North Pole Mass Casualty

Last shift I came on and the hotline phone was ringing. I expected to hear from one of the community nursing stations but a very unusual voice was on the line. My usual line for answering the phone shot out of my mouth without a thought - " Stanton ER can you hold please."

"Ho Ho Ho! Is this the Emergency Department in Yellowknife?"

I was gobsmacked. Was this a prank? "Yes it is. Can I help you?"

"We've had a bit of an accident up here and we're going to need to send a few patients your way."

I was still trying to get my head around all this. "Who is this? What do you mean about a few patients?"

A long sigh came through the phone into my ear. "Dr Hoechsmann. I know you've got three little girls who have been very nice all year who would love to have a few presents on Christmas but we have a situation here that could put all of that at risk!"

How did he know my name? I started to realize that this was not a prack. "What's going on up there Santa?" I asked.

"Well," he said, "One of the plastics injection molding machines has given us some problems for the last month. The thing has a high pressure actualizer that usually shuts off if it the pressure gets to high. We've had to deactivate the pressure sensor because it keeps going off even when the pressure is normal - sorry I am not getting to the point - "ELEVEN OF MY ELVES ARE INJURED!!"

"Can you describe their injuries Santa?"

"The pressure got to high and the whole thing exploded. Basically, it was like shrapnel flying all around the toy factory. We have a few elves trained in industrial first aid but their telling me it is pretty serious. Clive, the foreman, is unconscious and Blaise, the second deputy assistant chronographer is covered in blood."

(Part 2 coming soon)

Fall down go boom!!

Well today Dr Sam Wong gave a very nice presentation on pediatric head trauma at rounds. The two take home points I want to summarize are a good rule to predict who needs a CT and some back to play rules for concussion.

1) Catch Study Rule: This based on a Canadian Study of 3866 kids with a score of 13–15on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability (not for kids without these features)

2) Concussion return to play guidelines:

(Here's a handout!)

A concussion is defined as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

1. Concussion may be caused either by a direct blow to the head, face or neck or a blow elsewhere on the body with an ‘‘impulsive’’ force transmitted to the head.

2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.

3. Concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In a small percentage of cases, however, post-concussive symptoms may be prolonged.

5. No abnormality on standard structural neuroimaging studies is seen in concussion.

A concussion is a serious event, but you can recover fully from such an injury if the brain is given enough time to rest and recuperate. Returning to normal activities, including sport participation, is a step-wise process that requires patience, attention, and caution. Sometimes these steps can cause symptoms of a concussion to return. This means that the brain has not yet healed, and needs more rest. If any signs or symptoms return during the Return To Play process, the player must be re-evaluated by a physician before trying any activity again. Remember, symptoms may return later that day or the next, not necessarily during the activity!

Step 1: No activity, only complete rest. This means no work, no school, and no physical activity. When symptoms are gone, a physician must be consulted. The physician will be able to clear the player to slowly return to some activities.

Step 2: Light aerobic exercise, such as walking or stationary cycling. The player should be supervised by someone who can help monitor for symptoms and signs. No resistance training or weight lifting. The duration and intensity of the aerobic exercise can be gradually increased over time if no symptoms or signs return during the exercise or the next day. Symptoms? Go back to Step 1. No symptoms? Proceed to Step 3 the next day.

Step 3: Sport specific activities, such as skating or throwing, can begin at step 3. There should be no body contact or other jarring motions such as high speed stops or hitting a baseball with a bat. Symptoms? Go back to Step 2. No symptoms? Proceed to Step 4 the next day.

Step 4: Drills without body contact.

Symptoms? Go back to Step 3. No symptoms? Read below:

The time needed to progress from non-contact exercise will vary with the severity of the

concussion and with the player. Proceed to Step 5 only after medical clearance.

Step 5: Begin drills with body contact.

Step 6: Game play

Please remember: these steps do not correspond to days! It may take many days to progress through one step, especially if the concussion is severe. As soon as symptoms appear, the player should return to the previous step and wait at least one more day before attempting any activity. The only way to heal a brain is to rest it. Never return to play if symptoms persist! A player who returns to active play before full recovery from the first concussion is at high risk of sustaining another concussion, with symptoms that may be increased and prolonged.

Homelessness at minus 20 C - Is this not an Emergency?

On many a night shift I have witnessed the ambulance bringing in yet another intoxicated homeless person. Sadly, the vast majority are aboriginal as well. In the summer months, like in most ERs in the south, my goal is to rule out a serious medical emergency, treat any superficial injuries and come up with a disposition. This is challenging sometimes but mostly it is fairly obvious what to do. Some people end up sleeping it off in the RCMP drunk tank and the more sober ones either end up at one of the shelters in town or just walking out the door.

But what to do on a cold winter's night?

Often, the temperature around here in Yellowknife dips below - 20C. Some of the homeless sleep at the shelters, others have tents that are set up in some of the wooded areas around town. Unfortunately, some are banned from the shelters for inappropriate or violent behavior. Others still look for a warm place where ever they can (indoor bank machine rooms, unlocked doors, etc.).

