Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI.

Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann–Whitney U test and presented graphically with Kaplan–Meier curves.

Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67–108) preprotocol to 62 minutes (IQR 40–80) postprotocol (p < 0.001).

In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

We assessed the self-reported theoretical and practical preparedness training of Canadian emergency medical services (EMS) providers in chemical, biological, radiological and nuclear (CBRN) events.

We designed an online survey to address the theoretical and practical CBRN training level of prehospital providers. Emergency medical services staff in British Columbia and Ontario were invited to participate.

Of the 1028 respondents, 75% were male, and the largest demographic groups were front-line personnel with more than 15 years of experience. Only 63% of respondents indicated they had received either theoretical or practical training to work in a contaminated environment, leaving 37% who indicated they had received neither type of training. Of those that had received any training, 61% indicated they had received “hands-on” or practical training and 82% indicated they had received some training in identification of a possibly contaminated scene. Only 42% had received training for symptoms of nerve agents, 37% had received training for symptoms of blister agents and 46% had received training for symptoms of asphyxiants. Thirty-two percent had received training for the treatment of patients exposed to nerve agents, and 30% had received training for the treatment of patients exposed to blister agents. Only 31% of all respondents had received training for detecting radiation.

CBRN events involve unique hazards and require specific education and training for EMS providers. A large proportion of Canadian EMS providers report not having received the training to identify and work in contaminated environments.

Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs.

Sixteen emergency medicine residents volunteered for a pre- and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence.

Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p < 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p < 0.01) and all felt satisfied with the training program.

This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.

Somatization of emotions accounts for excess emergency department (ED) visits in the form of medically unexplained symptoms (MUS). Intensive short-term dynamic psychotherapy (ISTDP) has been used to diagnose and manage somatization. We examined the effectiveness of this procedure for ED patients with MUS.

We implemented a service that included staff education, timely access to consultation and gathering of outcome data.

Patients were assessed and treated shortly after referral. There was a mean reduction of 3.2 (69.0%) ED visits per patient (standard deviation [SD] 6.4) the year afterward (95% confidence interval [CI] 1.3–5.0, p < 0.001). In comparison revisit rates during the same time interval for 3 available ED populations (i.e., those matched by visit rates, those with matching complaints and all patients referred to the service but never seen) showed either smaller reductions or higher ED use (ranging from a 15% reduction to a 43% increase). Treatments averaged 3.8 sessions per patient (SD 5.3). Self-reported symptoms improved significantly with the Brief Symptom Inventory global rating, which changed from a mean of 1.21 (SD 0.58) before assessment to 0.86 (SD 0.63) (p < 0.01) at the end of contact with the service. The service appeared acceptable to both emergency physicians and patients.

This emotion-focused assessment and treatment method appeared to be feasible and may be effective in reducing both symptoms and repeat ED use.

We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation.

This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis.

A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%–100%), a specificity of 34.2% (95% CI 27.7%–41.2%), a negative predictive value of 99.2% (95% CI 92.8%–99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002–0.27). Patients younger than 40 years are at high risk for clinically important fracture-dislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%.

The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation.

Medical students are expected to make residency and career decisions early in their undergraduate medical education. In medical school curricula, there is limited exposure to emergency medicine (EM) in the preclerkship years. The purpose of this study was to evaluate a structured EM observership program for preclerks by surveying the students’ perceptions and attitudes about the program following their participation.

A structured observership program was developed and implemented at the University of Toronto Medical School in February 2007. All first- and second-year students were eligible to participate on a voluntary basis. Nine emergency department (ED) teaching sites were enlisted, with each site recruiting interested preceptors. The observership consisted of two 4-hour shifts with 1 preceptor at 1 site. Specific expectations were provided to the students at the start of the observership. A convenience sample was used for the period between Feb. 26 and Nov. 4, 2007, to conduct an anonymous online survey about the students' experience after the ob servership.

