Introduction: Trauma resuscitations are plagued with high stress and require time sensitive and intensive interventions. It is a landscape that is a perfect hot bed for clinical errors and adverse events for patients. We sought to describe the adverse events and errors that occur during trauma resuscitation and any associated outcomes. Methods: Medline was searched for a combination of key terms involving trauma resuscitation, adverse events and errors from January 2000 to May 2019. Studies that described adverse events or errors in initial adult trauma resuscitations were included. Two reviewers analyzed papers for inclusion and exclusion criteria with a third reviewer for any discrepancies. Descriptions of errors, adverse events and associated outcomes were collated and presented. Results: A total of 3,462 papers were identified by our search strategy. 18 papers met our inclusion and exclusion criteria and were selected for full review. Adverse events and errors reported in trauma resuscitation included missed injuries, aspiration, failed airway, and deviation from protocol. Rates of adverse events and errors were reported where applicable. Mortality outcomes or length of stay were not directly correlated to adverse events or errors experienced in the trauma resuscitation. Conclusion: Our study highlights the predominance of adverse events and errors experienced during initial trauma resuscitation. We described a multitude of adverse events and errors and their rates but further study is needed to determine outcome differences for patients and possibility for quality improvement.

Introduction: Delays in definitive management of critically ill patients are known to drive poor clinical outcomes. A scarcely studied time period in interfacility transfer is the time between initial patient presentation and the decision to transfer. This study seeks to identify patient, environmental and institutional characteristics associated with delays in decision to transfer critically ill patients by air ambulance to a tertiary care centre. Methods: Patients >18 years old who underwent emergent air ambulance interfacility transport to a tertiary care centre were included. Patient records were located in a provincial air ambulance database. The primary exposure variable was time from patient presentation to initial call to facilitate transfer. Patient, environmental and institutional characteristics were identified using stepwise variable selection at a significance of 0.1. These characteristics were then explored using quantile regression to identify significant factors associated with delay in transport initiation. Results: A total of 11231 patients were included in the analysis. There were 5009 females (44.60%) and 6222 males (55.4%). The median age of patients was 57. The median time to initiate the transfer was 3.05 hours. The variables identified with stepwise selection were gender, category of illness, heart rate, systolic blood pressure, Glasgow coma scale, vasopressor usage, blood product usage, time of day, and type of sending site. The following factors were significantly (p < 0.05) associated with an increase in time to initiate transfer compared to the reference category at the 90th centile of time: cardiac illness (+1.45h), gastrointestinal illness (+3.27h), respiratory illness (+4.90h), sepsis (+3.03h), vasopressors (+2.31h), and an evening hour of transport (+3.67h). The following factors were significantly (p < 0.05) associated with a decrease in time to initiate transfer compared to the reference category at the 90th centile of time: neurologic illness (-1.45h), obstetrical illness (-1.56h), trauma (-3.14h), GCS <8 (-0.98h), blood transfusion (-1.47h), and sending site being a community hospital >100 beds (-2.26h), <100 beds (-4.71h), or nursing station (-10.02h). Conclusion: Time to initiate transfer represents a significant window in a patient's transport journey. In looking at the predictors of early or late initiation of transfers, these findings provide education and quality improvement opportunities in decreasing time to definitive care in critically ill populations.

Introduction: Trauma resuscitations are sporadic high acuity situations that can be difficult to assess for areas of quality improvement. We aim to analyse the type of observation that occurs during trauma resuscitations and outcomes that develop as a result. Methods: Medline was searched from 1946 to May 2019 for studies involving direct observation of trauma resuscitation. English studies of both adult and pediatric populations from 2000 onwards were included for study. They were compared for type of observation (in-person vs video) as well as primary outcomes of their observation and any quality improvement as a result. Results: A total of 413 publications were identified with 10 meeting eligibility for inclusion. All 10 studies underwent video review with no in-person review being performed. The most common primary outcome was analysis of a critical procedure (6 studies), with tracheal intubation being studied in 4 studies and thoracotomy and vascular access each being studied once. The remaining studies measured communication styles and team effectiveness. Overall 5 of the 10 studies resulted in new policies being put in place for trauma resuscitations, including; use of interosseous lines as first lines in trauma patients in extremis, tracheal intubation check list, and continuing with medical student participation in cardiopulmonary resuscitation. Conclusion: This study highlights some of the common focuses of trauma resuscitation observation; critical procedures, team dynamics and communication. A majority of studies focused on critical procedures during resuscitations and quality improvement in the form of checklists to improve them. Remaining studies focused on equally important aspects of team functioning and communication which can be more difficult to objectively measure and derive quality improvement measures for. These studies led an emphasis on use of a horizontal assessment style and closed loop communication in all their trauma resuscitation.

