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Background: Trauma care in Nunavik, Quebec, is highly challenging. Geographic distances and delays in transport can translate into precarious patient transfers to tertiary trauma care centres. The objective of this study was to identify predictors of clinical deterioration during transport and eventual intensive care unit (ICU) admission for trauma patients transferred from Nunavik to a tertiary trauma care centre. Methods: This is a retrospective cohort study using the Montreal General Hospital (MGH) trauma registry. All adult trauma patients transferred from Nunavik and admitted to the MGH from 2010 to 2019 were included. Main outcomes of interest were hemodynamic and neurologic deterioration during transport and ICU admission. Results: In total, 704 patients were transferred from Nunavik and admitted to the MGH during the study period. The median age was 33 (interquartile range [IQR] 23-47) years and the median Injury Severity Score was 10 (IQR 5-17). On multiple regression analysis, transport time from site of injury to the MGH (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.06), thoracic injuries (OR 1.75, 95% CI 1.03-2.99), and head and neck injuries (OR 3.76, 95% CI 2.10-6.76) predicted clinical deterioration during transfer. Injury Severity Score (OR 1.04, 95% CI 1.01-1.08), abnormal local Glasgow Coma Scale score (OR 2.57, 95% CI 1.34-4.95), clinical deterioration during transfer (OR 4.22, 95% CI 1.99-8.93), traumatic brain injury (OR 2.44, 95% CI 1.05-5.68), and transfusion requirement at the MGH (OR 4.63, 95% CI 2.35-9.09) were independent predictors of ICU admission. Conclusion: Our study identified several predictors of clinical deterioration during transfer and eventual ICU admission for trauma patients transferred from Nunavik. These factors could be used to refine triage criteria in Nunavik for more timely evacuation and higher level care during transport. Contexte : Au Nunavik, au Québec, la traumatologie est confrontée à un énorme défi. Les distances et les temps de transport peuvent donner lieu à des transferts de cas précaires vers les centres de traumatologie tertiaires. L'objectif de cette étude était de dégager les prédicteurs d'une détérioration de l'état clinique durant le transport et d'une éventuelle admission à l'unité des soins intensifs (USI) pour les cas de traumatologie transférés du Nunavik vers un centre de traumatologie tertiaire. Méthodes : Il s'agit d'une étude de cohorte rétrospective menée à partir du registre de traumatologie de l'Hôpital général de Montréal (HGM). Tous les cas de traumatologie touchant des adultes transférés du Nunavik et admis à l'HGM de 2010 à 2019 ont été inclus. Les principaux paramètres d'intérêt concernaient la détérioration des variables hémodynamiques et neurologiques durant le transport et l'admission à l'USI. Résultats : En tout, 704 cas ont été transférés du Nunavik et admis à l'HGM durant la période de l'étude. L'âge moyen était de 33 (écart interquartile [ÉI] 23-47) ans et l'indice de gravité des blessures (IGB) médian était de 10 (ÉI 5-17). À l'analyse de régression multiple, le temps de transport entre le lieu où la blessure est survenue et l'arrivée à l'HGM (rapport des cotes [RC] 1,04, intervalle de confiance [IC] de 95% 1,01-1,06), les blessures thoraciques (RC 1,75, 95% IC 1,03-2,99), et les blessures à la tête et au cou (RC 3,76, IC de 95% 2,10-6,76) ont été des prédicteurs de la détérioration de l'état clinique durant le transfert. L'IGB (RC 1,04, IC de 95% 1,01-1,08), le score de Glasgow selon l'échelle locale (RC 2,57, IC de 95% 1,34-4,95), la détérioration de l'état clinique durant le transfert (RC 4,22, IC de 95% 1,99-8,93), un traumatisme crânien (RC 2,44, IC de 95% 1,05-5,68), et le recours à des transfusions une fois à l'HGM (RC 4,63, IC de 95% 2,35-9,09) ont été des prédicteurs indépendants d'admission à l'USI. Conclusion : Notre étude a permis de dégager plusieurs prédicteurs de la détérioration de l'état clinique lors du transfert et de l'éventuelle admission à l'USI des cas de traumatologie transférés du Nunavik. Ces facteurs pourraient être utilisés pour affiner les critères de triage au Nunavik, et ainsi accélérer l'évacuation et prodiguer un niveau de soins plus avancés durant le transport., Trauma care in Nunavik involves unique challenges related to the vast and isolated geographic location, in addition to unpredictable meteorologic conditions that create substantial difficulty in transferring injured patients in [...]

