bluuebunny/crossref_metadata_2025_split huggingface dataset:
Accidental injection of epinephrine by a child: a unique approach to treatment
Authors: Sellens Catharine , Morrison Laurie 
Published: July 2016

ABSTRACT:
A 9-year-old girl accidentally injected her right thumb with an adult dose of epinephrine through an auto-injector syringe, delivering 0.3 mg of 1:1000 epinephrine. This injection caused immediate ischemic changes in the digit. This is the first reported case of accidental self injection by a child of an adult dose of epinephrine and its successful treatment with low-dose phentolamine simultaneously infiltrated directly into the puncture area and along the course of the digital artery. The use of phentolamine as a specific competitive alpha-adrenergic antagonist to epinephrine has been well documented in adults and animal models. This report compares the management of a pediatric case to that of all reported adult cases of accidental subcutaneous epinephrine injections. This case suggests a pattern of infiltration with low-dose phentolamine that may be the most effective form of treatment for this condition in a patient of any age.
African drumbeats: a first conference on emergency medicine
Authors: Dickinson Garth 
Published: July 2016

SUMMARY:
Africa’s first conference on emergency medicine was held in October 1998 in Johannesburg, South Africa. Attended by 305 delegates from 13 countries, it was an important milestone in the development of Africa, emergency medicine’s last frontier. The violence of South Africa’s post-apartheid society was portrayed in mock scenario demonstrations of the private sector emergency medical services (EMS) system. Many of the presentations had a distinctly African flavour; they dealt with penetrating trauma and with making the best of extremely limited resources. A session reviewing the activities of traditional healers was not only terrifyingly revealing, it also upset and offended a segment of the African audience. The conference ended positively with the creation of the Emergency Medicine Society of South Africa, a step toward recognition of emergency medicine as a specialty in Africa.
Emergency medicine training in Canada
Authors: Moore Kieran , Lucky Cindy-Ann 
Published: July 2016

SUMMARY:
Canada is the only country with two colleges governing emergency medicine (EM) certification. Does this serve us well or does it divide us and our resources? If most CCFP(EM) graduates practise strictly EM, with no family or rural practice, then reform in the certification process may be necessary. At the same time, FRCPC residencies seem excessively long and lack the numbers to develop “critical mass.” Shortening the length of training would allow more residency positions to be created, thus advancing the goal of optimum emergency care for the Canadian public. Canadians deserve one standardized, certified, accredited EM training program that produces the highest quality emergency physicians.
Commentary: Chest pain evaluation in the emergency department
Authors: Allen Tim 
Published: July 2016

In this issue, Dr. David Mutrie illustrates both the utility of departmental care protocols and the caution we must take in drawing conclusions from them. The latter point is particularly important if one wishes to apply these conclusions to other institutions.The Thunder Bay Regional Hospital (TBRH), in Ontario, established simple guidelines for the management of patients with chest pain. Following the implementation of these guidelines, Mutrie reports shorter chest pain assessment times and reduced admission rates for non-myocardial infarction and non-unstable angina patients, without any obvious increase in inappropriate discharge of patients with ischemic disease. Can we therefore conclude that the guidelines were responsible for these improvements and that this set of guidelines would similarly improve performance in other emergency departments? The answer, unfortunately, is No. The fact is, the establishment of any organized approach to a clinical problem tends to improve performance. This is perhaps a sad reflection on “individual” practice patterns, but it is true nonetheless.
Prehospital emergency medical services’ ethical dilemma with do-not-resuscitate orders
Authors: Sherbino Jonathan , Guru Veena , Verbeek P. Richard , Morrison Laurie J. 
Published: July 2016

ABSTRACT

Objective:
Our primary objectives were to estimate how frequently emergency medical technicians with defibrillation skills (EMT-Ds) are forced to deal with prehospital do-not-resuscitate (DNR) orders, to assess their comfort in doing so, and to describe the prehospital care provided to patients with DNR orders in a system without a prehospital DNR policy (i.e., where resuscitation is mandatory).

Methods:
Using Dillman methodology, the authors developed a 13-item survey and mailed it to 382 of 764 EMT-Ds in the metropolitan Toronto area. Responses were evaluated using 5-point Likert scales, limited-option and open-ended questions. Narrative responses were categorized. Two authors independently categorized narrative responses from 20 surveys, and kappa values for agreement beyond chance were determined.

