Introduction: A cricothyroidotomy is a life-saving procedure and essential skill for EM physicians. The bougie-assisted cricothyroidotomy (BAC) is a newly describe technique that is both simple and reliable. There remains no consensus for the essential steps and ideal training strategy for the procedure. Using a modified Delphi process, we created an expert-derived checklist as a transferable educational tool for BAC instruction. Methods: A literature search was conducted to identify relevant articles describing the steps for BAC performance. These steps formed the first-iteration checklist for the modified Delphi process. Fourteen experts from general surgery, emergency medicine, otolaryngology, and anesthesia were recruited as participants for the Delphi process which consisted of three iterations. In the first two rounds, experts ranked each checklist step on a scale of 1-7, suggested additions, and provided comments. After each round the comments and rankings were integrated and steps with an average ranking of ≤3.0 were removed from the checklist for the next round. In the final round, consensus was sought by asking experts to indicate if this checklist was acceptable for teaching BAC to a novice learner. Results: A 22-item checklist was developed from a literature review. Following a modified Delphi methodology, the final BAC checklist contained 17 items. Internal consistency of the checklist was very good (α=0.855). In the third and final round, 86% of the participants agreed that the final iteration of the checklist. There was disagreement regarding “bougie hold up” as an appropriate method to confirm bougie position within the tracheal lumen. The checklist was modified, replacing “hold up” with digital palpation in the trachea as confirmation of successful bougie placement. With these modifications, consensus was achieved. Conclusion: Using a modified Delphi process, derived from existing literature and expert opinion, a 17-item BAC checklist was developed for novice instruction. This BAC checklist represents the first consensus-based set of steps for the procedure which may serve as a useful tool for trainee instruction and evaluation. Future research is required to test the validity of this checklist in training for a BAC and its applicability within competency-based medical education.

Introduction: The acute onset of flashes and floaters is a common presentation to the emergency department (ED). The most emergent etiology is retinal detachment (RD), which requires prompt ophthalmologic assessment. Previous studies of point of care ultrasound (POCUS) have reported high sensitivity and specificity for RD, but are limited by small sample size, use of highly trained and experienced sonographers, and referral bias. Our primary objective was to assess the test characteristics of POCUS performed by a large heterogeneous group of emergency physicians (EPs) for the diagnosis of RD. Methods: This was a prospective diagnostic test assessment of POCUS performed by EPs with varying ultrasound experience on a convenience sample of ED patients presenting with the complaint of flashes or floaters in one or both eyes. Participating EPs completed a one hour didactic lecture and were expected to demonstrate appropriate performance of one practice scan before enrolling patients. After standard ED assessment, patients underwent an ocular POCUS scan targeted to detect RD. EPs recorded the presence or absence of RD on the data collection instrument based on their POCUS scan. After completing their ED visit, all patients were assessed by a retina specialist who was blinded to the results of the POCUS scan. We calculated sensitivity and specificity with associated exact binomial confidence intervals (CI) using the retina specialist’s determination of the final diagnosis as the criterion standard. Results: A total of 30 EPs, consisting of 21 staff physicians and 9 residents, participated in this study. These EPs performed a total of 128 POCUS scans. Of these scans, 13 were excluded. Of the remaining 115 enrolled patients, median age was 60 years, and 64% were female. The retina specialist diagnosed RD in 16 (14%) cases. The sensitivity and specificity of POCUS for detecting RD was 75% (95% CI 48% to 93%) and 94% (95% CI 87% to 98%), respectively. The positive likelihood ratio was 12.4 (95% CI 5.4 to 28.3), and negative likelihood ratio was 0.27 (95% CI 0.11 to 0.62). Conclusion: In a heterogeneous group of EPs with varying ultrasound experience, POCUS demonstrates high specificity but only intermediate sensitivity for the detection of RD. A negative POCUS scan is not sufficiently sensitive to rule out RD in a patient with new onset flashes or floaters.