Background: Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec. Methods: We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals--the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC)--and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data. Results: Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%). Conclusion: Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing life-saving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives. Contexte : La prestation de soins en traumatologie et en chirurgie dans le Nord du Québec présente plusieurs défis découlant de l'éloignement, de la météo extrême et du transport limité dans la région; l'expansion de la télésanté pourrait aider à surmonter ces obstacles. Nous avons donc évalué la capacité actuelle en chirurgie, en traumatologie et en télémédecine au Nunavik. Méthodes : Des outils d'évaluation validés incluant l'enquête Personnel, Infrastructure, Procedures, Equipment and Supplies, l'indice International Assessment for Capacity for Trauma et l'outil Telemedicine Readiness de la Maryland Health Care Commission ont été utilisés pour évaluer respectivement la capacité en chirurgie, en traumatologie et en télémédecine. Nous avons collaboré avec les responsables locaux pour adapter ces outils au contexte du Nord du Québec. Des données ont été recueillies dans 2 hôpitaux régionaux, le Centre de santé Tulattavik de l'Ungava (CSTU) et le Centre de santé Inuulitsivik (CSI), ainsi que dans 12 centres locaux de services communautaires (CLSC) dans 6 villages le long de la baie d'Hudson et 6 villages le long de la baie d'Ungava. Résultats : La capacité chirurgicale était la plus élevée au CSI (6,76) et la plus faible aux CLSC de la baie d'Ungava (5,52). Les ressources en personnel (0%-0%) et en procédures (13%-33%) étaient les moins disponibles. La capacité traumatologique était la plus élevée au CSI (7,25) et la plus faible aux CLSC de la baie d'Hudson (5,58). L'équipement (90%-100%) et les fournitures (100%-100%) étaient disponibles, mais il n'y avait pas assez de personnel (0%-0%) et de procédures (25%-56%). Le CSTU était le mieux préparé à la télémédecine (67,80%), tandis que les CLSC de la baie d'Ungava l'étaient le moins (51,13%). Les critères de sous-développement en télémédecine incluent le financement, le soutien administratif, l'amélioration de la qualité et les espaces physiques (3 3%-67% dans chaque cas). Conclusion : La capacité en soins actifs au Nunavik semble hétérogène avec de l'équipement et des fournitures disponibles, mais un manque de personnel capable d'effectuer des interventions salvatrices. Afin de combler le besoin de télémédecine, des initiatives axées sur l'amélioration du financement, le soutien administratif, les programmes d'amélioration de la qualité et les espaces physiques sont nécessaires., Quebec is the largest province in Canada, with a land area of 1.35 million square kilometres inhabited by the country's second-largest population, 8.5 million residents. (1,2) The Nunavik region is [...]

Background: In medical education, simulation can be defined as an activity in which an individual demonstrates skills, procedures and critical thinking using interactive mannequins in a setting closely resembling the clinical environment. To our knowledge, the complexity of trauma simulations has not previously been assessed. We aimed to develop an objective trauma simulation complexity score and assess its interrater reliability. Methods: The McGill Simulation Complexity Score (MSCS) was designed to address the need for objective evaluation of the complexity of trauma scenarios. Components of the score reflected the Advanced Trauma Life Support approach to trauma. The score was developed to take into account the severity of trauma injuries and the complexity of their management. We assessed interrater reliability at 5 highfidelity simulation events. Interrater reliability was calculated using the Pearson correl ation coefficient (PCC) and the intraclass correlation coefficient (ICC). Results: The MSCS has 5 categories: airway, breathing, circulation, disability, and extremities or exposure. The scale has 5 levels for each category, from 0 to 4; level increases with complexity, with 0 corresponding to normal or absent. Cases designed to lead to cardiac arrest, regardless of whether or not the trainee has the ability to resuscitate the simulated patient and regardless of the level of each category, are automatically assigned the maximum score. Between 3 and 9 raters used the MSCS to grade the level of complexity of 26 scenarios at the 5 events. The mean MSCS was 10.2 (range 3.0-20.0). Mean PCC and ICC values were both above 0.7 and therefore statistically significant. Conclusion: The MSCS for trauma is an innovative scoring system with high interrater reliability. Contexte : Dans le contexte de la formation medicale, la simulation peut se definir comme une activite au cours de laquelle une personne demontre ses habiletes, pose des gestes et exerce son jugement critique en se servant de mannequins interactifs dans un environnement qui imite de pres la realite clinique. A notre connaissance, la complexite des simulations en traumatologie n'avait encore jamais ete evaluee. Nous avons voulu mettre au point un indice de complexite objectif des simulations en traumatologie et en evaluer la fabilite interevaluateurs. Methodes : L'indice McGill de complexite des simulations (IMCS) a ete concu pour repondre au besoin d'evaluer objectivement la complexite des scenarios en traumatologie. Les elements de l'indice faisaient echo a l'approche dite des soins avances de reanimation traumatologique. L'indice a ete concu de maniere a tenir compte de la gravite des traumatismes et de la complexite de leur prise en charge. Nous avons mesure la fabilite interevaluateurs de 5 evenements simules en haute-fidelite. La fabilite interevaluateurs a ete calculee a l'aide du coefficient de correlation de Pearson (CCP) et du coefficient de correlation intraclasse (CCI). Resultats : L'IMCS compte 5 categories : voies respiratoires, respiration, circulation, incapacite et membres ou exposition. Pour chaque categorie, il y a une echelle a 5 niveaux allant de 0 a 4; le niveau augmente en fonction de la complexite, 0 corres pondant a une situation normale ou a l'absence de probleme. Les scenarios concus pour mener a l'arret cardiaque, independamment de la capacite du stagiaire a proceder a une reanimation sur le mannequin et independamment de chaque categorie, recoivent d'emblee le score maximum. De 3 a 9 evaluateurs ont utilise l'IMCS pour classer le niveau de complexite de 26 scenarios pour les 5 evenements. L'IMCS moyen a ete de 10,2 (ecart 3,0-20,0). Le CCP et le CCI ont tous deux ete superieurs a 0,7 et donc statistiquement significatifs. Conclusion : L'IMCS en traumatologie est un systeme de classification novateur dote d'une grande fabilite interevaluateurs., In medical education, simulations are increasingly being used for clinical skill practice and evaluation. Simulation can be defined as an activity in which an individual demonstrates skills, procedures and critical [...]