Introduction: Vast geography and low population density limit availability of specialized trauma and medical care in many areas of Ontario. As such, patients with severe illnesses often require a higher level of care than local facilities can provide and thus require an interfacility transfer to access tertiary or quaternary care. In Ontario, Ornge, a provincially run air ambulance, serves as the sole provider of air-based medical and critical care transport. Patient outcomes are impacted by the time to definitive care, yet little research about reasons for delay in interfacility transfer within Ontario has been conducted. This study aimed to identify causes of delay in interfacility transport by air ambulance in Ontario. Methods: Causes of delay were identified by manual chart review of electronic patient care records (ePCR). All emergent adult interfacility transfers for patients transported by Ornge between Jan. 1-Dec. 31, 2016 were eligible for inclusion. Patient records were flagged to be manually reviewed if they met one or more of the following criteria: 1) contained a standardized delay code; 2) the ePCR free text contained “delay”, “wait”, “duty-out”, or common misspellings therein; 3) were above the 75th percentile in total transport time; or 4) were above the 90th percentile in time to patient bedside, time spent at the sending hospital, or time to receiving facility. Each trip was categorized as having delays that fall into one or more of the following categories: time-to-sending delays, in-hospital delays, and time-to-receiving/handover delays. Results: Our search strategy identified 1,220 records for manual review and a total of 872 delays were identified. The most common delays cited included aircraft refuelling (234 delays); waiting for land EMS escort (144); and unstable patients requiring advanced care such as intubation, procedures, or transfusion (79). Other delays included handover or delays at the receiving facility (42); mechanical issues (36); dispatch-related issues (53); environmental hazards (43); staffing issues (47); and equipment problems (38). Conclusion: Some common causes of interfacility delay are potentially modifiable: better trip planning around refueling, and improved coordination with local EMS could impact many delayed interfacility trips in Ontario. Our analysis was limited by number and completeness of available records, and documentation quality. To better understand causes for delay, we would benefit from improved documentation and record availability.

Introduction: Timely access to definitive care has been associated with improved outcomes for injured patients. Air ambulance services have become an integral part of Canadian trauma systems to help provide earlier access to a lead trauma centre (LTC). Multiple factors can lead to non-optimal resource utilization resulting in potential transport delays. The goal of this study is to identify patient, institutional and paramedic risk factors for non-optimal resource utilization for interfacility transfers of injured adult patients transported by air ambulance to a LTC. Methods: Ornge is a paramedic-staffed organization that is the sole provider of air ambulance services from a non-trauma centre to a LTC for the province of Ontario, Canada. This is a retrospective cohort study of all Ornge adult emergent interfacility transports over a 5-year period. Data was collected on patient demographics and clinical status, sending facilities, transport details and paramedic qualifications. Optimal resource utilization was determined based on distance and historical times. A logistic regression model was used to explore patient, provider and institutional risk factors for non-optimal resource use. Results: Between January 1, 2013 and December 31, 2017 a total of 1777 injured patients underwent interfacility transport with Ornge. Of these 805 were identified as having non-optimal resource utilization. Patients who had an optimal resource use were found to be older and mechanically ventilated. Risk factors increasing odds of non-optimal transport included patients transported from a nursing station (OR 1.94), transport with primary or advanced care paramedics (OR 6.57 and 1.44, respectively) and transport between both 0800-1700 and 1700-0000 (OR 1.40 and 1.54, respectively). The median delay to arrival to receiving facility if a patient had a non-optimal resource use was 40 minutes Conclusion: We were able to identify several factors resulting in non-optimal resource utilization. We believe that nursing stations as a sending facility and type of paramedics crew transporting patients resulted in non-optimal resource utilization mainly due to these patients being of lower acuity and this affecting their triage. However the timing of day is more likely to be a resource availability issue and something that can be further studied and potentially improved.