Is there an ethical duty to provide a place for someone to stay who has no safe place to go? I would argue that there is. I am not sure though that this duty falls to the emergency department. The fact that waiting times are too long and bed availability is often a factor makes this a dilemma. I figure with no other options, it becomes our obligation to house these individuals until we identify another location.

So in a sense homelessness is a real emergency and not just a chronic (and therefore not an ER) problem. But is it not really everyone's problem? Shouldn't the hospital as a whole have a plan for providing a place to sleep for the homeless? Maybe we need to start by asking them!

Life in the ER

Taking a Bite from the Big Apple

Just got back from a few days in New York city where I attended McMaster's Best Evidence in Emergency Medicine course. If ever there was a place to live up to Joyce's term "blooming buzzing confusion" this was it! What a trip. Just thinking back to being at the top of the Empire State Building is enough to get that vertiginous feeling back in the pit of my stomach.

We reviewed evidence in the EM literature from the past year. Here are a few highlights:

1) "Hot Potato" - Throat swabs should not be routinely done in a primary care setting for management of sore throats. Treat with ibuprofen and leave the antibiotics out of it mostly. see http://www.sign.ac.uk/guidelines/fulltext/117/index.html"SIGN

2) "Bell Ringer" - Kupperman's new CT head rule for kids is promising as is the CATCH trial from Canada. Note: Every 1500 CT scans on children leads to one mortality from radiation!

3) "Cooler heads prevail" - Arrich's review of cooling cardiac arrest survivors demonstates a clear benefit from cooling the patients to less than 35 degrees within 6 hours of the arrest.

4) "Don't Stop for Breathing" - In this big RCCT of chest compressions only vs conventional CPR, these authors showed that in out of hospital cardiac arrest, it looks like chest compressions are the only effective form of CPR.

5) "To bleed or not to bleed" - A simple and cheap drug for a big problem. The use of transexamic acid ( 1g IV over 10 minutes then 1 g over 8 hours) in the trauma patient with significant bleeding reduced mortlity by 1.5%.

6) "A Whole Lotta Shakin Going on" - 0.5 mg Intranasal or buccal Midazolam or (0.1 mg IV) is enough to stop most pediatric seizures.

7) "Rub it to make it better" - Topical NSAIDs have a significant effect on treating acute pain without the GI side effects.

8) "Ain't no bugs in here" - acylclovir is useless in Bell's palsy. Just use steroids (prednisone is good).

9) "If Dad can do it so can I!" - Ottawa Ankle Rules validated in kids greater than 5.

10) "Was blind but now I see..." - Triage who needs a stroke work-up in TIA patients is a lot easier with the ABCD2 rule. (For patients with a low score the two-day stroke risk was 1%. )

There were lots of other goodies in this course including new guidelines for antibiotics usage in surgical infections, procedural sedation facts, migraines...

It ended with a good game of Jeopardy too. I'll have to go again I think.

Oh and by the way, if you're going to New York check out Ludlow guitars in the East Village!

Boy that EKG looks bad

So this guy comes in confused. Seems to be a pretty commonplace occurrence. What was different this time is that this man was not drunk - he was a known diabetic.

After a while we got the story that he had not been taking his insulin for a few days as he wasn't feeling well and hadn't been eating.

His initial reading on the glucometer was "HIGH." It seemed pretty clear that we were looking at severe DKA. He was put on the monitor which revealed a wide complex sinus tach alternating with V tach. Yikes.

Well the good news is that his confused ramblings persisted even during the v tach.

The EKG showed huge T waves.

His initial pH was 6.9.

He got a gram of calcium gluconate, an amp of bicarb, insulin sub q and IV and his EKG started to normalize quickly.

After a while we got his labs. His potassium was 7.9 mmol/L.

Wow.

Disasters and Disaster Planning

The tragedy in Haiti has put my heart and mind through the proverbial ringer. One of the outcomes has been to re-examine how we plan for disasters in the North. What kinds of disasters could we anticipate? Nothing on the scale of the Haitian earthquake - we just don't have the population up here.

However, it doesn't take millions of injured people to make a disaster. If only 10% of the 20 000 people who live in Yellowknife required immediate emergency care, we could easily be overwhelmed. There are many ways this could happen.

We had to plan for this during the H1N1 epidemic. Had the virus been more virulent and many people required hospitalization we would have needed to use the schools as hospital wards. The same kind of problem would arise with contamination of the water system.

Another of the possibilities for a disaster scenario involves climate change. What if there was a period of prolonged abnormal cold? What if there was no power during that period? There would be no heat, no water and only frozen food.

As one designs disaster, mass casualty and code orange policies, it's hard not to realize that any of these events are likely to result in a very chaotic response. The amount of inter-agency communication required to build a complete plan is astounding. In the end it will be the communication systems that are used during a disaster that makes or breaks the quality of the response.