Background: Virtual patient simulations are interactive, computer-based cases. We designed scenarios based on the McGill Simulation Complexity Score (MSCS), a previously described objective complexity score. We aimed to establish validity of the MSCS and introduce a novel learning tool in trauma education at our institution. Methods: After design of an easy and difficult patient scenario, we randomized medical students and residents to each perform 1 of the 2 scenarios. We conducted a 2-way analysis of variance of training level (medical student, resident) and scenario complexity (easy, difficult) to assess their effects on virtual time, the number of steps taken in the scenario, beneficial and harmful actions, and the ratio of beneficial over harmful actions. Results: Virtual patient scenarios were successfully designed using the MSCS. Twenty-four medical students and 12 residents participated in the easy scenario (MSCS = 3), and 27 medical students and 12 residents did the difficult scenario (MSCS = 18). Though beneficial actions were similar between students and residents, sudents performed more harmful actions, particularly when the scenario was difficult. One virtual patient died in the easy scenario and 3 died in the diffcult one (all medical students). Performance varied with level of complexity and there was significant interaction between level of training and number of steps, as well as with number of harmful actions. Decreasing performance with increasing level of complexity, as defined by the MSCS, suggests this score can accurately quantify difficulty. Conclusion: We established validity of the MSCS and showed its successful application on virtual patient scenario design. Contexte : Les simulations medicales virtuelles sont des cas interactifs informatises. Nous avons concu des scenarios en utilisant le score de complexite des simulations McGill (SCSM), un score de complexite objectif decrit precedemment. Nous avons voulu confirmer la validite du SCSM et presenter un nouvel outil d'apprentissage en traumatologie pour notre etablissement. Methodes : Apres avoir concu le scenario d'un cas facile et d'un cas difficile, nous avons assigne aleatoirement des etudiants en medecine et des residents a 1 des 2 scenarios pour qu'ils y travaillent. Nous avons procede a une analyse de la variance a 2 facteurs, formation (etudiant en medecine, resident) et complexite des cas (facile, difficile,) pour mesurer leurs effets sur le temps virtuel, le nombre d'etapes franchies dans le scenario, les interventions benefques et nuisibles et le rapport entre les deux. Resultats : Les scenarios de cas virtuels ont ete concus avec succes a l'aide du SCSM. Vingt-quatre etudiants en medecine et 12 residents ont travaille au scenario facile (SCSM = 3), et 27 etudiants en medecine et 12 residents ont travaille au scenario difficile (SCSM = 18). Meme si les interventions benefques etaient similaires entre les etudiants et les residents, les etudiants ont applique plus d'interventions nuisibles que les residents, particulierement lorsque le scenario etait difficile. Un patient virtuel du scenario facile et 3 du scenario difficile sont decedes (etudiants dans tous les cas). Le rendement a varie selon le degre de complexite et on a note un lien significatif entre le niveau de formation et le nombre d'etapes et de mesures nuisibles. Le fait que le rendement ait ete inversement proportionnel a la complexite definie par le SCSM, suggere que ce dernier mesure avec exactitude le degre de complexite. Conclusion : Nous avons confirme la validite du score SCSM et montre son utilite dans la conception de scenarios de cas virtuels., Virtual patient simulations are interactive, computer -based cases through which trainees can navigate by selecting various management options offered to them. As Cook and colleagues illustrated, (1) in a world [...]