Introduction: Emergency physicians (EP) often work at undesirable hours. In response to deleterious effects on quality of life for EPs, traditional 2300-0700 night shifts have been replaced at some centres with staggered 6-hour casino shifts (22:00-04:00 and 04:00-10:00). Though purported to allow for better sleep and recovery patterns, no evidence exists to support the benefits on sleep or quality of life that is used to justify a casino shift model. Using a before and after survey model, this study examines the impact of overhauling night work from a traditional 8-hour shift to casino shifts on the quality of life and job satisfaction of EPs working in an academic emergency department (ED). Methods: In 2010, an initial online, 37-item survey, was sent to all EPs working in the ED, just prior to the transition to casino shifts. 6 years following the transition, a slightly modified 37-item survey was again distributed to all current EPs working at that same centre. Participants rated their level of agreement on a 7-point Likert scale regarding questions related to night work. Results from the two surveys were compared. Results: 43 2010- and 47 2016-surveys were completed. In 2016, recovery to baseline function after a single early shift (22:00-04:00) was most common after 1 day at 52.4%, and after multiple early shifts was ≥2 days at 66.7%. Recovery after a single late shift (04:00-10:00) was most common at 1 day at 54.8%, and after multiple late shifts was ≥2 days at 59.5%. This was in contrast to 2010, when 55.8% recovered from a single traditional night shift after 1 day, and 95.3% required ≥2 days to recover from multiple traditional night shifts. In relation to casino shifts, 40.5% of respondents stated that night shifts are the greatest drawback of their job, compared to 79.1% previously. A minority of respondents felt that teaching (36.5%), diagnostic test interpretation (23.2%), and quality of handover (33.5%) were inferior on early and late night shifts compared to other shifts (74.4%, 58.1%, and 60.5% for traditional night shifts respectively).95.0% of respondents preferred casino over traditional night shifts. Conclusion: There were self-reported improvements in all domains following the implementation of casino shifts.

Introduction: Most current cricothyroidotomy simulation models are either expensive or low fidelity and limit the learner to an unrealistic simulation experience. The goal of this project is to innovate current simulation techniques by 3D printing anatomically accurate trachea models. By doing so emergency cricothyroidotomy simulation can be accessible, high fidelity, cost effective and replicable. Methods: 3D modelling software was used in conjunction with a desktop 3D printer to design and manufacture an anatomically accurate model of the cartilage within the trachea (thyroid cartilage, cricoid cartilage, and the tracheal rings). The initial design was based on dimensions found in studies measuring the dimensions of tracheal anatomy. This ensured an appropriate anatomical landmark design was achieved. Several revisions of the model were designed and qualitatively assessed by medical and simulation professionals to ensure anatomical accuracy that exceeded that of the currently used, low cost, cricothyroidotomy simulation model in St. John’s. Results: Using an entry level desktop 3D printer, a low cost tracheal model was successfully designed that can be printed in under 3 hours. Due to its anatomical accuracy, flexibility and durability, this model is ideal for use in emergency medicine simulation training. Additionally, the model can be assembled in conjunction with a membrane to simulate tracheal ligaments and skin for appearance. Conclusion: The end result is a high fidelity simulation that will provide users with an anatomically correct model to practice important skills used in emergency airway surgery, specifically land marking, incision and intubation. This design is a novel, easy to manufacture, replicable, low fidelity trachea model that can be used by educators with limited resources such as those in rural and remote areas.

Introduction: Atrial fibrillation and flutter (AF/AFL) are the most common arrhythmias encountered in the emergency department (ED); however, little information exists regarding the preventive management of patients with AF/AFL by emergency physicians (EPs). This study explored whether patients with AF/AFL received the recommended thrombo-embolic (TE) prophylaxis at discharge from the ED; patients’ TE risks, bleeding risks, and TE prophylaxis upon discharge from the ED were examined following assessment for symptomatic acute AF/AFL. Methods: Patients ≥18 years of age identified by the EP as having a diagnosis of acute AF/AFL confirmed by ECG were prospectively enrolled from three urban Canadian EDs. Using standardized patient enrollment forms, trained research assistants collected data on the patient’s demographics, TE risk (using the CHADS2 and CHA2DS2-VASc score), bleeding risk (using the HAS-BLED score), and management both in the ED and at discharge. Treating physicians were surveyed on their use of risk scores when making TE prophylaxis decisions as well as their estimate of the patient’s stroke and bleeding risk. Descriptive analyses were performed. Results: From a total of 196 patients, 62% were male and the mean age was 63 years (standard deviation [SD] ±14). Most patients had previous history of AF/AFL (71%); hypertension was documented in 40% of them and ≤10% had other risk factors (e.g., congestive heart failure, vascular disease, diabetes, previous stroke, transient ischemic attack). Based on the CHADS2 score and previous management, there was opportunity for new or revised antiplatelet/anticoagulant treatment by EPs in 19% of the patients. Consultations were requested in 28% of the patients, and the majority (89%) were discharged with anticoagulant or antiplatelet agents. EPs expressed concerns that an increased risk of falls, lack of access to facilities for INR monitoring, and significant cognitive impairment would affect their willingness to prescribe anticoagulation. Conclusion: Most patients in the ED with acute AF/AFL are receiving the recommended TE prophylaxis; however, given the significant morbidity and mortality associated with AF/AFL, improved short-term prescribing practices for anticoagulants would benefit 1 in 5 ED patients. More research on barriers to EPs prescribing anticoagulants is required to improve clinician comfort in treating this high-risk population.

