Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study.

ABSTRACT: Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital's general ED. Mean ED-LOS was 4.12 ±â€Š3.18 hours. Mean treatment time and decision time were 1.79 ±â€Š1.82 hours, 2.84 ±â€Š2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14-0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43-0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.

The Impact of Suspension of Dermatology On-Call Services.

BACKGROUND: Dermatological conditions are commonly seen in the emergency department and inpatient wards. The ability to access dermatology on-call services improves the accuracy of diagnosis and management of common and sometimes life-threatening conditions. Limitations of dermatologist availability led to the suspension of the dermatology on-call service for 3 months in Ottawa, Canada. OBJECTIVES: Our objective was to assess the impact of this call suspension on patient care and the need for a dermatology on-call service at our hospital, as perceived by nondermatologist physicians at our center. METHODS: A survey was sent to all departments at The Ottawa Hospital, addressed to staff physicians and residents. Participation was entirely voluntary. Descriptive statistics were used to analyze survey responses. RESULTS: A total of 105 physicians completed the survey including staff physicians (85%) and resident trainees (15%). The most represented specialties were emergency medicine (N = 21), general internal medicine (N = 19), nephrology (N = 17), neurology (N = 13), and plastic surgery (N = 13). Over half of the respondents felt that the lack of dermatology on-call service impacted the care of their patients by a moderate or great extent. Over half reported performing dermatology-related clinical work during the call suspension and two-thirds of these individuals reported feeling uncomfortable or very uncomfortable doing so. Most (94%) participants felt that an on-call dermatology service was useful and 57% deemed it essential. CONCLUSION: Our survey results demonstrate a significant impact of the suspension of a dermatology on-call service, as perceived by nondermatologist physicians. Hospitals need to recognize the importance of on-call dermatology consultations and provide support for divisions to enable this service to continue.

The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians.

BACKGROUND: Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE: To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS: A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS: Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS: In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.

Perfil dos atendimentos realizados pelo Serviço de Atendimento Móvel de Urgência no município de Colombo (PR) / Profile of care provided by the Mobile Emergency Care service of the city of Colombo-PR

Objetivo: Descrever o perfil dos atendimentos realizados pelo Serviço de Atendimento Móvel de Urgência (SAMU) do município de Colombo (PR). Método: Estudo descritivo de abordagem quantitativa, utilizando as informações contidas nas fichas de atendimentos do SAMU do município de Colombo (PR) para a coleta dos dados no período de dezembro de 2016 a agosto de 2017. Resultados: Foram analisados 2.784 fichas e os resultados mostram predominância do sexo masculino com 1.441 (51,76%), faixa etária de 19-59 anos com 1.531 (54,99%), ocorrências de perfil clínico com 1.715 (61,60%) e, tendo como destino final a UPA do município 1.377 casos (63,75%). Conclusões: O estudo contribui na quantificação de informações de atendimento do SAMU realizados no município de Colombo, a fim de qualificar a organização das demandas de atendimento pela rede de Urgência e Emergência no município

Epidemiología del trauma maxilofacial, tratado quirúrgicamente en el Hospital de Urgencia Asistencia Pública: 3 años de revisión / Epidemiology of maxillofacial trauma, surgically treated in the Emergency Hospital Public Assistance: 3 years of revision