Background: Nutritional assessment can be challenging in patients with traumatic brain injury (TBI), and indirect calorimetry may be a more suitable method than predictive equations. We compared the Penn State equation versus the gold standard of indirect calorimetry for the nutritional assessment of patients with TBI, and quantified the difference between nutritional requirements and actual patient intake. Methods: This single-centre, prospective cohort study included patients with moderate (Glasgow Coma Scale score 9-12) and severe (Glasgow Coma Scale score 3-8) TBI admitted to the Montreal General Hospital intensive care unit (ICU) between June 2018 and March 2019. Penn State equation estimates and indirect calorimetry measurements were collected, and actual intake was drawn from medical records. We compared the 2 assessment methods using a Spearman correlation coefficient. Results: Twenty-three patients with TBI (moderate in 7 and severe in 16) were included in the study. Overall, there was a moderate positive correlation between the Penn State equation estimate and indirect calorimetry readings (correlation coefficient 0.457, p = 0.03); however, the correlation was weaker in severe TBI (correlation coefficient 0.174, p = 0.5) than in moderate TBI (correlation coefficient 0.929, p = 0.003). When compared to indirect calorimetry assessment, patients received 5.4% (p = 0.5) of required intake on the first day and 43.9% (p = 0.8) of required daily intake throughout their ICU stay. Conclusion: Patients with moderate or severe TBI in the ICU received less than 50% of their nutritional requirements. The difference between the Penn State equation and indirect calorimetry assessments was most noticeable for patients with severe TBI, which indicates that indirect calorimetry may be a more suitable tool for assessment of nutritional needs in this population. Contexte : L'évaluation nutritionnelle peut être compliquée chez les patients qui ont subi un traumatisme crânien (TC), et dans ce contexte, la méthode appelée calorimétrie indirecte pourrait être mieux adaptée que les équations prédictives. Nous avons comparé l'équation de Penn State à la norme en matière de calorimétrie indirecte pour l'évaluation nutritionnelle de patients victimes d'un TC, et calculé la différence entre les besoins nutritionnels des patients et leur apport nutritionnel réel. Méthodes : Cette étude de cohorte prospective menée dans un seul centre a inclus des patients présentant des TC modérés (score de 9-12 à l'échelle de Glasgow) et graves (score de 3-8 à l'échelle de Glasgow) admis à l'unité des soins intensifs (USI) de l'Hôpital général de Montréal entre juin 2018 et mars 2019. Les estimations de Penn State et les mesures de calorimétrie indirecte ont été recueillies et les apports réels ont été tirés des dossiers médicaux. Nous avons comparé les 2 méthodes d'évaluation au moyen du coefficient de corrélation de Spearman. Résultats : Vingt-trois patients victimes de TC (7 cas modérés et 16 cas graves) ont été inclus dans l'étude. Dans l'ensemble, on a noté une corrélation positive modérée entre les estimations fournies par l'équation de Penn State et les lectures de calorimétrie indirecte (coefficient de corrélation 0,457, p = 0,03); toutefois, la corrélation était plus faible dans les cas de TC graves (coefficient de corrélation 0,174, p = 0,5) que dans les cas modérés (coefficient de corrélation 0,929, p = 0,003). Comparativement aux évaluations de calorimétrie indirecte, les patients ont reçu 5.4% (p = 0,5) de l'apport requis le premier jour, et 43,9% (p = 0,8) de l'apport quotidien requis pendant le reste de leur séjour à l'USI. Conclusion : Les patients victimes de TC modérés ou graves hospitalisés à l'USI ont reçu moins de 50% de l'apport nutritionnel recommandé. La différence entre l'équation de Penn State et les évaluations de calorimétrie indirecte était plus manifeste chez les patients victimes de TC graves, ce qui indique que la calorimétrie indirecte pourrait mieux convenir à l'évaluation des besoins nutritionnels chez cette population., Avast amount of resources are used by patients who are admitted in the intensive care setting, particularly those with a high acuity of illness. Along with continuous monitoring, regular imaging [...]

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology., Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. (1-4) International literature has described the indications, technique and outcomes of 7- to 12-French [...]