Introduction: The Canadian Computed Tomography Head Rules (CCTHR) is a validated and well-known head injury clinical decision rule that allows Emergency Room Physicians (ERPs) to determine which patients are most likely to benefit from a diagnostic CT. However, this clinical decision rule is not uniformly adhered to and a number of preventable CT scans are ordered. Choosing Wisely Canada has ranked decreasing unnecessary head CT scans as the number one priority for Emergency Departments (ED). As such, the purpose of this study was to investigate if an educational intervention for ERPs would increase adherence to the CCTHR. Methods: In September 2015 the CCTHR were presented and discussed at three ED departmental meetings at Kelowna General Hospital (KGH) a large tertiary hospital in the interior of British Columbia, Canada. Educational materials were distributed to the ERPS and a CTTHR checklist was made available throughout the ED. Rates of adherence to the CCTHR criteria were calculated from MHI patients that were seen in the four years prior to the educational intervention and were compared to rates of adherence for patients 12 months post educational intervention. Only patients that agreed to participate in the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) were included in this analysis. Differences in adherence rates were tested using the chi-squared test. Results: 477 patients were included in the analysis for the pre-education cohort (control) and 257 for the post-education cohort(intervention). In the control cohort, 348 of the 477 (73%) of the patients were managed in accordance to the CCTHR compared to 194 of the 257 (75%) in the intervention cohort. There was no statistically significant difference in rates of adherence (p=0.457).In the control cohort, 44 of the 321 (14%) of patients received a CT that did not meet any CCTHR criteria compared to 15 of the 163 (9%) in the intervention cohort. The overall CT imaging rate was 24% in each patient cohort. Conclusion: Although adherence rates between the two cohorts were not statistically different, a greater proportion of patients had a CTAS of 2 or 3 and met criteria in the intervention cohort suggesting a higher level of acuity. Imaging rates remained constant at 24%, which was lower than expected if there was full adherence to the CCTHR. Further study is required to determine if educational interventions can improve adherence to the CCTHR.

Introduction: Pre-hospital telecommunication (patches) requires a special type of conversation. Receiving and processing correct information is critical when making clinical decisions, such as a termination of resuscitation (ToR). In a study of radio patches, a common patch structure emerged from the data analysis. Use of this standard structure resulted in shorter and less confusing patches. We sought to understand patch structure to be able to target interventions to improve the quality and efficiency of communication needed for critical clinical decisions. Methods: We undertook a retrospective analysis of all ToR patches between physicians and paramedics from 4 paramedic services, recorded by the Ambulance Dispatch Centre between Jan 01-Dec 31, 2014. Four services used Primary Care Paramedics and 1 service also used Advanced Care Paramedics. MP3 patch recording files were anonymized, transcribed, and read multiple times by the authors. Transcripts were coded and analyzed using mixed methods-quantitative descriptive statistics and qualitative thematic framework analysis. Results: The data set was 127 ToR patches-466 pages of transcripts. 116 patches (91.3%) had a standard structure (SS): participant introduction, clinical data presentation, clarification of data, making the decision, exchange of administrative information, and sign off. Paramedics used a mean of 81 words (95CI 74,88) to present the ‘clinical data’. Enough data was presented to meet ToR rule criteria in 52 cases (44.8%). Before making a decision to terminate resuscitation, physicians sought clarification in 100 cases (78.7%). After making the ToR decision, some physicians needed to justify their decision by seeking more data in 17 cases (13.4%). Exchange of non-clinical information (numbers, times, name spellings) took a mean of 200 words (95CI 172,228) and averaged 84 seconds or 35% of the average patch time. SS patches used a mean of 558 words, and lasted 234 sec (95CI 215,252). Non-SS patches used a mean of 654 words and lasted 286 sec (95CI 240,332). Conclusion: The most common patch structure consisted of participant introduction, data presentation, clarification of data, making the clinical decision, exchange of administrative information, and a sign off. Deviation from this SS resulted in longer patches. When a non-SS patch structure was used, the patching paramedic was tied up 25% longer and unavailable to provide patient care.