Resumen Introducción: El trauma maxilofacial (TMF) constituye un problema de relevancia en los centros hospitalarios de alta complejidad. Objetivo: Evidenciar y actualizar la epidemiología del trauma maxilofacial de resolución quirúrgica bajo anestesia general, en pabellón central tratado en el Hospital de Urgencia Asistencia Pública durante el período comprendido entre diciembre de 2014 a diciembre de 2017 y compararla con la realidad epidemiológica de otros centros hospitalarios de alta complejidad en Chile y en el extranjero. Materiales y Método: Se realizó un estudio retrospectivo en el que se analizaron los protocolos operatorios de los pacientes intervenidos quirúrgicamente por trauma maxilofacial, en pabellón central, bajo anestesia general, en un período de 37 meses. Las variables analizadas fueron diagnóstico, edad, género, tercio facial y zona anatómica afectada. Resultados: Se realizaron 127 procedimientos quirúrgicos, para resolver 259 fracturas. La edad promedio de los pacientes intervenidos fue de 33 años, con predominio del género masculino (85,8%); el tercio inferior fue el más afectado (77,2%), específicamente en la zona parasinfisiaria mandibular (22,4%). Discusión: Los resultados expuestos concuerdan con estudios realizados internacionalmente, pero tiene discordancia en relación a la zona anatómica más afectada al comparalo con los otros centros que analizaron su epidemiología. Conclusión: Resulta necesario continuar la investigación epidemiológica de estas patologías y unificar criterios de diagnóstico y tratamiento para poder establecer políticas de prevención y tratamiento eficientes en relación a cada servicio y en conjunto a nivel de salud pública.

Introduction: Maxillofacial trauma (MFT) is a relevant problem in highly complex hospital centers. Aim: To show and update the epidemiology of the maxillofacial trauma of surgical resolution under general anesthesia, in a major operating room, treated in the Emergency Hospital Public Assistance during the period from December 2014 to December 2017 and to compare it with the epidemiological reality of other high complexity hospital centers in Chile and abroad. Materials and Method: A retrospective study was carried out and the surgical protocols of the patients operated for maxillofacial trauma, in a major operating room, under general anesthesia, in a period of 37 months, were analyzed. The variables considered were diagnosis, age, gender, facial third and affected anatomic area. Results: 127 surgical procedures were performed, for the resolution of 259 fractures. The average age of the operated patients was 33 years, with predominance of the male gender (85.8%), the lower third was the most affected (77.2%), specifically in the parasymphysis area (22.4%). Discussion: The exposed results agree with studies carried out internationally, but it has discordance in relation to the most affected anatomical area at national level comparing it with the other hospitals that analyzed its epidemiology. Conclusion: It is necessary to continue the epidemiological investigation of these pathologies and to unify diagnostic and treatment criteria in order to establish efficient prevention and treatment policies in relation to each service and jointly at the level of public health.

Development of an Outpatient Palliative Care Protocol to Monitor Fidelity in the Emergency Medicine Palliative Care Access Trial.

Introduction: Palliative care is recommended for patients with life-limiting illnesses; however, there are few standardized protocols for outpatient palliative care visits. To address the paucity of data, this article aims to: (1) describe the elements of outpatient palliative care that are generalizable across clinical sites; (2) achieve consensus about standardized instruments used to assess domains within outpatient palliative care; and (3) develop a protocol and intervention checklist for palliative care clinicians to document outpatient visit elements that might not normally be recorded in the electronic heath record. Methods: As part of a randomized control trial of nurse-led telephonic case management versus specialty, outpatient palliative care in older adults with serious life-limiting illnesses in the Emergency Department, we assessed the structural characteristics of outpatient care clinics across nine participating health care systems. In addition, direct observation of outpatient palliative care visits, consultation from content experts, and survey data were used to develop an outpatient palliative care protocol and intervention checklist. Implementation: The protocol and checklist are being used to document the contents of each outpatient palliative care visit conducted as a part of the Emergency Medicine Palliative Care Access (EMPallA) trial. Variation across palliative care team staffing, clinic session capacity, and physical clinic model presents a challenge to standardizing the delivery of outpatient palliative care.

Ophthalmology training and competency levels in care of patients with ophthalmic complaints in United States internal medicine, emergency medicine and family medicine residents.