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada. Contexte : Les services de chirurgie dans les unites de soins actifs (CSA) et de chirurgie generale dans les services d'urgence (CGSU) doivent fournir rapidement des soins et des interventions a des patients dont les besoins sont parmi les plus complexes. En effet, les patients pris en charge par les services de CSA sont souvent gravement malades et presentent des comorbidites sur fond de faible reserve physiologique. Meme si les services de CSA/CGSU se sont repandus en Amerique du Nord, les taux reels de morbidite postoperatoire demeurent pour une bonne part inconnus. Methodes : Dans cette etude prospective, on a suivi pendant 30 jours ou jusqu'a leur conge, les patients hospitalises pour des interventions chirurgicales dans 8 centres de CSA/CGSU achalandes de divers endroits au Canada. On a egalement tenu compte des readmissions dans les 30 jours. Les parametres pre-, per- et postoperatoires ont ete enregis tres. Une methodologie statistique standard a ete appliquee. Resultats : En tout, 601 patients de CSA/CGSU ont ainsi ete suivis pendant une duree allant jusqu'a 30 jours d'hospitalisation ou de readmission apres leur intervention urgente initiale. Cinquante et un pour cent etaient de sexe feminin et l'age moyen etait de 51 ans. Ces patients etaient nombreux a presenter des comorbidites de nature medicale substantielles (42 %) et une obesite morbide (15 %). La majorite des interventions ont ete minimalement effractives (66 % laparoscopiques). La duree mediane des sejours a ete de 3,3 jours et le taux de readmission precoce (< 30 j) a ete de 6 %. Six pour cent des patients ont ete admis aux soins intensifs. Les taux globaux de complications et de mortalite ont ete respectivement de 34 % et de 2 %. Cholecystite (31 %), appendicite (21 %), obstruction intestinale (18 %), hernie incarceree (12 %), hemorragie digestive (7 %) et infections des tissus mous (7 %) comptent parmi les diagnostics les plus frequents. Les taux de morbidite et de mortalite dans les cas de chirurgies ouvertes ont ete respectivement de 73 % et 5 %. Conclusion : Les interventions de CSA/CGSU non liees a la traumatologie sont associees a un taux de morbidite postoperatoire eleve. Cette etude fournira un ensemble de valeurs de references pour l'etude prospective des complications chez les patients pris en charge par les services de CSA/CGSU et l'amelioration subsequente des soins partout au Canada., It is clear to every surgeon working in acute care surgery (ACS) and emergency general surgery (EGS) that timely and complex surgical care is required to achieve optimal outcomes for [...]

The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in penetrating injuries is an emerging adjunct in the civilian trauma surgeon's toolbox for the management of traumatic hemorrhagic shock. Furthermore, within the Canadian civilian context, little has been reported with regard to its use as an assisted damage-control measure in vascular reconstruction of the lower extremity. We report a case of penetrating gunshot injury of the lower extremity where the preoperative deployment of REBOA had a remarkable positive impact in the resuscitation phase and the intraoperative control of blood loss. A description of the procedure and the advantage gained from REBOA are discussed., Hemorrhage is the leading cause of preventable death in trauma casualties. Early control of hemorrhage in traumatic injuries is paramount to improving the likelihood of survival. (1) Initially, this can [...]

Background: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. Methods: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. Results: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). Conclusion: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity. Contexte : Les services de chirurgie generale d'urgence (CGU) gagnent en popularite au Canada en tant qu'approches systemiques aux urgences chirurgicales. Malgre le volume eleve, le caractere urgent et la complexite des populations de patients desservies en CGU, peu de rapports ont porte sur la structure, les processus, les clienteles ou les resultats de ces services. La presente etude instaure une demarche de surveillance nationale qui servira a definir et a ameliorer la qualite des chirurgies destinees a cette population importante et heterogene. Methodes : Une etude transversale nationale sur les services de CGU a ete realisee sur une periode de 24 heures en janvier 2017 dans 14 hopitaux de 7 provinces canadiennes recrutes par l'entremise du comite pour les soins aigus de l'Association canadienne des chirurgiens generaux. On y a inclus les patients admis dans les services de CGU, les nouvelles consultations et les patients de l'exterieur suivis par les services de CGU pendant la periode de l'etude. On a recueilli les caracteristiques demogra phiques des patients et les donnees sur les interventions, les procedures et les complications. Resultats : Douze sites ont fait etat de la couverture assuree par les residents. La plupart des services ont exclu la traumatologie. Dix sites disposaient de temps protege au bloc operatoire. En tout, 393 rencontres avec des patients ont eu lieu pendant la periode de l'etude (195/386 [50,4 %] chirurgicales, 191/386 [49,5 %] non chirurgicales), avec une moyenne de 3,8 chirurgies par service. La population regroupait des cas complexes : 136 patients (34,6 %) presentaient plus de 3 comorbidites. La clientele etait diversifiee et comprenait des cas de maladie de la vesicule biliaire (69 cas [17,8 %]) et de l'appendice (31 [8,0 %]), de meme que des situations d'urgence delicates, telle qu'obstruction (56 [14,5 %]) et perforation (23 [5,9 %]). Conclusion : Leurs caracteristiques et leurs clienteles sont heterogenes, mais les services de CGU sont tous achalandes et ils offrent tous des soins chirurgicaux et non chirurgicaux complets a des patients gravement malades porteurs d'importantes comorbidites., General surgical emergencies are common. They may account for 25%-50% of a general surgeon's overall workload and 7% of all hospital admissions. (1,2) In 2006, the Institute of Medicine declared [...]

Background: Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative [...]