Introduction: Approximately 15 years ago cell phones replaced portable VHF radios as the means of communication between paramedics and base hospital physicians. Cellphones, like VHF radio, do not allow voice transmission and reception to occur simultaneously. Radio use requires a learned technique to signal the end of each speaker’s turn talking. These techniques are not used in normal cellphone conversation. Poor cellphone reception and poor technique result in breakdowns in communication. The literature about paramedic-physician telecommunication is almost nonexistent. There is an extensive literature in other industries, such as aviation, concerning problems in radio communication. This literature predicts that communication breakdowns are common and have critical consequences. We sought to determine how frequently problems attributable to cell phone technology arose in paramedic-physician communication. Methods: We conducted a retrospective analysis of all patch calls between physicians and paramedics from 4 municipal paramedic services from January 01-December 31, 2014. MP3 audio files, recorded during normal operating procedures by the Central Ambulance Communication Centre, were anonymized and transcribed. Transcripts were read multiple times by the authors and analyzed using mixed methods-qualitative thematic framework analysis and quantitative descriptive statistics. Results: 161 calls were identified. 155 tapes were usable for analysis. 127 (81.9%) patches involved termination of resuscitation orders, 28 (19.1%) were for advice or other orders. The data set consisted of 567 pages of transcripts. Communication problems were identified in 138 (89.0%) patches. Most had multiple problems. Technical problems included disconnections (13.5%), or difficulty hearing (56.8%)-indicated by phrases such as “what?”, “I can’t hear you”. Disorganized cell phone technique was common-individuals interrupted each other (34.2%), and talked simultaneously (54.8%). Signalling the end of “talk turns”-using terms such as “10-4” or “over”-was never used. Conclusion: In addition to technical problems (poor transmission, disconnections), disorganized cell phone ‘technique’ caused a high incidence of communication problems. This is concerning because critical clinical decisions (e.g. ceasing resuscitation) depend on clear communication. Understanding the limitations of cellphone technology might improve communication.

Introduction: Frailty is associated with functional decline and physiological impairments in seniors with minor injuries. Serum biomarkers have also been suggested as potential markers of these impairments in clinical studies. However, no study has addressed the usefulness of serum biomarkers among pre-frail seniors consulting emergency departments (ED) in order to detect these impairments.Objectives: The purpose of the present study was to explore the association between several serum biomarkers and the frailty status of seniors seen in ED for a minor injury who are at risk of functional decline and 2) assist professionals in clinical decisions while identifying frail seniors in whom interventions should be started in order to prevent potential functional decline. Methods: This cross-sectional study includes 190 seniors retrieved from the larger CETI cohort and discharged home from 4 EDs after treatment of minor injuries. Their frailty status was measured by the Canadian Study of Health & Aging-Clinical Frailty Scale (CSHA-CFS). Then, patients were classified as “Robust” (CHSA-CFS levels 1 and 2) vs. “Pre-frail/Frail” (CHSA-CFS levels ≥3). Biomarkers (Albumin, Creatinine, C-reactive protein (CRP), Vitamin D, Ferritin, Glucose and Insulin-Growth Factor (IGF-1)) were obtained from blood samples. “Normal” vs. “Impaired” (low and/or high) clinical threshold values were used for statistical analyses. Results: The proportion of patients with clinically high creatinine levels (>105 µmol/L for male and >85 µmol/L for female) was higher in Pre-frails/Frails when compared to Robusts (P-value=0.01). Also, regarding IGF-1, we observed that the proportion of patients with lower IGF-1 levels (<50 µg/L) was higher in patients showing Pre-frail/Frail status (P-value=0.01). Finally, a significant correlation was found between frailty status and blood glucose (r=0.22; P-value=0.02) whereas a tendency was noted for CRP level (r=0.14; P-value=0.1). Conclusion: When compared to Robust seniors, Pre-frail/Frail individuals presenting to EDs tend to have physiological dysregulations that may help detect pre-frail status in community-dwellers. Larger prospective studies are needed to specify the usefulness and clinical implications of frailty biomarkers in the continuum of acute elder care.

