Safety and Adverse Events During Primary Care Paramedic Interfacility Transfer of Stable STEMI Patients.

Objective: Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 min. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available.

The impact of alternate defibrillation strategies on shock-refractory and recurrent ventricular fibrillation: A secondary analysis of the DOSE VF cluster randomized controlled trial.

Background: The DOSE VF randomized controlled trial (RCT) employed a pragmatic definition of refractory ventricular fibrillation (VF after three successive shocks). However, it remains unclear whether the underlying rhythm during the first three shocks was shock-refractory or recurrent VF.

Objective: To explore the relationship between alternate defibrillation strategies employed during the DOSE VF RCT and the type of VF, either shock-refractory VF or recurrent VF, on patient outcomes.

Association of coronary angiography with ST-elevation and no ST-elevation in patients with refractory ventricular fibrillation - A substudy of the DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE-VF randomized control trial).

Background: Refractory ventricular fibrillation or pulseless ventricular tachycardia (rVF/pVT) during out-of-hospital cardiac arrest (OHCA) is associated with poor survival. Double sequential defibrillation (DSED) and vector change (VC) improved survival for rVF/pVT in the DOSE-VF RCT. However, the role of angiography and percutaneous coronary intervention (angiography/PCI) during the trial is unknown.

The Impact of Out-of-Hospital Time and Prehospital Intubation on Return of Spontaneous Circulation following Resuscitative Thoracotomy in Traumatic Cardiac Arrest.

Introduction: Resuscitative thoracotomy (RT) is a critical procedure performed in certain trauma patients in extremis, with extremely low survival rates. Currently, there is a paucity of data pertaining to prehospital variables and their predictive role in survival outcomes in traumatic cardiac arrest (TCA) patients requiring RT. The aim of the study was to determine the impact of prehospital intubation and out-of-hospital time (OOHT) on return of spontaneous circulation (ROSC) and survival in TCA requiring RT.

Defibrillation Strategies for Refractory Ventricular Fibrillation.

Background: Despite advances in defibrillation technology, shock-refractory ventricular fibrillation remains common during out-of-hospital cardiac arrest. Double sequential external defibrillation (DSED; rapid sequential shocks from two defibrillators) and vector-change (VC) defibrillation (switching defibrillation pads to an anterior-posterior position) have been proposed as defibrillation strategies to improve outcomes in patients with refractory ventricular fibrillation.

Methods: We conducted a cluster-randomized trial with crossover among six Canadian paramedic services to evaluate DSED and VC defibrillation as compared with standard defibrillation in adult patients with refractory ventricular fibrillation during out-of-hospital cardiac arrest.

Predefibrillation end-tidal CO and defibrillation success in out-of-hospital cardiac arrest: an observational cohort study.

Background: Predefibrillation end-tidal CO (ETCO) may predict defibrillation success and could guide defibrillation timing in ventricular fibrillation (VF) cardiac arrest. This relationship has only been studied using advanced airways. Our aim was to evaluate this relationship using both basic (bag-valve-mask (BVM)) and advanced airways (supraglottic airways and endotracheal tubes).

The association between end-tidal CO2 and return of spontaneous circulation after out-of-hospital cardiac arrest with pulseless electrical activity.

Introduction: End-tidal carbon dioxide (ETCO2) has been suggested to have prognostic implications during out-of-hospital cardiac arrest (OHCA). Our objective was to determine if the change in ETCO2 (delta ETCO2) during resuscitation was predictive of future return of spontaneous circulation (ROSC) in patients with pulseless electrical activity (PEA) arrests.

Methods: We performed a retrospective, observational study of adult (≥18 years of age) non-traumatic PEA OHCAs in two Canadian EMS systems over a two-year time frame beginning on January 1, 2018.

Gallstone ileus with an enterovaginal fistula: a rare complication of pelvic radiotherapy.

Gallstone ileus is a rare cause of small bowel obstruction. Chronic gallstone irritation can lead to the formation of a cholecystoduodenal fistula, with gallstone impaction typically in the terminal ileum. Rarely gallstones can become impacted in other structures such as the colon or can even erode through the bowel.

DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial.

Background: Despite high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and antiarrhythmic medications, some patients remain in refractory ventricular fibrillation (VF) during out-of-hospital cardiac arrest. These patients have worse outcomes compared to patients who respond to initial treatment. Double sequential external defibrillation (DSED) and vector change (VC) defibrillation have been proposed as viable options for patients in refractory VF.

Double sequential external defibrillation for refractory ventricular fibrillation: The DOSE VF pilot randomized controlled trial.

Objectives: The primary objective was to determine the feasibility and safety of a cluster randomized controlled trial (RCT) with crossover comparing vector change defibrillation (VC) or double sequential external defibrillation (DSED) to standard defibrillation for patients experiencing refractory ventricular fibrillation (VF). Secondary objectives were to assess the rates of VF termination (VFT) and return of spontaneous circulation (ROSC).