OBJECTIVE: The purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming. METHODS: Using a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1-3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated. RESULTS: A total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47-52 vs. 44%, 95% CI 42-45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52). CONCLUSIONS: Although above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders. KEY WORDS: Head protective devices; prevalence; brain injuries; prevention & control OBJECTIF : Decrire le port du casque de cycliste chez les cyclistes montrealais en vue d'instaurer des programmes de prevention des blessures. METHODE : A la faveur d'une etude transversale, nous avons observe les cyclistes sur des periodes de 60 minutes a 22 endroits sur l'Tle de Montreal. Il y a eu de 1 a 3 periodes d'observation a chaque endroit. Les observations ont eu lieu entre le 16 aout et le 31 octobre 2011. Nous avons utilise des methodes statistiques types et calcule les rapports de cotes ajustes et non ajustes et les intervalles de confiance de 95%. RESULTATS : Nous avons observe 4 789 cyclistes en tout. La proportion observee de cyclistes portant le casque etait de 46% globalement (IC de 95% : 44-47). Cette proportion etait plus elevee chez les femmes (50%, IC de 95% : 47-52) que chez les hommes (44%, IC de 95% : 42-45). Les jeunes etaient proportionnellement les plus nombreux a porter un casque (73%, IC de 95% : 64-81), tandis que les jeunes adultes etaient proportionnellement les moins nombreux a le faire (34%, IC de 95% : 30-37). Le port du casque observe chez les cyclistes membres de minorites visibles etait de 29% (IC de 95% : 25-34), contre 47% chez les cyclistes blancs (IC de 95% : 46-49). Les utilisateurs du BIXI (velo en libre-service) ont ete observes en train de porter un casque 12% du temps (IC de 95% : 10-15), contre 51% du temps chez les cyclistes ayant leur propre velo (IC de 95% : 49-52). CONCLUSIONS : Bien qu'il soit superieur a la moyenne nationale, le port du casque de cycliste a Montreal est encore tres faible, car la majorite des cyclistes n'en porte pas. Les programmes de prevention des blessures pourraient cibler tous les cyclistes, mais il serait justifie d'accorder une attention particuliere a certains groupes : les jeunes hommes, les minorites visibles, les utilisateurs du BIXI et les cyclistes dans les zones touristiques. Par ailleurs, une collaboration avec le systeme de velos en libre-service BIXI Montreal[MC] en vue d'assurer la disponibilite de casques de cyclistes pour les usagers du BIXI pourrait etre fructueuse. MOTS CLES : dispositifs de protection de la tete; prevalence; lesions cerebrales; prevention et controle, The city of Montreal has recently been encouraging bicycle use as an alternative mode of transportation by expanding the bike path network, implementing urban bicycle paths, increasing bicycle parking spaces, [...]

Background: With various types of complex patients being treated in a mixed medical-surgical-trauma intensive care unit (ICU), we hypothesized that there should be no difference in patient mortality with respect to the core training of the intensivist. Methods: We reviewed the cases of all patients admitted to a mixed medicalsurgical-trauma ICU at a Canadian university teaching hospital in 2007. Patients were assigned to 1 of 2 treatment groups (internal medicine, surgery/anesthesiology) based on the treating intensivist's training. Our primary outcome was to compare patient mortality in the ICU between the groups. We used generalized estimating equations to determine 10-day mortality after admission to the ICU. A multivariate Cox hazard model was used to determine statistical significance and 95% confidence intervals (CIs) for 11- to 60-day mortality in the ICU. Results: A total of 961 patients were admitted from January to December, 2007. We found no significant difference between the groups in 10-day mortality (odds ratio 0.73, 95% CI 0.46-1.18, p = 0.20) and 11- to 60-day mortality (hazard ratio 1.43, 95% CI 0.62-3.30, p = 0.40) after admission to the ICU. Conclusion: In a large university trauma centre that operates a mixed medicine-surgical-trauma ICU, there was no significant difference in mortality between patients managed by intensivists with core training in internal medicine and those managed by intensivists with training in surgery/anesthesiology. Contexte: Compte tenu de la variete de cas complexes traites dans les unites de soins intensifs (USI) mixtes de medecine-chirurgie-traumatologie, nous avons emis l'hypothese selon laquelle il ne devrait y avoir aucune difference en ce qui concerne la mortalite chez les patients selon la formation de base de l'intensiviste. Methodes: Nous avons passe en revue les dossiers de tous les patients admis dans l'USI mixte de medecine-chirurgie-traumatologie d'un centre hospitalier universitaire canadien en 2007. Les patients ont ete assignes a l'un de 2 groupes (medecine interne ou chirurgie/anesthesie) selon la formation de l'intensiviste traitant. Notre parametre principal visait a comparer la mortalite des patients des USI selon leur groupe. Nous avons utilise des equations d'estimation generalisees pour determiner la mortalite a 10 jours suivant l'admission a l'USI. Et nous avons utilise un modele de risque multivarie de Cox pour determiner la portee statistique et les intervalles de confiance (IC) de 95% en ce qui concerne la mortalite dans les 11 a 60 jours d'hospitalisation a l'USI. Resultats: En tout, 961 patients ont ete admis entre janvier et decembre 2007. Nous n'avons observe aucune difference significative entre les 2 groupes pour ce qui est de la mortalite a 10 jours (rapport des cotes 0,73, IC de 95% 0,46-1,18, p = 0,20) et de la mortalite dans les 11 a 60 jours (rapport des risques 1,43, IC de 95% 0,62-3,30, p = 0,40) suivant l'admission a l'USI. Conclusion: Dans un important centre universitaire de traumatologie dote d'une USI mixte medecine-chirurgie-traumatologie, on n'a note aucune difference significative quant a la mortalite entre les patients soignes par des intensivistes ayant une formation de base en medecine interne et les patients soignes par des intensivistes ayant une formation de base en chirurgie/anesthesie., The organization of critical care delivery varies substantially among hospitals and sometimes within the same hospital. Different organizational models include closed, high-intensity staffing units and open units. Critical care is [...]