Introduction/Innovation Concept: In 2014, Eastern Ontario paramedic services, their medical director staff and area community colleges developed an EMS Boot Camp experience to orient Queen’s University and the University of Ottawa emergency medicine residents to the role of paramedics and the challenges they face in the field. Current EMS ride-alongs and didactic classroom sessions were deemed ineffective at adequately preparing residents to provide online medical control. From those early discussions came the creation of a real-world, real-time (RWRT) educational experience. Methods: Specific challenges unique to paramedicine are difficult to communicate to a medical control physician at the other end of a telephone. The goal of this one-day educational experience is for residents to gain insight into the complexity and time sensitive nature of delivering medical care in the field. Residents are immersed as responding paramedics in a day of intense RWRT simulation exercises reflecting the common paramedic logistical challenges to delivering patient care in an uncontrolled and dynamic environment. Curriculum, Tool, or Material: Scenarios, run by paramedic students, are overseen by working paramedics from participating paramedic services. Residents learn proper use of key equipment found on an Ontario ambulance while familiarize themselves with patient care standards and medical directives. Scenarios focus on prehospital-specific clinical care issues; performing dynamic CPR in a moving vehicle, extricating a bariatric patient with limited personnel, large scale multi-casualty triage as well as other time sensitive, high risk procedures requiring online medical control approval (i.e. chest needle thoracostomy). Conclusion: EMS Boot Camp dispels preconceived biases regarding “what it’s really like” to deliver high quality prehospital clinical care. When providing online medical control in the future, the residents will be primed to understand and expect certain challenges that may arise. The educational experience fosters collaboration between prehospital and hospital-based providers. The sessions provide a reproducible, standardized experience for all participants; something that cannot be guaranteed with traditional EMS ride-alongs. Future sessions will evaluate participant satisfaction and self-efficacy with the use of a standard evaluation form including pre/post self-evaluations.

Introduction: Trauma remains the primary cause of death in people under 40 in Québec. Although trauma care has dramatically improved in the last decade, no empirical data on the effectiveness of trauma care in rural Québec are available. This study aims to establish a portrait of trauma and trauma-related mortality in rural versus urban pre-hospital and hospital settings. Methods: Data for all trauma victims treated in the 26 rural hospitals and 32 Level-1 and Level-2 urban trauma centres was obtained from Québec’s trauma registry (2009-2013). Rural hospitals were located in rural small towns (Statistics Canada definition), provided 24/7 physician coverage and admission capabilities. Study population was trauma patients who accessed eligible hospitals. Transferred patients were excluded. Descriptive statistics were used to compare rural with urban trauma case frequency, severity and mortality and descriptive data collected on emergency department (ED) characteristics. Using logistic regression analysis we compared rural to urban in-hospital mortality (pre-admission and during ED stay), adjusting for age, sex, severity (ISS), injury type and mode of transport. Results: Rural hospitals (N=26) received on average 490 000 ED visits per year and urban trauma centres (N=32), 1 550 000. Most rural hospitals had 24/7 coverage and diagnostic equipment e.g. CT scanners (74 %), intensive care units (78 %) and general surgical services (78 %), but little access to other consultants. About 40% of rural hospitals were more than 300 km from a Level-1 or Level-2 trauma centre. Of the 72 699 trauma cases, 4703 (6.5%) were treated in rural and 67 996 (93.5%) in urban hospitals. Rural versus urban case severity was similar: ISS rural: 8.6 (7.1), ISS urban: 7.2 (7.2). Trauma mortality was higher in rural than urban pre-hospital settings: 7.5% vs 2.6%. Reliable pre-hospital times were available for only a third of eligible cases. Rural mortality was significantly higher than urban mortality during ED stays (OR (95% IC): 2.14 (1.61-2.85)) but not after admission (OR (95% IC): 0.87 (0.74-1.02)). Conclusion: Rural hospitals treat equally severe trauma cases as do urban trauma centres but with fewer resources. The higher pre-hospital and in-ED mortality is of grave concern. Longer rural transport times may be a factor. Lack of reliable pre-hospital times precluded further analysis.

Introduction: Patients with mild traumatic brain injury (mTBI) often present to the emergency department (ED). Incorrect diagnosis may delay appropriate treatment and recommendations for these patients, prolonging recovery. Notable proportions of missed mTBI diagnosis have been documented in children and athletes, while diagnosis of mTBI has not been examined in the general adult population. Methods: A prospective cohort study was conducted in one academic (site 1) and two non-academic (sites 2 and 3) EDs in Edmonton, Canada. On-site research assistants enrolled adult (>17 years) patients presenting within 72 hours of the injury event with clinical signs of mTBI and Glasgow comma scale score ≥13. Patient demographics, injury characteristics, and ED flow information were collected by chart review. Physician-administered questionnaires and patient interviews documented the recommendations given by emergency physicians at discharge. Bi-variable comparisons are reported using Pearson’s chi-square tests, Student’s t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Results: Overall, 130/250 enrolled patients were female, and the median age was 35. Proportions of successfully diagnosed mTBI varied significantly across study sites (Site 1: 89%; Site 2: 73%, Site 3: 53%; p>0.001). Patients without a diagnosis were less likely to receive a recommendation to follow-up with their family physician (OR=0.08; 95% CI: 0.03, 0.21) or advice about return to work (OR=0.17; 95% CI: 0.08, 0.04) or physical activity (OR=0.08; 95% CI: 0.04, 0.17). Patients with missed diagnoses had longer ED stays (median=5.0 hours; IQR: 3.8, 7.0) compared with diagnosed mTBI patients (median=3.9 hours; IQR: 3.0, 5.3). In the adjusted model, patients presenting to non-academic centers had reduced likelihood of mTBI diagnosis (Site 2: OR=0.21; 95% CI: 0.08, 0.58; Site 3: OR=0.07; 95% CI: 0.02, 0.24). Conclusion: The diagnostic accuracy of physicians assessing patients presenting with symptoms of mTBIs to these three EDs is suboptimal. The rates of missed diagnosis vary among EDs and were associated with length of ED stay. Closer examination of institutional factors, including diagnosis processes and personnel factors such as physician training, is needed to identify effective strategies to heighten the awareness of mTBI presentations.