Methods: We conducted a pilot cluster RCT with crossover in four Canadian paramedic services including all treated adult OHCA patients who presented in VF and received a minimum of three successive defibrillation attempts.

The impact of double sequential external defibrillation on termination of refractory ventricular fibrillation during out-of-hospital cardiac arrest.

Background: Despite significant advances in resuscitation efforts, there are some patients who remain in ventricular fibrillation (VF) after multiple shocks during out-of-hospital cardiac arrest (OHCA). Double sequential external defibrillation (DSED) has been proposed as a treatment option for patients in refractory VF.

Objective: We sought to explore the relationship between type of defibrillation (standard vs DSED), the number of defibrillation attempts provided and the outcomes of VF termination and return of spontaneous circulation (ROSC) for patients presenting in refractory VF.

Serious gaming: A tool to educate health care providers about domestic violence.

Due to many adverse health effects, victims of domestic violence are frequently seen in the health care system. Yet, health care providers may lack the training to assist them. Online curricula can be an effective instructional tool.

Labeling Bacterial Flagella with Fluorescent Dyes.

We describe labeling of bacteria with amino-specific or sulfhydryl-specific Alexa Fluor dyes, methods that allow visualization of flagellar filaments, even in swimming cells. Bacterial flagellar filaments are long (~10 μm), but of small diameter (~20 nm), and their rotation rates are high (>100 Hz), so visualization is difficult. Dark-field microscopy works well with isolated filaments, but visualization in situ is hampered by light scattered from cell bodies, which obscures short filaments or the proximal ends of long filaments.

Evaluation of a primary care paramedic STEMI bypass guideline.

Objective: Limited evidence supports primary care paramedic (PCP) direct transport of ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI). The goal of this study was to evaluate an urban-based PCP STEMI bypass guideline.

Methods: We reviewed consecutive Toronto Paramedic Services call reports between April 7, 2015, and May 31, 2016, regarding STEMI patients identified by PCPs.

Applying Kane's validity framework to a simulation based assessment of clinical competence.

Assessment of clinical competence is complex and inference based. Trustworthy and defensible assessment processes must have favourable evidence of validity, particularly where decisions are considered high stakes. We aimed to organize, collect and interpret validity evidence for a high stakes simulation based assessment strategy for certifying paramedics, using Kane's validity framework, which some report as challenging to implement.

A comparison of intimate partner and other sexual assault survivors' use of different types of specialized hospital-based violence services.

Background: Little is known about the health service utilization of women sexually assaulted by their intimate partners, as compared with those sexually assaulted by other perpetrators. To address this gap, we describe the use of acute care services post-victimization, as well as a broad range of survivor and assault characteristics, across women assaulted by current or former intimate partners, other known assailants, and strangers.

Methods: Information was gathered from individuals presenting to 30 hospital-based sexual assault and domestic violence treatment centres using a standardized data collection form.

Visualizing Flagella while Tracking Bacteria.

A complete description of the swimming behavior of a bacterium requires measurement of the displacement and orientation of the cell body together with a description of the movement of the flagella. We rebuilt a tracking microscope so that we could visualize flagellar filaments of tracked cells by fluorescence. We studied Escherichia coli (cells of various lengths, including swarm cells), Bacillus subtilis (wild-type and a mutant with fewer flagella), and a motile Streptococcus (now Enterococcus).

On-Premise Alcohol Establishments and Ambulance Calls for Trauma, Assault, and Intoxication.

Alcohol contributes to intentional and unintentional injury. We explored on-premise licensed alcohol establishments (LAEs) and emergency medical service (EMS) ambulance calls.We completed a retrospective population-based study in the Region of Peel, Ontario, 2005 to 2014, where alcohol sales are tightly regulated and healthcare is universally available.

Expanding Paramedicine in the Community (EPIC): study protocol for a randomized controlled trial.

Background: The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting.

Assessment of the safety and effectiveness of emergency department STEMI bypass by defibrillation-only emergency medical technicians/primary care paramedics.

Introduction: The American Heart Association (AHA) suggests emergency medical service (EMS) providers transporting ST-segment elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) center require advanced life support (ALS) skills.

Objectives: To evaluate the potential safety and time savings effectiveness of defibrillation-only emergency medical technician/primary care paramedic (EMT-D/PCP) EMS transport to a PCI center in a system where only emergency medical technician-paramedics/advanced care paramedics (EMT-Ps/ACPs) are authorized to bypass non-PCI hospitals.

Methods: We reviewed 89 consecutive patients meeting STEMI criteria transported by EMT-Ds/PCPs per protocol by one of three paths: 1) closest non-PCI center emergency department (ED) with secondary transfer by EMT-Ps/ACPs to a PCI lab, 2) rendezvous with EMT-Ps/ACPs and diversion to a PCI lab, and 3) PCI center ED if it was closest.