Do patient outcomes differ when the trauma team leader is a surgeon or non-surgeon? A multicentre cohort study.

PURPOSE: Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients. METHODS: Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL. RESULTS: Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated. CONCLUSIONS: After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres.

ABSTRAIT: OBJECTIF: Les chefs d'équipe de traumatologie (CET) sont traditionnellement des chirurgiens généralistes; cependant, certains centres de traumatologie utilisent un modèle mixte de soins où des chirurgiens et des non-chirurgiens (principalement des médecins d'urgence) qui jouent ce rôle. L'objectif de cette étude multicentrique était de fournir une étude bien menée pour déterminer si la spécialité CET est associée à la mortalité chez les patients traumatisés majeurs. MéTHODES: Les données ont été recueillies à partir des registres provinciaux de 6 niveau 1 centres de traumatologie au Canada sur une période de 10 ans. Nous avons inclus des patients adultes traumatisés (âge ≥ 18 ans) qui ont provoqué l'activation traumatique de niveau le plus haut. Le primaire résultat était la différence de mortalité hospitalière ajustée en fonction du risque pour les patients traumatisés qui ont reçu des soins primaires d'un chirurgien par rapport à un CET non chirurgien. RéSULTATS: En totale, 12 961 patients traumatisés majeurs ont été la partie de cette analyse. Le soin primaire a été assuré par un chirurgien CET dans 57,8 % (n=7 513) des cas, alors que 42,2 % (n=5 448) des patients ont été traités par un CET non chirurgien. Une mortalité non ajustée s'est produit chez 11,6 % des patients du groupe de chirurgien CET et 12,7 % des patients du groupe de non chirurgien CET (OR 0,87, IC à 95 % 0,78 à 0,98, p = 0,02). La mortalité ajustée en fonction du risque n'était pas significativement différente entre les patients pris en charge par des CET chirurgiens et non-chirurgiens (RC 0,92, IC à 95 % 0,80 à 1,06, p = 0,23). De plus, nous ne pouvons pas observer de différences de mortalité ajustée au risque pour aucun des sous-groupes évalués. CONCLUSIONS: Après avoir ajusté du risque, il n'y avait pas de différence de mortalité entre les patients traumatisés traités par des chirurgiens ou non chirurgiens CET. Notre étude soutient les médecins d'urgences jouent le rôle de CET dans les centres de traumatologie de niveau 1.

The Future of Emergency Medicine (EM) Sim Cases: A Modified Massive Online Needs Assessment.

Objective Emergency Medicine (EM) Sim Cases was initially developed in 2015 as a free open-access simulation resource. To ensure the future of EM Sim Cases remains relevant and up to date, we performed a needs assessment to better define our audience and facilitate long-term goals. Methods We delivered a survey using a modified massive-online-needs-assessment methodology through an iterative process with simulation experts from the EM Simulation Educators Research Collaborative. We distributed the survey via email and Twitter and analyzed the data using descriptive statistics and thematic analysis. Results We obtained 106 responses. EM Sim Cases is commonly used by physicians primarily as an educational resource for postgraduate level trainees. Perceived needs included resuscitation, pediatrics, trauma, and toxicology content. Prompted needs included non-simulation-case educational resources, increased case database, and improved website organization. Conclusions Data collected from our needs assessment has defined our audience allowing us to design our long-term goals and strategies.

Restraint in police use of force events: examining sudden in custody death for prone and not-prone positions.

Little is understood about the incidence of sudden death, its underlying pathophysiology, or its actual relationship to subject positioning. We report data from 4828 consecutive use of force events (August 2006-March 2013) in 7 Canadian police agencies in Eastern and Western Canada. Consecutive subjects aged >18 years who were involved in a police use of force event were included regardless of outcome. Officers prospectively documented: final resting position of the subject (prone or non-prone), intoxicants and/or emotional distress, presence of features of excited delirium, and the use of all force modalities. Our outcome of interest was sudden in-custody death. Our study has 80% power to detect a difference of 0.5% in sudden death between the positions. In over 3.25 million consecutive police--public interactions; use of force occurred in 4,828 subjects (0.1% of police public interactions; 95% CI = 0.1%, 0.1%). Subjects were usually male (87.5%); median age 32 years; 81.5% exhibited alcohol and/or drug intoxication, and/or emotional distress at the scene. Significantly more subjects remained in a non-prone vs. prone position; but over 2000 subjects remained prone. One individual died suddenly and unexpectedly in the non-prone position with all 10 features of excited delirium. No subject died in the prone position. There was no significant difference in sudden in custody death, in a worst case scenario 99.8% of subjects would be expected to survive being in either the prone or non-prone position following police use of force.

"Bath salts" intoxication: a new recreational drug that presents with a familiar toxidrome.

It is important for emergency physicians to be aware of new psychoactive agents being used as recreational drugs. "Bath salts," which include 3,4-methylenedioxypyrovalerone (MDPV), mephedrone, and methylone, are the newest recreational stimulants to appear in Canada. There are currently more than 12 synthetic cathinones marketed as bath salts and used with increasing frequency recreationally. Although these drugs are now illegal in Canada, they are widely available online. We present a case report and discuss bath salts intoxication and its anticipated sympathomimetic toxidrome, treatment strategies, and toxicologic analysis, Treatment should not rely on laboratory confirmation. Since the laboratory identification of such drugs varies by institution and toxicologic assay, physicians should not misconstrue a negative toxicology screen as evidence of no exposure to synthetic cathinones. Illicit bath salts represent an increasing public health concern that involves risk to the user, prehospital personnel, and health care providers.