Background: Ongoing gastrointestinal bleeding (GIB) following endoscopic therapy and deciding between mesenteric angiography and surgery often challenge surgeons. We sought to identify predictors of positive angiographic study (active contrast medium extravasation) and characterize outcomes of embolization for acute GIB. Methods: We retrospectively analyzed angiographies for GIB at 2 teaching hospitals from January 2005 to December 2008. The [chi square], Wilcoxon rank sum and t tests determined significance. A Cox proportional hazards model was used for multivariate analyses. Results: Eighteen of 83 (22%) patients had active extravasation on initial angiography and 25 (30%) were embolized. Patients with active extravasation had more packed red blood cell (PRBC; 5.3 v. 2.8 units, p < 0.001) and fresh frozen plasma (4.8 v. 1.7 units, p = 0.005) transfusions 24 hours preangiography and were more likely to be hemodynamically unstable at the time of the procedure (67% v. 28%, p = 0.001) than patients without active extravasation. Each unit of PRBC transfused increased the risk of a positive study by 30% (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6 per unit). Embolization did not decrease recurrent bleeding (53% v. 52%) or length of stay in hospital (28.1 v. 27.5 d, p = 0.95), but was associated with a trend toward fewer emergency surgical interventions (13% v. 26%, p = 0.31) and greater 30-day mortality (33% v. 7%, p = 0.006) than nonembolization. Blind embolization was performed in 10 of 83 (12%) patients and was found to be an independent predictor of death in patients without active extravasation (HR 9.2, 95% CI 1.5-55.9). Conclusion: The number of PRBC units transfused correlates with greater likelihood of a positive study. There was a significant increase in mortality in patients who underwent angioembolization. Large prospective studies are needed to further characterize the indications for angiography and blind embolization. Contexte: En presence d'un saignement gastro-intestinal persistant apres un traitement endoscopique, les chirurgiens hesitent souvent entre l'angiographie mesenterique et la chirurgie. Nous avons voulu degager les predicteurs d'un examen angiographique positif (extravasation active de l'agent de contraste) et caracteriser les resultats de l'embolisation pour saignement gastro-intestinal aigu. Methodes: Nous avons effectue une analyse retrospective des angiographies pour saignement gastro-intestinal dans 2 hopitaux d'enseignement entre janvier 2005 et decembre 2008. Le [ji al cuadrado], le test de Wilcoxon et le test t ont permis d'en etablir la portee. Nous avons utilise un modele de risques proportionnels de Cox pour les analyses multivariees. Resultats: Dix-huit patients sur 83 (22 %) presentaient une extravasation active lors de l'angiographie initiale et 25 (30 %) ont subi un traitement d'embolisation. Les patients qui presentaient une extravasation active ont recu plus de culots globulaires (5,3 unites c. 2,8,p < 0,001) et de plasma frais congele (4,8 unites contre 1,7,p = 0,005) 24 heures avant l'angiographie et etaient plus susceptibles d'etre stables au plan hemodynamique au moment de l'intervention, comparativement aux patients ne presentant pas d'extravasation active (67 % c. 28 %, p = 0,001). Chaque unite de culot globulaire transfuse a fait augmenter de 30 % le risque que les resultats de l'examen soient positifs (risque relatif [RR] 1,3, intervalle de confiance [IC] a 95 % 1,2-1,6 par unite). L'embolisation n'a pas reduit la recurrence des saignements (53 % c. 52 %) ni la duree du sejour hospitalier (28,1 j c. 27,5 j, p = 0,95), mais a ete associee a une tendance a moins d'interventions urgentes (13 % c. 26 %, p = 0,31) et a une mortalite a 30 jours plus elevee que la non-embolisation (33 % c. 7 %, p = 0,006). L'embolisation a l'aveugle a ete realisee chez 10 patients sur 83 (12 %) et s'est revelee etre un predicteur independant de mortalite en l'absence d'extravasation active (RR 9,2, IC a 95 % 1,5-55,9). Conclusion: Le nombre d'unites de culots globulaires transfuses est en correlation avec une probabilite plus grande de resultats positifs a l'examen. On a note une augmentation significative de la mortalite chez les patients qui ont subi une angioembolisation. Il faudra proceder a des etudes prospectives de plus grande envergure pour completer la caracterisation des indications de l'angiographie et de l'embolisation a l'aveugle., Acute gastrointestinal bleeding (GIB) is a common clinical problem that accounts for up to 2% of hospital admissions. (1) Upper GIB (UGIB), defined as proximal to the ligament of Treitz, [...]