PURPOSE: To evaluate ophthalmic educational training and confidence levels in care of patients with ophthalmic complaints in internal, emergency, and family medicine residencies in the United States. METHODS: A 41-item cross-sectional survey was sent to 529 internal medicine, 237 emergency medicine and 629 family medicine Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program directors. The survey included the number of ophthalmic education hours residents received during their respective training programs. Respondents were asked to rate their confidence levels in performing an ophthalmic exam and treating patients with ocular conditions using a 5-point Likert scale ranging from "not-confident" to "very confident". RESULTS: In total 92.5% of internal medicine, 66.8% emergency medicine and 74.5% family medicine residents received less than 10 hours of ophthalmic education during their residencies. A majority of respondents (59.1% internal medicine, 76.0% emergency medicine, and 65.7% family medicine) reported that patients with ocular complaints constitute 1-5% of visits. Mean confidence levels in performing an eye exam and treating patients with ophthalmic conditions was highest in emergency medicine residency programs 2.9 (SD 0.7), followed by family medicine 2.3 (SD 0.6) and internal medicine 2.2 (SD 0.6). Reported higher number of ophthalmic education hour's received in residency was associated with greater confidence levels in emergency (P<0.001), family (P<0.001), and internal (P=0.005) medicine programs. CONCLUSION: Internal, emergency ,and family medicine residents receive limited ophthalmic education and is reflected in the overall low confidence levels in performing an ophthalmic exam and treating patients with ocular complaints. An increase in ophthalmic educational hours during their respective residencies is recommended to improve upon this knowledge gap.

Epidemiology of otorhinolaryngologic emergencies in a secondary hospital: analysis of 64,054 cases.

PURPOSE: To determine the incidence and distribution of care in relation to urgent otorhinolaryngologic pathologies by the different medical specialist units. METHODS: A descriptive, observational and retrospective study was conducted of patients seen by the Emergency Service at a secondary hospital over the course of 7 years (2011-2017). RESULTS: A total of 546,701 patients were seen during the period in question, of which 64,054 presented with otorhinolaryngologic symptoms. The attendance rate was 450/1000 inhabitants/year. The most frequent diagnoses were upper respiratory tract infection, with 13,639 cases (21.3%), tonsillopharyngitis, with 10,150 cases (15.8%) and vertigo/dizziness with 8761 cases (13.7%). Patients seen by the Hospital Emergency Service physicians and those referred to the Otorhinolaryngology or Paediatric Units were analysed both together and separately. The Hospital Emergency Service dealt with 77.1% of the cases, and referred 15.4% to the Otorhinolaryngology Unit and 7.5% to the Paediatrics Unit. Within the subgroup of patients referred to the Otorhinolaryngology Unit, the most frequent diagnoses were problems related to inflammatory ear disease (25.6%), followed by cervicofacial trauma (15.4%) and bleeding with otorhinolaryngologic symptoms (12.5%). The percentage of hospital admissions for the entire sample was 3%, while for patients referred to the Otorhinolaryngology Unit this figure was 6.8%. CONCLUSIONS: A large percentage of patients presenting at the Hospital Emergency Service do so with otorhinolaryngologic symptoms, and the vast majority are treated effectively by the physicians in that service and are referred to the specialist services on the basis of sound criteria.

Surgical Procedures Performed by Emergency Medical Teams in Sudden-Onset Disasters: A Systematic Review.

BACKGROUND: Emergency medical teams (EMTs) frequently provide surgical care after sudden-onset disasters (SODs) in low- and middle-income countries. The purpose of this review is to describe the types of surgical procedures performed by EMTs with general surgical capability in order to aid the recruitment and training of surgeons for these teams. METHODS: A search of electronic databases (PubMed, MEDLINE, and EMBASE) was carried out to identify articles published between 1990 and 2018 that describe the type of surgical procedures performed by EMTs in the impact and post-impact phases of a SOD. Further relevant articles were obtained by hand searching reference lists. RESULTS: A total of 16 articles met the inclusion criteria. Articles reporting on EMTs from a number of different countries and responding to a variety of SODs were included. There was a high prevalence of procedures for extremity soft tissue injuries (46.8%) and fractures (28.3%), although a number of abdominal and genitourinary/obstetric procedures were also reported. CONCLUSIONS: Based upon this review, deployment of surgeons or teams with experience in the management of soft tissue wounds, orthopaedic trauma, abdominal surgery, and obstetrics is recommended.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study.