Results:
Among 382 EMT-Ds surveyed, 236 (62%) responded, of whom 221 (94%) answered the questionnaire. Overall, 126 of 219 (58%) indicated that they were called to resuscitate patients with DNR orders “sometimes,” “frequently,” or “all the time.” In such situations, 22 of 207 (11%) stated they would honour the DNR order and 55 of 207 (27%) would honour the order but appear to provide basic resuscitation, in order to adhere to mandatory resuscitation regulations. Willingness to honour a DNR order did not vary by years of emergency medical service. EMT-Ds cited concern for the family and the patient, fear of repercussions and conflict with personal ethics as key factors contributing to this ethical dilemma. If legally allowed to honour DNR orders, 212 of 221 (96%) respondents would be comfortable with a written order and 137 of 220 (62%) with a verbal order.

Conclusion:
Prehospital DNR orders are common, and a significant number of EMT-Ds disregard current regulations by honouring them. EMT-Ds would be more comfortable with written than verbal DNR orders. An ethical prehospital DNR policy should be developed and applied.
Review of the selective COX-2 inhibitors celecoxib and rofecoxib: focus on clinical aspects
Authors: Loewen Peter S. 
Published: July 2016

ABSTRACT:The selective cyclooxygenase-2 (COX-2) inhibitors celecoxib and rofecoxib were designed to have similar efficacy but less gastrointestinal toxicity than traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Their efficacy has been demonstrated in the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, postoperative dental pain and dysmenorrhea. These agents produce fewer endoscopic ulcers, symptomatic ulcers and gastrointestinal bleeds than traditional NSAIDs; although the absolute benefit is small and the gastropreserving effect is negated by concurrent use of low-dose aspirin for cardiovascular risk reduction. Nephrotoxicity and hyptertension remain concerns with COX-2 inhibitors, as they are with traditional NSAIDs. COX-2 inhibitors may be safe alternatives to traditional NSAIDs for patients with aspirin-sensitive asthma.
On a wing and a prayer: medical emergencies on board commercial aircraft
Authors: Drummond Robert , Drummond Alan J. 
Published: July 2016

ABSTRACT:
Medical emergencies sometimes arise in the isolated and confined environment of a commercial aircraft. Because a physician passenger may be on board in 40% to 90% of all commercial flights, it follows that this physician may be asked to render assistance to an acutely ill passenger. Although data suggest that the incidence of such emergencies is low, the potential for serious events necessitates a degree of familiarity with the nature of emergencies in the air and with the options available to the travelling physician.
Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training
Authors: Murray Michael J. , Vermeulen Marian J. , Morrison Laurie J. , Waite Tim 
Published: July 2016

ABSTRACT:

Introduction:
The laryngeal mask airway (LMA™ airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room.

Objective:
To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service.

Methods:
This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables.

Results:
208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics’ perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001).

Conclusions:
This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.
Disaster Medicine Online: evaluation of an online, modular, interactive, asynchronous curriculum
Authors: Lund Adam , Lam Kenneth , Parks Paul 
Published: July 2016

ABSTRACT
Canada has no formal training program in disaster medicine for health care professionals. The University of Alberta’s Division of Emergency Medicine has developed a means to fill the gap. Disaster Medicine Online (DMO) is an Internet-based, interactive, facilitator-guided distance-learning course on the fundamentals of disaster medicine. The 3-week pilot of DMO was offered in March 2002 and taken by a multidisciplinary group of 22 health care professionals, including resident and attending physicians, paramedics and nurses. Evaluation of the learning materials and educational methodology by experts and learners demonstrated a high degree of satisfaction with the Web interface, site usability, lesson content and format, and the interactive components of the online course. Learners reported spending a mean of 11.2 hours (range = 5–20) over the 3-week course period. Twenty of 22 learners completed the final assignment, and all 20 were successful in passing the course. Overall, 95% of learners said they would pursue another module if offered, and 100% would recommend DMO to their colleagues. DMO is a viable option for health care professionals who would like to pursue continuing medical education in this area without having to take time out of their personal and professional lives to travel to a face-to-face, traditional educational program.
Epinephrine in digital blocks: refuting dogma
Authors: Katis Peter G. 
Published: July 2016