Introduction: Patient co-morbidities contribute to survivability from out-of-hospital sudden cardiac arrest. Many studies have been conducted regarding contributing factors to sudden cardiac arrest survival, though very few studies have been published detailing specific analysis of morbid obesity association with return of spontaneous circulation (ROSC) in adults treated by paramedics. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Due to an increasing prevalence of morbid obesity in the United States adult population, a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was initiated in June 2016. As exact body weight is logistically difficult to obtain in the EMS care environment, a paramedic-estimated weight at the time of resuscitation to be 100 kg or greater was deemed representative of “morbid obesity” for this analysis. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT, Physio-Control Corporation, Redmond, WA). ROSC was determined from both paramedic and hospital clinician EMRs reviewed by a paramedic researcher. Results: During the 5 month study period, paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 49/90 (54.4%) with weight <100 kg as estimated by paramedics at the time of resuscitative care achieved at least transient ROSC. Only 17/43 (39.5%) with estimated weight ≥100 kg achieved any ROSC, despite paramedics authorized to perform defibrillations at higher joule energy settings for such weight. The OR for ROSC if <100 kg estimated weight is 1.83 (95% CI 0.87-3.83), though given limited sample size p=0.11. Conclusion: While survival from out-of-hospital sudden cardiac arrest in adults is multi-factorial, the presence of morbid obesity, defined as estimated weight ≥100 kg, trends towards less ROSC. Continued community health efforts to decrease the prevalence of morbid obesity in the adult population may confer improved ability to survive out-of-hospital sudden cardiac arrest.

Introduction: Emergency Medical Services (EMS) care confers distinct impact upon survivability from sudden cardiac arrest. Many studies have been conducted regarding EMS interventions for cardiac arrest, though fewer studies have been published detailing specific analysis of paramedic compliance with standing orders, particularly those involving a novel energy strategy in defibrillation. Methods: Adults in sudden cardiac arrest with resuscitation initiated, including at least one defibrillation, between July 1, 2016 and December 1, 2016 were enrolled. Education on a novel defibrillation strategy, involving weight-based joule settings and double sequential external defibrillation (DSED) was delivered in classroom and internet-accessed settings. Paramedics then performed hands-on practice in DSED. All resuscitations were reviewed from electronic medical records (EMRs) completed by treating paramedics, alongside telemetry and defibrillation events recorded, transmitted, and analyzed in proprietary software (CODE-STAT™, Physio-Control Corporation, Redmond, WA). All ECGs and defibrillation events were reviewed by an emergency physician to determine energy settings used by paramedics for determining the accuracy of compliance with protocol-based standing orders. Results: During the 5 month study period, the paramedics involved treated 133 adults in sudden cardiac arrest involving perceived ventricular fibrillation that was treated with at least one defibrillation. 76/90 (84.4%) with estimated weight <100 kg were treated with correct joule settings, though only 7/43 (16.3%) with estimated weight ≥100kg received all defibrillations at 360J as protocol-specified. 26/44 (59.1%) in refractory ventricular fibrillation, defined as requiring a fourth defibrillation, received DSED as protocol-specified. Conclusion: Paramedics, when specifically trained on a novel defibrillation strategy, involving both weight-based joule settings and use of DSED for refractory ventricular fibrillation, are inconsistently able to quickly and successfully incorporate that strategy in EMS resuscitation care. Further educational endeavours are warranted to achieve higher defibrillation strategy protocol compliance.