BACKGROUND: Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions. METHODS: From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED. RESULTS: Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%). CONCLUSIONS: Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

How Much Time Do Residents Spend on Inpatient Clinical Computing?

OBJECTIVE: To evaluate the time that residents spend on clinical computing. METHODS: Our electronic health record system was used to record clinical computing time. Residents were unaware that we were tracking their time. Prior studies have reported computing times by watching the users. We evaluated residents in internal medicine, general surgery, and emergency medicine. The postgraduate year 1 (PGY1) and PGY3 residents were evaluated in July 2016 and January 2017. RESULTS: Emergency medicine residents spent approximately 3 hours/day and internal medicine and general surgery residents spent approximately 2 hours/day on clinical computing. For internal medicine and general surgery, there was a decrease in time spent on clinical computing from July to January and from PGY1 to PGY3. CONCLUSIONS: Residents in some specialties may decrease the time spent on clinical computing. There are many possible reasons for the changes. Our study serves as a computerized observation baseline for future assessments, interventions, and for developing improvements that increase the value of clinical computing.

Satisfaction of Emergency Physicians with the Care Provided to Patients with Cardiovascular Diseases in the Northern Region of Minas Gerais / Satisfação de Médicos dos Serviços de Urgência com o Cuidado às Doenças Cardiovasculares na Região Ampliada Norte de Minas Gerais

Abstract Background: The dissatisfaction of health professionals in emergency services has a negative influence on both the quality of care provided for acute myocardial infarction (AMI) patients and the retention of those professionals. Objective: To assess physicians' satisfaction with the structure of care and diagnosis at the emergency services in the Northern Region of Minas Gerais before the implementation of the AMI system of care. Methods: This cross-sectional study included physicians from the emergency units of the ambulance service (SAMU) and level II, III and IV regional hospitals. Satisfaction was assessed by using the CARDIOSATIS-Team scale. The median score for each item, the overall scale and the domains were calculated and then compared by groups using the non-parametric Mann-Whitney test. Correlation between time since graduation and satisfaction level was assessed using Spearman correlation. A p value < 0.05 was considered significant. Results: Of the 137 physicians included in the study, 46% worked at SAMU. Most of the interviewees showed overall dissatisfaction with the structure of care, and the median score for the overall scale was 2.0 [interquartile range (IQR) 2.0-4.0]. Most SAMU physicians expressed their dissatisfaction with the care provided (54%), the structure for managing cardiovascular diseases (52%), and the technology available for diagnosis (54%). The evaluation of the overall satisfaction evidenced that the dissatisfaction of SAMU physicians was lower when compared to that of hospital emergency physicians. Level III/IV hospital physicians expressed greater overall satisfaction when compared to level II hospital physicians. Conclusion: This study showed the overall dissatisfaction of the emergency physicians in the region assessed with the structure of care for cardiovascular emergencies.

Resumo Fundamentos: A insatisfação dos profissionais de saúde dos serviços de urgência tem influência negativa na qualidade do cuidado ao infarto agudo do miocárdio (IAM) e na fixação desses profissionais. Objetivo: Avaliar a satisfação de médicos com a estrutura de atendimento e diagnóstico de serviços públicos de urgência na Região Ampliada Norte de Minas Gerais, previamente à implantação da linha de cuidado ao IAM. Métodos: Estudo transversal, que incluiu médicos das unidades de emergência do SAMU e de hospitais regionais nível II, III e IV. Foi avaliada a satisfação usando a escala CARDIOSATIS-Team. O escore mediano para cada item, a escala global e os domínios foram calculados e então comparados por grupos, utilizando o teste não paramétrico de Mann-Whitney. Foi avaliada a correlação entre tempo de formação e nível de satisfação com o método de Spearman. Um valor-p < 0,05 foi considerado significativo. Resultados: De 137 médicos incluídos, 46% trabalhavam no SAMU. A maior parte dos entrevistados demonstrou insatisfação geral com a estrutura de atendimento, cuja mediana da escala global foi 2,0 (intervalo interquartil [IQ] 2,0-4,0). A maioria dos médicos do SAMU demonstrou-se insatisfeita quanto a atendimento prestado (54%), estrutura para condução das doenças cardiovasculares (52%) e tecnologia disponível para diagnóstico (54%). Na avaliação da satisfação global, evidenciou-se que a insatisfação dos médicos do SAMU foi menor quando comparada à dos médicos de urgência hospitalar. Os médicos de hospitais nível III/IV demonstraram maior satisfação global quando comparados aos de hospitais nível II. Conclusão: Este estudo demonstrou insatisfação geral dos médicos dos serviços de urgência na região em relação à estrutura de atendimento às emergências cardiovasculares.

