John Ross

Acute airway management in the emergency department by non-anesthesiologists.

PurposeThe responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed.SourceA narrative review of the literature on the practice of airway management by non-anesthesiologists.Principal findingsA significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor.ConclusionsThe role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.RésuméObjectifLa responsabilité de l’assistance respiratoire d’urgence revient souvent à des médecins non-anesthésiologistes. Les urgentistes utilisent maintenant de routine le bloc neuromusculaire pour faciliter l’intubation. La documentation à l’appui de cette pratique a été publiée presque exclusivement dans les journaux de médecine d’urgence (MU). Nous présentons l’ensemble de ces documents et exposons les questions de formation.SourceUne revue traditionnelle de la documentation sur la pratique de l’assistance respiratoire par des non-anesthésiologistes.Constatations principalesUne proportion significative de l’assistance respiratoire d’urgence, réalisée à l’extérieur de la salle d’opération, relève de non-anesthésiologistes. L’intubation en séquence rapide (ISR) est reconnue comme une intervention centrale dans le domaine de la MU. L’ISR est généralement réalisée par des urgentistes dans les grands centres. Le soutien anesthésiologique pour la pratique de l’ISR par des non-anesthésiologistes est plutôt faible. Un soutien éducatif formel en dehors de la formation de spécialiste, par des programmes dédiés à l’assistance respiratoires avancée, est maintenant offert. La majorité des publications sur l’usage de l’ISR par des non-anesthésiologistes consiste en séries rétrospectives, études par observation et enregistrement de données publiées dans des journaux de MU. Les taux de succès rapportés pour l’ISR réalisée par des non-anesthésiologistes y sont élevés. Les taux de complications sont significatifs, quoique la cohérence des rapports laisse à désirer.ConclusionLe rôle des non-anesthésiologistes dans l’assistance respiratoire immédiate est significatif. Malgré des défauts de méthodologie, les preuves actuelles et la pratique appuient l’usage de l’ISR par des urgentistes formés. Des efforts de collaboration constructive entre l’anesthésiologie et la MU sont nécessaires pour répondre aux besoins éducationnels et assurer la compétence en assistance respiratoire.

Diagnosing urinary tract infections in febrile infants and children: when evidence-based medicine and clinical practice collide.

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.

Ultrasound in the emergency department: Emergency department ultrasound for the assessment of abdominal trauma: an overview

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. A focused abdominal sonogram in trauma (FAST) exam takes 5 minutes or less. The FAST scan examines the right upper quadrant, left upper quadrant, subxiphoid area, pelvis at the pouch of Douglas, and, in some cases, the paracolic gutters. But can FAST scans tell us which patients require surgery? English-language publications document trauma U/S data from over 10,000 patients. These data suggest that U/S is 80–100% sensitive and 88–100% specific for detecting hemoperitoneum in adult, pediatric, blunt or penetrating abdominal trauma. Serial scanning over minutes to hours increases both sensitivity and specificity. Several studies have compared U/S, either single or serial, with DPL and CT. The figures presented in Table 1 are typical of the results of these studies. Although sensitive for hemoperitoneum, U/S, like CT, has poor sensitivity (in the range of 50–60%) for hollow viscus and pancreatic injuries. Most studies report U/S

Comparison of Simulation-based Resuscitation Performance Assessments With In-training Evaluation Reports in Emergency Medicine Residents: A Canadian Multicenter Study

Simulation stands to serve an important role in modern competency‐based programs of assessment in postgraduate medical education. Our objective was to compare the performance of individual emergency medicine (EM) residents in a simulation‐based resuscitation objective structured clinical examination (OSCE) using the Queens Simulation Assessment Tool (QSAT), with portfolio assessment of clinical encounters using a modified in‐training evaluation report (ITER) to understand in greater detail the inferences that may be drawn from a simulation‐based OSCE assessment.

How to safely extubate a patient in the emergency department: a user's guide to critical care

A 35-year-old male is found unconscious at the bottom of a staircase. His Glasgow Coma Scale (GCS) score is 3, and he is intubated by the paramedics for failure to protect his airway. On assessment in the emergency department (ED), the GCS score remains 3, but his examination and investigations (including a normal head computed tomographic [CT] scan) are unremarkable except for a serum ethanol of 97 mmol/L. Five hours later, he remains intubated in the ED but is starting to wake up. Should you extubate him or sedate him to keep him intubated? How do you ensure the optimal outcome for this patient?

Predicting community emergency medicine needs and emergency physician compensation modeling; two sides of the same coin?

To the editor: Dubinsky’s broad overview of emergency physician (EP) ‘‘workload’’ models has important implications to population health outcomes and national physician resource planning. It seems that this is a complex issue and that there is ‘‘no perfect single existing model.’’ I wonder, however, whether this article adequately differentiates between 1) matching emergency medicine capacity with patient/population needs and 2) modeling workload for the purposes of fair compensation. Practically, they may be two sides of the same coin, but conflating these two perspectives risks creating conflicting priorities. As Einstein has said, ‘‘Formulating the problem is more essential than the solutions.’’ If matching capacity is the problem, then we will solve this with a public health lens. We know that prolonged emergency department wait times are associated with mortality in a doseresponse relationship that suggests causality. And we know that inadequate EP coverage prolongs wait times in a nonlinear relationship similar to the oxygen-dissociation curve (when it starts to fall apart, it really falls apart). In this context, problem solving is patient outcome centred and forward looking (predicting patient/community needs). This process, then, is evidence based and policy driven. Ideally, the Canadian Association of Emergency Physicians could use its national perspective and patient advocacy role to endorse a ‘‘best practice’’ methodology (which may look very similar to the author’s hybrid model). If modeling workload for compensation is the problem, then the hours of coverage issue gets bundled with the hourly rate issue, and we will ‘‘solve’’ this issue through negotiations. Although this makes intuitive sense to funding bodies transitioning from a fee-for-service framework, this can lead to some unintended consequences. In this context, the approach becomes remuneration focused and backward looking (measuring physician work). Physician negotiators (with less fiscal/system accountability) are incented to inflate workload metrics, and government negotiators (with less patient care accountability) are incented to consider the coverage issue as just another leverage point for give and take. Also, any increase in funding that may occur (in relation to increased volume/acuity/complexity) gets framed as a raise in physician’s salaries (rather than as a need to recruit more full-time equivalents to improve patient access). Situating discourse and decision making in the realm of health care policy (rather than in the potentially adversarial and opaque process of physician services negotiations) brings more evidence, transparency, public accountability, patient centredness, and fiscal responsibility to dialectically working toward creating a safe and sustainable emergency health care system.