Introduction: Included in the first list of recommendations from the Choosing Wisely Canada (CW) Emergency Medicine (EM) group was to avoid ordering lumbosacral radiographs for patients with non-traumatic low back pain (LBP) in the absence of red flags. It has been suggested that these lumbosacral radiographs lead to unnecessary ionizing radiation and increase emergency department (ED) wait times without improving patient outcomes. This study evaluates lumbosacral imaging practices of emergency physicians (EPs) in four urban EDs. Methods: Data was retrospectively collected from patients, ages 18-60 and CTAS codes 2-5, who presented with non-traumatic LBP from April 1, 2014 to March 31, 2016 to four urban EDs. The time frame included both pre- and post-CW recommendation. Patients considered high risk, specifically with PTT >40 s or INR >1.2 s, neurology/neurosurgery/spine consults, admission to hospital, and history of cancer, were excluded. The primary outcome was to establish lumbosacral radiograph usage rates for non-traumatic LBP. The secondary outcome was to identify factors that influenced lumbosacral spine imaging. Factors analyzed included patient age, patient sex, ED wait times, physician age, physician experience, and physician sex. Statistical significance was determined by chi-squared analysis. Results: The data from 3140 low-risk patients showed that 16.5% of the patients received lumbosacral radiographs. Physician variation in X-ray ordering was 0% to 85.7% (IQR 4.6 to 25%). There was a significant difference between the X-rays ordered at each site (site 1 (23.1%)>site 2 (17.2%)>site 3 (14.9%)>site 4 (11.3%), p<0.001). CCFP-EM licensed physicians (17.9%) ordered more X-rays compared to licensed physicians (13.7%, p<0.001). Time of presentation, physician sex, and patient sex did not affect the imaging practices. There was a trend towards decreased ordering of X-rays (17.6% vs. 15.1%, p=0.06) post-CW recommendation. Conclusion: Considerable variation exists in the ordering practices of Calgary EPs; however, on average they are choosing wisely in terms of ordering imaging for non-traumatic LBP.

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.

Introduction: Between June 15 and Aug 31st 2014, Canada’s Northwest Territories (pop 44,000: Stats Can), a subarctic region which is over 2°C warmer than it was in the 1950’s, experienced an unprecedented number of forest fires, with 385 fires and approximately 3.4 million hectares of forest affected. This resulted in one of Canada’s most severe and prolonged urban smoke exposures for the capital city of Yellowknife and surrounding Aboriginal communities. Our objective was to obtain a big-picture sense of the health impact of the Summer of Smoke on the population of these communities through a mixture of quantitative and qualitative analysis. Methods: We analyzed PM2.5 levels, salbutamol dispensations, clinic and hospital cardiorespiratory variables, and in-depth video interviews with community members from Yellowknife, N’Dilo, Dettah and Kakisa. Results: 49% of days June15-Aug31 in 2014 had a PM2.5 over 30 mcg/m3, as compared to 3% in 2012 and 9% in 2013 and 2015. Max daily PM 2.5 in 2014 was 320.4 mcg/m3. There was a 22% increase in outpatient salbutamol dispensations in 2014 compared to the average of 2012, 2013 and 2015. More cough, pneumonia and asthma were seen in clinics compared to 2012-2015 (P<0.001). There was a 42% increase in respiratory ER visits in 2014 compared to 2012-13, but no change in cardiac variables. The respiratory effect was most pronounced in children 0-4 (114% increase in ER visits). Qualitative analysis demonstrates themes of fear, isolation, lack of physical activity, alteration of traditional summertime activities for both aboriginal and non-aboriginal subjects, elements of resilience and expectation for future smoky summers in the context of a changing climate. Conclusion: Prolonged wildfire seasons have a profound effect on overall wellbeing. Responses to help minimize mental and physical impacts such as the creation of clean-air community shelters, recreation programming, initiatives to support community cohesion, and “go outside when it is not smoky” messaging require further study.

Introduction: The first-ever EM postgraduate training program in Ethiopia was launched at Addis Ababa University in 2010. EM faculty from the University of Toronto were invited to design and implement an EM rotation-based curriculum with tri-annual teaching trips to support the overall AAU EM program. To date, three cohorts of EM specialists (n=15) have graduated from the three-year program. After six years of implementation, we undertook a qualitative evaluation of the TAAAC-EM curriculum. Methods: Data collection took place in 2016 in Ethiopia via in-person graduate interviews (n=12). Participants were interviewed by a trained research assistant who used a semi-structured interview guide. Standard interview, transcription and analysis protocols were utilized. Qualitative software (QSR-NVIVO 9) was used for thematic grouping and analysis. Results: Graduates of AAU’s EM residency training program reported very positive experiences with the TAAAC-EM curriculum overall. All graduates acknowledged the positive impact of TAAAC-EM’s emphasis on bedside teaching, a unique component of the TAAAC-EM model compared to traditional teaching methods at AAU. Graduates felt that TAAAC-EM teachers were effective in creating a novel culture of EM at AAU and in role-modeling ethical, evidence-based EM practice. When asked about specific areas for program improvement, the following themes emerged: 1) a desire to shift delivery of the didactic clinical epidemiology curriculum to the senior residency years (PGY2-3) to coincide with completion of a required residency research project; 2) a desire for increased simulation and procedural teaching sessions and 3) the need for more nuanced context specificity in the curriculum delivery to incorporate local guidelines and practice patterns. A lack of educational supports during non-TAAAC-EM visits was also identified as an area for further work. Conclusion: Interviewing graduates of AAU’s EM residency training program proved important for determining areas of curriculum improvement for future trainees. It also provided critical input to TAAAC-EM strategic planning discussions as the partnership considers expanding its scope beyond Addis Ababa.