Acidentes de transporte terrestre entre crianças, adolescentes e jovens: estudo epidemiológico / Transporte de accidente entre los niños, adolescentes y young: estudio epidemiológicos / Transportation accidents among children, adolescents and young people: epidemiological study

Objetivo: analisar acidentes de trânsito ocorridos com pessoas na faixa etária de 0 a 24 anos, atendidas no Pronto Socorro Municipal de Cuiabá em 2013. Método: Estudo transversal com dados capturados por meio de um formulário fechado. A análise dos dados foi feita por meio do Epi Info. Resultados: Dos 2.122 atendimentos, 67,9% foram do sexo masculino, com idade entre 15 e 24 anos (82,1%), e 49,7% ocorreram nos finais de semana, sendo que 9,6% ocorreram em dezembro, destacando-se os acidentes com motocicleta/triciclo (71,0%), prevalecendo trauma de membros superiores (30,4%) com sequela física imediata em 0,5% das vítimas. Em relação ao desfecho (95,7%), recebeu alta após o atendimento, e houve sete óbitos (0,3%). Conclusão: A ocorrência significativa de acidentes de trânsito atendidos pelo serviço de urgência e emergência em pauta, envolvendo a população do estudo, evidencia a necessidade de políticas e estratégias de prevenção específicas.

Objective: to analyze traffic accidents occurred in the age group 0-24 years treated at the Emergency Room of City Cuiabá in 2013. Method: Cross-sectional study with data captured through a closed form. Data analysis was done using Epi Info. Results: Of the 2,122 calls, 67.9% were males aged 15-24 years (82.1%) and 49.7% occurred on weekends, and 9.6% occurred in December, highlighting the accidents with motorcycle/tricycle (71.0%), prevailing trauma of the upper limbs (30.4%) with immediate physical sequelae in 0.5% of the victims. Regarding the outcome, (95.7%) were discharged after treatment, and there were 7 deaths (0.3%). Conclusion: The significant occurrence of traffic accidents attended by the emergency service and emergency at hand, involving the study population, highlights the need for specific policies and prevention strategies.

Objetivo: analizar los accidentes de tráfico se produjo en el grupo de edad de 0-24 años atendidos en la sala de emergencias de la ciudad de Cuiabá, en El año 2013. Método: Estudio transversal con datos capturados a través de una forma cerrada. El análisis de datos se realizó usando Epi Info. Resultados: De las 2.122 llamadas, el 67,9% fueron varones de 15-24 años (82,1%) y el 49,7% se produjeron los fines de semana, y corrieron 9,6% en diciembre, destacando- si los accidentes con motocicleta / triciclo (71,0%), predominando el trauma de las extremidades superiores (30,4%) con secuelas físicas inmediata en El 0,5% de las víctimas. En cuanto a los resultados (95,7%) fueron dados de alta después del tratamiento, y no hubo 7 muertes (0,3%). Conclusión: La presencia significativa de los accidentes de tráfico atendidos por el servicio de emergencia y de emergencia a la mano, con la participación de la población de estudio, pone de relieve la necesidad de políticas específicas y estrategias de prevención.