ABSTRACT
In the medical community there is a widely held belief that epinephrine should not be used with lidocaine when attempting a digital block because it will cause tissue gangrene. This belief is reinforced by several of the more prominent emergency textbooks, but a review of the medical literature fails to reveal a sound basis for this dogma.
Unusual case of acute onset abdominal pain: uses and limitations of medical imaging
Authors: Bandiera Glen , Poulin Eric 
Published: July 2016

ABSTRACT
A 28-year-old male with atraumatic abdominal pain and transient hypotension was assessed using bedside emergency department (ED) ultrasonography and contrast enhanced helical computed tomography (CT). Both tests revealed free intraperitoneal fluid, but neither detected a splenic defect. The patient subsequently underwent splenectomy for a ruptured spleen. His serology for typical viral causes was negative. This article discusses spontaneous splenic rupture, the role of imaging in diagnosis, and the limitations of ED ultrasound and contrast enhanced helical CT.
Accuracy of clinical diagnosis versus the World Health Organization case definition in the Amoy Garden SARS cohort
Authors: Wong W.N. , Sek Antonio C.H. , Lau Rick F.L. , Li K.M. , Leung Joe K.S. , Tse M.L. , Ng Andy H.W. , Stenstrom Robert 
Published: July 2016

ABSTRACT

Objectives:
To compare the diagnostic accuracy of emergency department (ED) physicians with the World Health Organization (WHO) case definition in a large community-based SARS (severe acute respiratory syndrome) cohort.

Methods:
This was a cohort study of all patients from Hong Kong’s Amoy Garden complex who presented to an ED SARS screening clinic during a 2-month outbreak. Clinical findings and WHO case definition criteria were recorded, along with ED diagnoses. Final diagnoses were established independently based on relevant diagnostic tests performed after the ED visit. Emergency physician diagnostic accuracy was compared with that of the WHO SARS case definition. Sensitivity, specificity, predictive values and likelihood ratios were calculated using standard formulae.

Results:
During the study period, 818 patients presented with SARS-like symptoms, including 205 confirmed SARS, 35 undetermined SARS and 578 non-SARS. Sensitivity, specificity and accuracy were 91%, 96% and 94% for ED clinical diagnosis, versus 42%, 86% and 75% for the WHO case definition. Positive likelihood ratios (LR+) were 21.1 for physician judgement and 3.1 for the WHO criteria. Negative likelihood ratios (LR–) were 0.10 for physician judgement and 0.67 for the WHO criteria, indicating that clinician judgement was a much more powerful predictor than the WHO criteria.

Conclusions:
Physician clinical judgement was more accurate than the WHO case definition. Reliance on the WHO case definition as a SARS screening tool may lead to an unacceptable rate of misdiagnosis. The SARS case definition must be revised if it is to be used as a screening tool in emergency departments and primary care settings.
Benign pneumatosis intestinalis: a cause of massive pneumoperitoneum in the adult
Authors: Liu David M. , Torreggiani William C. , Rowan Kevin , Nicolaou Savvas 
Published: July 2016

ABSTRACT
Pneumatosis intestinalis (gas in the bowel wall) is often a benign condition, but it may mimic bowel ischemia or infarction and lead to unnecessary surgical intervention, especially when associated with pneumoperitoneum. We present a case of benign pneumatosis intestinalis with massive pneumoperitoneum and discuss various distinguishing features that may aid in its diagnosis.
Sentinel surveillance of HIV and hepatitis C virus in two urban emergency departments
Authors: Houston Stan , Rowe Brian H. , Mashinter Laura , Preiksaitis Jutta , Joffe Mark , Mackey Duncan , Galbraith John , Wiebe Natasha 
Published: July 2016

