We determine success rates of endotracheal intubation performed in emergency departments (EDs) by North American emergency medicine residents.
During 58 months, physicians performing intubations at 31 university-affiliated EDs in 3 nations completed a data form that was entered into the National Emergency Airway Registry 2 database. Included were all patients undergoing endotracheal intubation in the ED. The data form included patients' age, sex, weight, indication for intubation, technique of airway management, names and dosages of all medications used to facilitate intubation, level of training and specialty of the intubator, number of attempts, success or failure, and adverse events. We queried this prospectively gathered, observational data to analyze intubations done by US and Canadian emergency medicine residents.
Enrollment was incomplete (eg, 85% at the main study center), so the study sample did not include all consecutive patients. Emergency medicine residents performed 77% (5768/7498; 95% confidence interval [CI] 76% to 78%) of all initial intubation attempts in the United States and Canada. The first intubator was successful in 90% (5,193/5,757; 95% CI 89% to 91%) of cases, including 83% (4,775/5,757; 95% CI 82% to 84%) on the first attempt. Success rates on the first attempt were as follows: postgraduate year 1 = 72% (498/692; 95% CI 68% to 75%), postgraduate year 2 = 82% (2,081/2,544; 95% CI 80% to 83%), postgraduate year 3 = 88% (1,963/2,238; 95% CI 86% to 89%), postgraduate year 4+ = 82% (233/283; 95% CI 77% to 87%), and attending physician = 89% (689/772; 95% CI 87% to 91%). Success rates by the first intubator were as follows: postgraduate year 1 = 80% (553/692; 95% CI 77% to 83%), postgraduate year 2 = 89% (2,272/2,544; 95% CI 88% to 90%), postgraduate year 3 = 94% (2,105/2,238; 95% CI 93% to 95%), postgraduate year 4+ = 93% (263/283; 95% CI 89% to 96%), and attending physician = 98% (755/772; 95% CI 96% to 99%). Rapid sequence intubation technique was used in 78% (4,513/5,768; 95% CI 77% to 79%) of initial attempts: it resulted in 85% (3,843/4,513; 95% CI 84% to 86%) success on the first attempt and 91% (4,117/4,513; 95% CI 90% to 92%) success by the first intubator. The overall rate of cricothyrotomy for all emergency resident intubations was 0.9% (50/5,757; 95% CI 0.6% to 1.1%). When an initial intubator failed, 40% (385/954; 95% CI 37% to 44%) of rescue attempts were performed by emergency medicine residents. Among emergency medicine residents, success on the first rescue attempt was 80% (297/371; 95% CI 76% to 84%), and success by the first rescue intubator was 88% (328/371; 95% CI 85% to 91%).
Success of initial intubation attempts increased over the first 3 years of residency. This large multicenter study demonstrates the success of airway management by emergency medicine residents in North America. Using rapid-sequence intubation predominantly, emergency medicine residents achieved high levels of success.
In 1985, the Danish Board of Health published a review of the therapeutic value of heart ambulances. A report is presented here concerning the extent to which prehospital treatment of cardiac arrest recommended by the Board of Health has been intensified after publication of the review. The prehospital treatment of cardiac arrest has been intensified in four counties and in the municipalities of Copenhagen and Frederiksberg whereas it has not been altered in the remaining ten counties. Recent Danish investigations have demonstrated better prognosis both as regards survival and as regards recovery when intensified prehospital treatment of cardiac arrest is employed. Hence legislation steps should be taken to improve pre-hospital treatment of cardiac arrest.
Disaster medicine, which is based primarily on military and emergency medicine, is a young branch on the old tree of medicine. It touches on various disciplines within and outside the medical field. The subject is being taught on the academic and postacademic levels at many universities throughout Europe. The first chair in disaster medicine was established in Linkoping, Sweden; the second is now in Amsterdam, The Netherlands. Some aspects of disaster medicine specifically oriented toward Europe are presented.
Effective communication has been shown to be essential to physician-patient communication and may be even more critical for poison control center (PCC) calls because of the absence of visual cues, the need for quick and accurate information exchange, and possible suboptimal conditions such as call surges. Professionals who answer poison control calls typically receive extensive training in toxicology but very little formal training in communication.
An instrument was developed to assess the perceived need for communication training for specialists in poison information (SPIs) with input from focus groups and a panel of experts. Requests to respond to an online questionnaire were made to PCCs throughout the United States and Canada.
The 537 respondents were 70% SPIs or poison information providers (PIPs), primarily educated in nursing or pharmacy, working across the United States and Canada, and employed by their current centers an average of 10 years. SPIs rated communication skills as extremely important to securing positive outcomes for PCC calls even though they reported that their own training was not strongly focused on communication and existing training in communication was perceived as only moderately useful. Ratings of the usefulness of 21 specific training units were consistently high, especially for new SPIs but also for experienced SPIs. Directors rated the usefulness of training for experienced SPIs higher for 5 of the 21 challenges compared to the ratings of SPIs.
Findings support the need for communication training for SPIs and provide an empirical basis for setting priorities in developing training units.
Objectives of hospital-based post-doctoral general dentistry programs in Canada were assessed by questionnaire. Seventy percent (14 of 20) of the program directors responded. Educational goals and objectives were assessed in professional skills and practice management, public health and preventive dentistry, oral medicine and pathology, special needs patient care, trauma and emergency care, restorative/prosthodontic care, endodontics, orthodontics/pediatric dentistry, oral surgery, periodontics, pharmacology, and functioning in a hospital. High rankings of proficiency were related to primary care, restorative/prosthodontic, endodontic, and surgical care. Emergency care, sedation, and pharmacology were also ranked highly. Lower rankings of proficiency were reported in orthodontics, aspects of public health dentistry, practice management, and advanced oral and maxiliofacial surgery. When the results of the Canadian survey were compared with those of a survey of US post-doctoral general dentistry programs, substantial similarity was seen. The findings support continuing reciprocity in accreditation standards between the Canadian and American Commissions on Dental Education and Dental Accreditation.
Current debates around the choice of management strategy for patients with atrial fibrillation (AF) combined with limited efficacy and frequent adverse effects of current pharmacotherapies cause uncertainty and confusion, challenging optimal care delivery to AF patients.
To determine gaps in knowledge, skill, and competencies of Canadian physicians caring for patients with AF as well as underlying causes of these gaps.
A mixed-method approach --consisting of qualitative (semistructured interviews) and quantitative data collection techniques (online survey) --was conducted. Findings were triangulated to ensure the reliability and trustworthiness of findings. The combined sample (n = 161) included 43 family physicians/general practitioners, 23 internal medicine specialists, 48 cardiologists, 28 emergency physicians, 14 neurologists, and 5 patients.
Gaps and barriers impeding optimal care were related to an unclear definition of AF, uncertainty of its pathophysiology, and knowledge gaps across the care continuum, including screening, diagnosis, and treatment. Clinical decision-making, individualized patient therapy, communication with patients and between professionals, and application of guidelines were found to be particularly challenging. These issues are discussed in the context of the newly revised Canadian Cardiovascular Society (CCS) AF Guidelines.
Educational gaps exist across the entire continuum of care. Results from this study, along with the 2011 CCS guidelines for AF management, provide direction for solutions through physician education and professional development.