Characteristics of training and motivation of physicians working in emergency medicine

Summary Introduction: Emergency medicine is an area in which correct decisions often need to be made fast, thus requiring a well-prepared medical team. There is little information regarding the profile of physicians working at emergency departments in Brazil. Objective: To describe general characteristics of training and motivation of physicians working in the emergency departments of medium and large hospitals in Salvador, Brazil. Method: A cross-sectional study with standardized interviews applied to physicians who work in emergency units in 25 medium and large hospitals in Salvador. At least 75% of the professionals at each hospital were interviewed. One hospital refused to participate in the study. Results: A total of 659 physicians were interviewed, with a median age of 34 years (interquartile interval: 29-44 years), 329 (49.9%) were female and 96 (14.6%) were medical residents working at off hours. The percentage of physicians who had been trained with Basic Life Support, Advanced Cardiovascular Life Support and Advanced Trauma Life Support courses was 5.2, 18.4 and 11.0%, respectively, with a greater frequency of Advanced Cardiovascular Life Support training among younger individuals (23.6% versus 13.9%; p<0.001). Thirteen percent said they were completely satisfied with the activity, while 81.3% expressed a desire to stop working in emergency units in the next 15 years, mentioning stress levels as the main reason. Conclusion: The physicians interviewed had taken few emergency immersion courses. A low motivational level was registered in physicians who work in the emergency departments of medium and large hospitals in Salvador.

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position.

There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.

Consultas de niños pasibles de cuidados paliativos al Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell 2014- 2015 / Consultation of children in need of palliative care to the Pereira Rossell Hospital Center's, Pediatric Emergency Department 2014-2015

Introducción: la asistencia de niños con condiciones de salud pasibles de Cuidados Paliativos (CP) en servicios de emergencia pediátrica constituye un desafío para los equipos de salud. Objetivo: describir la prevalencia de consultas, problemas de salud y características de niños pasibles de CP asistidos en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell. Metodología: estudio descriptivo, retrospectivo entre el 20/06/2014 y el 19/06/2015. Variables: edad, condición de salud, requerimiento de prótesis, motivo de consulta, existencia de: consulta previa, pediatra tratante, vinculación con Unidad de Cuidados Paliativos Pediátricos (UCPP), directivas anticipadas y condición al egreso. Resultados: se incluyeron 175 niños pasibles de CP. Éstos significaron 0,7% (340/ 46.706) de las consultas en el período analizado. Mediana de edad: 5,7 años, (1 mes - 16 años). Presentaban afectación neurológica severa 65%; portaban prótesis o dispositivo de tecnología médica 50,3% (11% más de una); consultaron por infecciones 42% (respiratoria 81%), problemas neurológicos 20,3% (convulsiones 87%). Presentaban consulta previa por igual motivo 93%. Refirieron: contar con pediatra tratante 66,3%; estar vinculados con la UCPP 42,3%; contaban con directivas anticipadas 20%. Ingresaron a: cuidados moderados 39%; terapia intensiva 2%. No se registraron fallecimientos. Conclusiones: se constataron diversas situaciones y características de los pacientes incluidos que traducen la complejidad de su condición clínica y eventuales dificultades para el abordaje en el primer nivel de atención o en sus departamentos de procedencia.

Introduction: the assistance of children in need of Palliative Care (CP) in pediatric emergency services is a challenge for health teams. Objective: To describe the prevalence of consultations, health problems and characteristics of children in need of PC assisted in the Pereira Rossell Hospital Center Pediatric Emergency Department. Methodology: descriptive, retrospective study between 20/06/ 2014- 19/06/2015. Variables: age, health condition, prosthesis, previous consultation, attending pediatrician, relation with Pediatric Palliative Care Unit (UCPP), advanced care plan and condition at discharge. Results: 175 children in need of PC were included which represented 0.7% (340 / 46,706) of consultations in the period. Median age: 5.7 years (1 month - 16 years); 65% had severe neurological impairment; 50.3% carried prosthesis or medical technological devices (11% more than one); reason for consultation was: 42% infections, 42% (81% respiratory), 20. 3% neurological problems (87% seizures); 93% presented a previous consultation for the same reason; 66.3% reported having an attending pediatrician; 42.3% were under UCPP assistance; 20% had advanced care plan. At discharge: 39% were admitted in moderate care; 2% in intensive care. No deaths were recorded. Conclusion: the different situations and characteristics of the patients included represent the complexity of their clinical condition and may be related to possible difficulties in addressing their problems at the primary care level or their provinces of origin.