Introduction/Innovation Concept: Medical simulation is becoming increasingly useful for healthcare education. Simulation-based crisis resource management (CRM) has been shown to produce improvements in skill acquisition, communication and team behaviors. Simulation has become a key component of most Family Practice (FP) residency programs and many programs are moving towards developing formal simulation curriculums. The Coastal FP Residency is a relatively new and unique program with a large emphasis on rural medicine. Graduates have gone on to practice in remote areas with less access to supports for critically ill patients. Therefore, an effective simulation curriculum, focused on Emergency Medicine, is of great importance to this program. Methods: To develop our curriculum, Kern’s framework for medical education was selected given its prior success in similar endeavors. The first step of this approach involves a needs assessment, which we accomplished in the form of an online survey. The questionnaire included pre-defined topics pertaining to the training needs of FP Residents destined for Rural Practice with respect to technical skills, CRM skills, specific medical conditions and categories of medical conditions. Classification of answers included multiple choice, 5-point Likert scales as well as an option for free-text answers. The survey was distributed to pre-identified participants including stakeholders/educators within the Coastal FP residency program as well as simulation education leads for FP residencies throughout British Columbia (BC). Current residents, as well as program graduates were also asked to complete the survey. Curriculum, Tool, or Material: The results of this survey were used to develop formal goals and objectives which were in turn used to write or adapt 24 cases for the curriculum. Cases from categories (e.g. Pediatrics) rated as “Extremely Important” on the Likert scale were included proportionally more in the curriculum. The cases were also designed to assess/practice a higher proportion of CRM elements considered important and to address commonly identified difficulties in resuscitation. Cases were developed, where possible, using local or national guidelines and are currently in the stage of peer review (by a minimum of two peers). Conclusion: The curriculum will be implemented in July 2017 and we will transition towards the evaluation phase. Our goal is to develop and distribute formalized needs assessments to rural FP residencies across BC so that they may develop dynamic, formal curriculums of their own.

Introduction/Innovation Concept: There is a paucity of peer-reviewed works investigating the History of Emergency Medicine (EM) in Canada, and none examining a single centre. This study analyzed the academic and clinical evolution of EM in the City of Ottawa from its origins to present. Methods: The study comprised primary and secondary historical research and an oral history methodology. A literature review was performed on the following databases: PubMed, Medline, EMBASE, JSTOR, Web of Science, Historical Abstracts; five medical history journals were also searched. Data were collected from City of Ottawa Archives, Archives of the Sisters of Charity of Ottawa, The Ottawa Hospital Libraries, University of Ottawa Libraries, RCPSC and CFPC Archives, Historical Society of Ottawa documents, Ottawa newspaper archives, and professional correspondences. The oral history component consisted of formal interviews with seven practicing and retired Emergency Physicians in Ottawa. Ethics approval was not required though consent was obtained from respondents. Curriculum, Tool, or Material: The literature review yielded the following: PubMed: 218 results, 180 excluded for non-relevance, 3 papers included in analysis. Historical Abstracts: 1 result, overlap with PubMed. Other databases and medical history journals yielded no papers. Along with extensive archival data, these results were used to construct a detailed timeline of EM history in Ottawa and Canada more broadly. Residency training in EM in Ottawa was initiated in 1972 at the impetus of the Board of the Ottawa Civic Hospital. Two main themes recurred in the interviews: resistance from existing specialties to EM becoming a specialty, and early Emergency Rooms staffed by the least trained people treating the least differentiated patients. Early EM physicians were not viewed positively by other specialists. Conclusion: Pioneering EM physicians were forced to validate the specialty as distinct, rigorous, and credible. In Ottawa this was achieved by developing strong core academics and research. Nationally, this has been instrumental in establishing EM as a viable standalone academic specialty. Modern consult pushback may have evolved from existing specialists fighting against the creation of EM combined with their negative perception of EM physicians. These data could be incorporated into learning modules for EM residency academic programs, and the methods applied to other centres.