Background: A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. Methods: This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. Results: There were 32 patients in the preservice group and 54 patients in the postservice group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%,p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. Conclusion: Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve. Contexte : On a cree en 2005 une equipe multidisciplinaire de tracheostomie chargee de suivre jusqu'a leur conge d'hopital les patients en etat critique qui avaient subi une tracheostomie. Constituee d'un chirurgien, d'un resident en chirurgie, d'un therapeute respiratoire, d'un orthophoniste et d'une infirmiere clinicienne specialisee, l'equipe se reunit 2 fois par semaine pour visiter des patients qui sont passes des soins intensifs aux services de medecine et de chirurgie. Nous voulions evaluer l'effet de cette equipe multidisciplinaire sur la reduction du diametre des canules et le temps ecoule jusqu'a la decanulation, sur l'incidence de la mise en place de membranes vocales et sur l'incidence de complications reliees a la tracheostomie dans le service. Methodes : Cette etude qui s'est deroulee dans le centre de traumatologie de niveau 1 et de soins tertiaires d'un hopital universitaire a porte sur tous les patients qui ont subi une tracheostomie au moment de leur admission aux soins intensifs du 1 janvier au 31 decembre 2004 (groupe avant le service) et du 1 janvier au 31 decembre 2006 (groupe apres le service). Nous avons compare l'evolution de l'etat de sante des patients qui ont du subir une tracheostomie pendant 12 mois apres la creation de l'equipe a celle de l'etat de sante des patients pendant une periode semblable avant la creation de l'equipe. Resultats : Il y avait 32 patients dans le groupe anterieur a la creation de l'equipe et 54 patients dans le groupe posterieur a la creation de l'equipe. Dans le contexte du nouveau service de tracheostomie, on a constate une diminution de l'incidence du blocage de la canule (5,5 % c. 25,0 %, p = 0,016) et des appels pour cause de detresse respiratoire (16,7 % c. 37,5 %, p = 0,039) dans les services. Un pourcentage beaucoup plus important de patients ont aussi recu des membranes vocales (67,4 % c. 19,4 %, p< 0,001) apres la creation de l'equipe. De plus, les periodes ecoulees avant la premiere reduction du diametre de la canule (26,0 a 9,4 d) et le temps ecoule jusqu'a la decanulation (50,4 a 28,4 j) ont semble diminuer, meme si les chiffres n'ont pas atteint la signification statistique a cause de la petite taille de l'echantillon. Conclusion : La prestation de soins normalises par une equipe multidisciplinaire specialisee en tracheostomie a ete associee a une reduction du nombre de complications reliees a la tracheostomie ainsi qu'a une augmentation de l'utilisation d'une membrane vocale., Tracheostomy is a common procedure in the intensive care unit (ICU) and is being performed with increasing frequency in critically ill patients. (1) This trend is partly owing to the [...]

In recent years, there has been an important shift in the practice of global surgery. The traditional paradigm, which once consisted in large part of service-provision missions involving temporary transfers [...]

With surgical conditions being significant contributors to the global burden of disease, efforts aimed at increasing future practitioners' understanding, interest and participation in global surgery must be expanded. Unfortunately, despite the increasing popularity of global health among medical students, possibilities for exposure and involvement during medical school remain limited. By evaluating student participation in the 2011 Bethune Round Table, we explored the role that global surgery conferences can play in enhancing this neglected component of undergraduate medical education. Study results indicate high rates of student dissatisfaction with current global health teaching and opportunities, along with high indices of conference satisfaction and knowledge gain, suggesting that global health conferences can serve as important adjuncts to undergraduate medical education., Despite the substantial contribution of surgical conditions to the global burden of disease, the field of global surgery remains severely under-resourced, especially when compared with the well-staffed and well-funded campaigns [...]