Use of intraosseous devices in trauma: a survey of trauma practitioners in Canada, Australia and New Zealand.

BACKGROUND: Although used primarily in the pediatric population for decades, the use of intraosseous (IO) devices in the resuscitation of severely injured adult trauma patients has recently become more commonplace. The objective of this study was to determine the experience level, beliefs and attitudes of trauma practitioners in Canada, Australia and New Zealand regarding the use of IO devices in adult trauma patients. METHODS: We administered a web-based survey to all members of 4 national trauma and emergency medicine organizations in Canada, Australia and New Zealand. Survey responses were analyzed using descriptive statistics, univariate comparisons and a proportional odds model. RESULTS: Overall, 425 of 1771 members completed the survey, with 375 being trauma practitioners. IO devices were available to 97% (353 of 363), with EZ-IO being the most common. Nearly all physicians (98%, 357 of 366) had previous training with IO devices, and 85% (223 of 261) had previously used an IO device in adult trauma patients. Most respondents (79%, 285 of 361) were very comfortable placing an IO catheter in the proximal tibia. Most physicians would always or often use an IO catheter in a patient without intravenous access undergoing CPR for traumatic cardiac arrest (84%, 274 of 326) or in a hypotensive patient (without peripheral intravenous access) after 2 attempts or 90 s of trying to establish vascular access (81%, 264 of 326). CONCLUSION: Intraosseous devices are readily available to trauma practitioners in Canada, Australia and New Zealand, and most physicians are trained in device placement. Most physicians surveyed felt comfortable using an IO device in resuscitation of adult trauma patients and would do so for indications broader than current guidelines.

CONTEXTE: Bien que le dispositif de perfusion intraosseuse soit depuis des décennies utilisé principalement chez les enfants, son utilisation lors de la réanimation d'adultes victimes de trauma grièvement blessés a récemment gagné en popularité. Notre étude vise à déterminer le niveau d'expérience, les croyances et les attitudes des spécialistes en traumatologie canadiens, australiens et néo-zélandais en ce qui concerne l'utilisation de ces dispositifs chez des patients adultes victimes de trauma. MÉTHODES: Nous avons fait parvenir un sondage Web à tous les membres de 4 organisations nationales de traumatologie et d'urgentologie au Canada, en Australie et en Nouvelle-Zélande. Les réponses ont été analysées au moyen de statistiques descriptives, de comparaisons univariées et d'un modèle à cotes proportionnelles. RÉSULTATS: Au total, parmi les 1771 personnes visées, 425 ont répondu au sondage, dont 375 spécialistes en traumatologie. De tous les répondants, 97 % avaient accès à un dispositif de perfusion intraosseuse, et le modèle EZ-IO était le plus répandu. Presque tous les médecins (98 %) avaient été formés pour utiliser cet appareil, et 85 % d'entre eux l'avaient déjà utilisé chez des adultes victimes de trauma. De plus, la plupart des répondants (79 %) étaient très à l'aise de poser un cathéter intraosseux dans la voie tibiale proximale. La plupart auraient toujours ou souvent recours à ces cathéters pour traiter un patient sans accès intraveineux subissant des manoeuvres de réanimation à la suite d'un arrêt cardiaque traumatique (84 %) ou un patient hypotendu (aucun accès veineux périphérique) sur lequel on a tenté à 2 reprises ou pendant 90 s d'établir un accès vasculaire (81 %). CONCLUSION: Les spécialistes en traumatologie canadiens, australiens et néo-zélandais ont facilement accès à des dispositifs de perfusion intraosseuse, et la plupart d'entre eux ont été formés sur leur mise en place. La plupart des répondants au sondage se sont dits à l'aise d'utiliser le dispositif lors de la réanimation d'adultes victimes de trauma et prêts à s'en servir pour traiter des cas plus variés que ce que recommandent les lignes directrices actuelles.