ABSTRACTObjectives:This study was designed to determine the prevalence of HIV and hepatitis C virus (HCV) in a specific population, and to distinguish between known and previously unrecognized infections in the emergency department (ED) setting.Methods:Consecutive patients aged 15 to 54 years who had presented to the EDs of 2 urban hospitals during a 6-week period were enrolled in a prospective cross-sectional study if a complete blood count had been obtained as part of their care. The study patients were initially cross-referenced against local databases of known HIV and HCV seropositive patients. After removal of all personal identifiers, the study patients’ leftover blood was serotested for HIV and HCV, and seroprevalences were calculated. Univariate and multivariate analyses were performed to identify factors associated with HIV and HCV infection.Results:Of 3057 individuals whose files were analyzed, 1457 (48%) were male and 7% (213) were Aboriginal. Overall, 302 patients (10%; 95% confidence interval [CI], 9%–11%) were seropositive for HCV and, of these, only 132 (44%) were previously known to be. HCV seropositivity was associated with Aboriginal status, age, male gender, hospital site and HIV infection (allp&lt; 0.001). In contrast, 39 patients (1%; 95% CI, 1%–2%) were HIV seropositive. Of these, 32 (82%) were previously known to be HIV positive, and 27 (69%) were HCV seropositive. HIV seropositivity was only associated with HCV infection (p&lt; 0.001).Conclusions:The rate of previously undetected infections was relatively low for HIV but high for HCV. Emergency physicians in urban settings will frequently encounter patients not known to be HCV positive and not identified as such. These results emphasize the need for more effective preventive measures in the community and the importance of observing standard (universal) precautions in ED practice.
Screening urine for drugs of abuse in the emergency department: Do test results affect physicians’ patient care decisions?
Authors: Eisen Jeffrey S. , Sivilotti Marco L.A. , Boyd Kirsty U. , Barton Douglas G. , Fortier Christopher J. , Collier Christine P. 
Published: July 2016

ABSTRACT

Background:
Drug abuse is a frequent factor in emergency department (ED) visits. Although commonly performed, qualitative testing of urine for drugs of abuse (u-DOA) is inherently limited in its ability to establish the identity, timing or dose of substances used. Previous studies have demonstrated these limitations, but their designs cannot be used to determine whether the results of u-DOA tests affect physicians’ patient care decisions. Our objective was to determine the impact of u-DOA testing on the care of patients who present to the ED.

Methods:
All adults 18 years of age or older who had u-DOA testing in 2 urban teaching EDs were eligible. Victims of vehicular trauma or sexual assault were excluded. Just prior to communicating the results of u-DOA testing for a patient, an investigator interviewed the ordering physician or consultant physician about the patient care plans for that patient. Test results were then revealed, and the questions immediately repeated. This design isolated the impact of knowledge of u-DOA test results on physicians’ patient care decisions. Any intended changes in patient care plans reported by the interviewed physician were compared to a priori criteria for substantive change and then subsequently reviewed by an independent expert to determine whether that change was justified.

Results:
Of the 110 u-DOA test results studied and the resultant 133 opportunities to influence physician management plans, there were 4 reported changes in management. One management change was judged to be substantive, but none of the 4 reported changes were considered by the independent expert reviewer to be justified. Urine-DOA testing thus led to a justified change in management in 0/133 instances (95% confidence interval 0%–2.3%).

Conclusions:
Urine-DOA is rarely helpful in guiding patient care decisions in the ED. The results of this study call into question the need for this test in the ED setting.
Need for bedside emergency department ultrasonography: case report of a ruptured ectopic pregnancy
Authors: Laviolette Eric 
Published: July 2016

ABSTRACTUltrasonography is a useful tool for the immediate evaluation of patients with suspected ruptured ectopic pregnancy, abdominal aortic aneurysm, traumatic intra-abdominal hemorrhage or cardiac tamponade. The 1999 Canadian Association of Emergency Physicians position statement states that bedside emergency department ultrasonography should be available 24 hours per day. This case study illustrates how emergency physicians properly trained in emergency bedside ultrasonography can use this tool effectively to dramatically impact patient care.
When the MAGIC stops: magnesium in acute coronary syndromes — a lesson in medical humility
Authors: Patrick Shannon , Herbert Mel 
Published: July 2016

ABSTRACTThere has been much debate as to whether magnesium, a well-tolerated, readily available and cheap therapy, should be used to treat patients with suspected myocardial infarction. Despite promising results from animal studies and small clinical trials conducted in the 1980s, two large recent trials have concluded that the once phenomenal treatment is ineffective. The story of magnesium for acute myocardial infarction is a lesson in medical humility.
Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial
Authors: Worster Andrew , Gilboy Nicki , Fernandes Christopher M. , Eitel David , Eva Kevin , Geisler Rose , Tanabe Paula 
Published: July 2016

ABSTRACTIntroduction:The Emergency Severity Index (ESI©) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the fivelevelCanadian Emergency Department Triage and Acuity Scale(CTAS).Objective:To compare the inter-observer reliability of 2 five-level triage and acuity scales.Methods:Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses.Results:Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p= 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99). Conclusions: After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.