Paediatric procedural sedation using ketamine in a UK emergency department: a 7 year review of practice.

BACKGROUND: Ketamine is growing in popularity for procedural sedation in the paediatric population, yet safety concerns remain. We performed a retrospective review of practice and outcomes of paediatric ketamine sedation using the World SIVA International Sedation Task Force reporting tool. METHODS: A retrospective inspection of the dedicated emergency department electronic sedation database and subsequent note and sedation chart review was performed for all paediatric sedations throughout a 7 yr period from September 2006. All adverse events were stratified. RESULTS: During the study period, procedural sedation was provided for a total of 243 children, of whom 215 were sedated with ketamine, most commonly for wound management (n=131). The median patient age was 4 yr (14 months to 15 yr), and 63.7% were male. Of the total, 76.7% were discharged home either directly (n=101) or after brief observation (n=64). One patient required subsequent general anaesthesia after a failed sedation with paradoxical agitation. Of the total, 9.8% of patients had an adverse event, the most severe risk stratification being 'minor risk'. All interventions were 'minimal risk'. There were no 'sentinel risk' outcomes. CONCLUSIONS: These data support the ongoing use of ketamine for paediatric procedural sedation in the emergency department by emergency physicians. Relatively high resource requirements mean that ensuring adequate numbers of procedures may prove challenging.

Following up the follow up--long-term complications in paediatric burns.

Paediatric burn follow-up optimally follows a balance between complication detection and avoiding unnecessary hospital visits. In a long-term review, we assessed complication patterns in children with burns requiring surgery. Using the Welsh Burns Centre database, a retrospective note review of paediatric burns over 3 years from 1995 was performed, identifying all children undergoing surgery for their burns. 94 patients were identified with a median follow-up since injury of 13.6 years. Mean age was 5.27 (SD=4.9) years. TBSA ranged from <1 to 70%. 94% underwent split-skin grafting. 18% (n=17) developed contractures and 33% (n=31) developed hypertrophic scarring. Those developing contractures were younger, and suffered significantly greater TBSA burns (p<0.05) than those developing hypertrophic scarring or those without complications. All contractures developed within 1-13 months, and hypertrophic scarring within 1-17 months. All patients sustaining axillary burns developed contractures, whilst 75% of contractures developed around the upper limb. In conclusion, younger patients with larger TBSA burns in the upper limb were at higher risk for contractures and hypertrophic scarring, which all presented within 18 months. Therefore any patients that are complication-free 18 months after-injury can be safely discharged, allowing streamlining of follow-up for the benefit of patients, parents and hospital resources.

Postgraduate training positions. Follow-up survey of third-year residents in family medicine.

OBJECTIVE: To survey all family medicine programs in Canada to determine how many positions for third-year training were available. DESIGN: The survey instrument contained questions to determine how many second-year positions and how many third-year positions each program had. Descriptions of third-year positions were requested. One survey question asked about the percentage of people with third-year training who initially went into rural or small-town practice. Last, each program director was asked for an opinion on how many third-year positions should be available for further training. SETTING: The survey was administered to the program directors of all 16 family medicine programs in Canada. PARTICIPANTS: Program directors of departments of family medicine. RESULTS: The survey indicated that the number of third-year positions was 18% of the number of second-year positions currently available (an increase over the 10% determined in Busing's study in 1989). The largest proportion of third-year training was in emergency medicine, and approximately 30% of third-year positions were primarily reserved for physicians intending to go into rural practice. Academic family physicians and residents are in fairly close agreement that third-year positions should represent 40% of second-year positions. CONCLUSION: A survey of Canadian family medicine programs during the 1996-1997 academic years indicated that third-year positions available for family medicine residents have almost doubled since Busing's original survey in 1989.

Preparing for rural practice. Enhanced experience for medical students and residents.

PROBLEM ADDRESSED: Recruitment and retention of physicians appropriately trained for rural practice in Canada continues to be a serious challenge. We describe three integrated educational programs at the University of Alberta that aim to increase students' and residents' participation in rural health care and encourage them to take up practice in rural areas. OBJECTIVES OF PROGRAM: To expand and enrich rural educational experiences at undergraduate and postgraduate levels and to supplement family medicine postgraduate education with a third-year special-skills program for rural practice. MAIN COMPONENTS OF PROGRAM: Main components are sustained, reliable funding from the Government of Alberta for the Rural Physician Action Plan; adequate infrastructure to support the program; and commitment by university faculty, rural physicians, and communities. CONCLUSION: The rural-based educational programs have allowed more than 95% of medical students to gain experience in rural areas. The number of family medicine residents doing rural rotations has doubled, and the length of experiences in rural practice has increased fourfold. The third-year special-skills training for rural practice has expanded greatly, and at least 26 of 49 participants have gone on to enter rural practice. In more than 30 rural Alberta communities, 56 physicians have had an important influence on the training of medical students and family medicine residents.

Alberta's Rural Physician Action Plan: an integrated approach to education, recruitment and retention.

This paper describes the development and characteristics of a comprehensive, integrated and sustained program for the education, recruitment and retention of physicians for rural practice in Alberta--the Rural Physician Action Plan. The participation of key stakeholders (including government, the provincial medical association, the licensing authority, faculties of medicine, practising rural physicians and regional health authorities) and a sustained program budget have been key organizational issues for success. Critical to the effectiveness of this program has been the focus on professional and lifestyle issues targeting 3 distinct groups: physicians in training, physicians in practice, and rural communities and health authorities. Substantial program funding since 1991-92 of up to $3 million per year has increased rural-based activities significantly. For example, 87% of medical students and 91% of residents in family medicine in Alberta now experience 4 weeks or more of rural practice. The authors believe that the historic issues and recent trends militating against recruitment and retention of rural physicians will continue unchecked without comprehensive and sustained approaches such as Alberta's Rural Physician Action Plan.