During the study period, 82 students completed 99 observerships at 9 sites with 54 different preceptors. Of the 82 students who completed the observerships, 70 students completed the survey. Overall, all the students (70/70) found the experience to be worthwhile. Most students (68/70) viewed the preceptors as good role models. As a result of the observership, 47 of 70 students reported that their attitudes about and interest in EM had changed and most (59/70) planned on exploring other opportunities in EM (e.g., electives).

Structured EM observerships are viewed by medical students to be worthwhile. These observerships can change attitudes about and interest in EM and allow students to make more informed career choices.

Residents must become proficient in a variety of procedures. The practice of learning procedural skills on patients has come under ethical scrutiny, giving rise to the concept of simulation-based medical education. Resident training in a simulated environment allows skill acquisition without compromising patient safety. We assessed the impact of a simulation-based procedural skills training course on residents' competence in the performance of critical resuscitation procedures.

We solicited self-assessments of the knowledge and clinical skills required to perform resuscitation procedures from a cross-sectional multidisciplinary sample of 28 resident study participants. Participants were then exposed to an intensive 8-hour simulation-based training program, and asked to repeat the self-assessment questionnaires on completion of the course, and again 3 months later. We assessed the validity of the self-assessment questionnaire by evaluating participants' skills acquisition through an Objective Structured Clinical Examination station.

We found statistically significant improvements in participants' ratings of both knowledge and clinical skills during the 3 self-assessment periods (p < 0.001). The participants' year of postgraduate training influenced their self-assessment of knowledge (F2,25 = 4.91, p < 0.01) and clinical skills (F2,25 = 10.89, p < 0.001). At the 3-month follow-up, junior-level residents showed consistent improvement from their baseline scores, but had regressed from their posttraining measures. Senior-level residents continued to show further increases in their assessments of both clinical skills and knowledge beyond the simulation-based training course.

Significant improvement in self-assessed theoretical knowledge and procedural skill competence for residents can be achieved through participation in a simulation-based resuscitation course. Gains in perceived competence appear to be stable over time, with senior learners gaining further confidence at the 3-month follow-up. Our findings support the benefits of simulation-based training for residents.

We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS).

Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used.

The response rate was 67.3% (n = 230). During the SARS outbreak, an N95-type particulate respirator was reported to be always used by 91.5% of respondents. Conversely, 72.9% of the respondents reported that they never used the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to be always used (52.0%), while other items were used at an intermediate frequency. The most common reason for not always donning equipment was that paramedics deemed it unnecessary for the situation.

Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance.

The primary objective of this study was to compare the results of nurse-performed urinalysis (NPU) interpreted visually in the emergency department (ED) with laboratory-performed urinalysis (LPU) interpreted by reflectance photometry.

This was a prospective observational study based on a convenience sample from my emergency practice. Emergency nurses, who were unaware of the study, performed usual dipstick analysis before sending the same urine sample to the laboratory for testing.

Of 140 urinalyses performed during the study period, 124 were suitable for analysis. When compared with the reference standard LPU, the NPU had an overall sensitivity of 100% (95% confidence interval [CI] 95%–100%) and a specificity of 49% (95% CI 33%–65%) for the presence of any 1 of blood, leukocyte esterase, nitrites, protein, glucose or ketones in the urine. Of 20 falsely positive NPUs, 18 were a result of the nurse recording 1 or more components as “trace” positive.

Although NPU does not yield identical results to LPU, a negative LPU is expected when the initial NPU in the ED is negative.

Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP).

The literature search, abstract review and study selection were performed using predefined criteria. We abstracted the sensitivity and specificity of EDTU for IUP from included studies, and evaluated and summarized the evidence assessing the effect of EDTU use on time to diagnosis, time to treatment of ectopic pregnancy, emergency department (ED) length of stay and health care costs.

The specificity of EDTU for IUP in most studies exceeds 98%. The sensitivity in most studies exceeds 90%. Pooled estimates were not calculated because of statistical heterogeneity between studies. Published evidence indicates that EDTU use reduces the frequency of missed ectopic pregnancies, decreases time to surgery for ectopic pregnancy, shortens the length of stay for patients with normal pregnancies and may be more cost-effective than diagnostic strategies requiring formal ultrasonography.

EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.