauma (FAST) in a rural hospital provides information that prompts immediate transfer to a tertiary care facility for patients with blunt abdominal trauma who would otherwise be discharged or held for observation.

Methods:

Prior to the study, participating emergency physicians underwent a minimum of 30 hours of ultrasound training. All patients who presented with blunt abdominal trauma to our rural hospital between Mar. 1, 2002, and Apr. 30, 2003, were eligible for study. Following a history and physical examination, the emergency physician documented his or her disposition decision. A FAST was then performed, and the disposition reconsidered in light of the FAST results.

Results:

Sixty-seven FAST exams were performed on 65 patients. Three examinations (4.5%) were true-positive (95% confidence interval [CI] 0.9%–12.5%); 60 (89.6%) were true-negative (95% CI 79.7%–95.7%), 4 (6%) were false-negative (95% CI 1.7%–14.6%) and none (0%) were false-positive (95% CI 0%–5.4%). These values reflect sensitivity, specificity, negative predictive value and positive predictive values of 43%, 100%, 94% and 100% respectively. FAST results did not alter the decision to transfer any patient (0%: 95% CI 0.0%–5.4%), although one positive FAST may have led to an expedited transfer. One of 38 patients who was discharged after a negative FAST study returned 24 hours later because of worsening symptoms, and was ultimately found to have splenic and pancreatic injuries.

Conclusions:

This study failed to demonstrate that FAST improves disposition decisions for patients with blunt abdominal trauma who are evaluated in a hospital without advanced imaging or on-site surgical capability. However, the study is not sufficiently powered to rule out a role for FAST in these circumstances, and our data suggest that up to 5.4% of transfer decisions could be influenced by FAST. Rural emergency physicians should not allow a negative FAST study to override a clinical indication for transfer to a trauma centre; however, positive FAST studies can be used to accelerate transfer for definitive treatment.
Laryngoscopic views during rapid sequence intubation in the emergency department
Authors: Graham Colin A. , Oglesby Angela J. , Beard Diana , McKeown Dermot W.
Published: July 2016

Objectives:

Our objective was to document and compare the views obtained at laryngoscopy during emergency department (ED) rapid sequence intubation (RSI) by anesthetists and emergency physicians of varying seniority and experience.

Methods:

Data were prospectively collected on every intubation attempt in 7 urban Scottish EDs for 2 calendar years, commencing Jan. 11, 1999. Data included patient’s age, gender, grade and specialty of intubator, laryngoscopic grade, and number of intubation attempts. Quality of laryngoscopic visualization was graded using the Cormack–Lehane scale, with grades I and II considered good visualization. A descriptive analysis was performed, and key statistical comparisons made.

Results:

During the study period, 735 patients underwent RSI, and grade of intubation was documented in 672 cases (91%). In total, 68.2%, 23.4%, 6.1% and 2.4% of the intubations were classified as Cormack–Lehane grade I, II, III and IV respectively. Overall, anesthetists and anesthesia trainees achieved good laryngoscopic visualization in 94.0% of cases (95% confidence interval [CI], 90.8%–96.4%) and emergency physicians and emergency medicine trainees did so in 89.2% of cases (95% CI, 85.5%–92.3%;p= 0.027). Specialist registrars and senior house officers in anesthesia were more likely to obtain good visualization than their emergency medicine counterparts (p= 0.034 and 0.035 respectively). Consultants in emergency medicine were more likely to obtain good views than their anesthesia counterparts, but this difference was not statistically significant.

Conclusions:

Anesthetic trainees obtain better laryngoscopic views than emergency medicine trainees, but these differences disappear with increasing emergency physician seniority, suggesting a training and experience effect. Emergency medicine trainees may benefit from additional focus on laryngoscopic visualization techniques early in their training period.
Revisions to the Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines
Authors: Murray Michael , Bullard Michael , Grafstein Eric ,   the CTAS
Published: July 2016

There has been widespread implementation of theCanadian Emergency Department Triage and Acuity Scale(CTAS) across Canada since it was introduced in 1999. This consensus document, developed by the CTAS National Working Group (NWG) of nurse and physician leaders in emergency department (ED) triage, continues to be viewed as a dynamic document that requires modification over time as experience is gained in its application. This article presents the first major modification to the CTAS.