The present study evaluated the behaviour of the AusBeef model for beef production as part of a 2 × 2 study simulating performance on forage-based and concentrate-based diets from Oceania and North America for four methane (CH4)-relevant outputs of interest. Three sensitivity analysis methods, one local and two global, were conducted. Different patterns of sensitivity were observed between forage-based and concentrate-based diets, but patterns were consistent within diet types. For the local analysis, 36, 196, 47 and 8 out of 305 model parameters had normalized sensitivities of 0, >0, >0·01 and >0·1 across all diets and outputs, respectively. No parameters had a normalized local sensitivity >1 across all diets and outputs. However, daily CH4 production had the greatest number of parameters with normalized local sensitivities >1 for each individual diet. Parameters that were highly sensitive for global and local analyses across the range of diets and outputs examined included terms involved in microbial growth, volatile fatty acid (VFA) yields, maximum absorption rates and their inhibition due to pH effects and particle exit rates. Global sensitivity analysis I showed the high sensitivity of forage-based diets to lipid entering the rumen, which may be a result of the use of a feedlot-optimized model to represent high-forage diets and warrants further investigation. Global sensitivity analysis II showed that when all parameter values were simultaneously varied within ±10% of initial value, >96% of output values were within ±20% of the baseline, which decreased to >50% when parameter value boundaries were expanded to ±25% of their original values, giving a range for robustness of model outputs with regards to potential different ‘true’ parameter values. There were output-specific differences in sensitivity, where outputs that had greater maximum local sensitivities displayed greater degrees of non-linear interaction in global sensitivity analysis I and less variance in output values for global sensitivity analysis II. For outputs with less interaction, such as the acetate : propionate ratio and microbial protein production, the single most sensitive term in global sensitivity analysis I contributed more to the overall total-order sensitivity than for outputs with more interaction, with an average of 49, 33, 15 and 14% of total-order sensitivity for microbial protein production, acetate : propionate ratio, CH4 production and energy from absorbed VFAs, respectively. Future studies should include data collection for highly sensitive parameters reported in the present study to improve overall model accuracy.

Introduction: Helicopter emergency medical services (HEMS) have become an engrained component of trauma systems to expedite transportation to a trauma centre. Ornge is a provincially run, paramedic-staffed HEMS that is responsible for all air ambulance service within Ontario, Canada. They provide transportation for trauma patients through one of three ways: scene call, modified scene call or interfacility transfer. In this study we report the characteristics of patients transported by each of these methods to two level 1 trauma centres and assess for any impact on morbidity or mortality. Methods: A local trauma registry was used to identify all patients transported to our two trauma centres by HEMS over a 36-month period. Data surrounding patient demographic, arrival characteristics, transport times and in-hospital course were abstracted from the registry. Statistical analysis will be used to compare methods of transport and characterize any association between mode of transport and mortality. Results: From January 1st, 2012 to December 31st, 2014 HEMS transferred a total of 911 patients to our trauma centers with an overall mortality rate of 11%. Of these patients 139 were scene calls with a mortality rate of 8%, 333 were modified scene calls with a mortality rate of 14% and 439 were interfacility transfers with a mortality rate of 10%. Conclusion: Identifying any association between the type of HEMS transport and morbidity and mortality, we may be able to predict those that need more urgent transfer to a trauma centre and find ways to decrease our overall pre-trauma center time.

Introduction: Smartphones are everywhere. Recent technological advances allow for instantaneous high quality video and audio recordings with the touch of a button. In Canada, physician smartphone use is highly regulated by provincial legislature and multiple policies have been published from provincial physician colleges and the Canadian Medical Protective Association (CMPA). Patients on the other hand have no such laws to observe. We set out to look at what legislation and policies exist to provide guidance to physicians in two potential scenarios: when a patient requests to record a patient-physician interaction and if a patient surreptitiously records a patient-physician interaction without consent of the physician. Methods: A literature review searching for articles on patient video recordings and patient smartphone use was completed on both Medline and PubMed. Further review of each provincial privacy act and communication with each provincial privacy office was performed. Consultation with each provincial physician college and the CMPA was also done to identify any policies or recommendations to guide physicians. Results: Patients making video recordings do not fall under any provincial privacy law and there are no existing policies from any provincial physician college or the CMPA to provide guidance. Therefore, physicians must rely on their own institution’s policy regarding patient video recording in the health care setting. Be familiar with your institution’s policy. If your institution does not have a policy, create one with the input of appropriate stakeholders. Patients may surreptitiously video record medical interactions without physician consent. Although this may not be permitted under an individual institution’s policy, it is not illegal under the Criminal Code. Thus, it is important to behave in a professional manner at all times and assume you may be recorded at any time. Conclusion: The majority of patients’ recordings will be done without litigious intentions, but rather with the goal of understanding more about their own health and medical care. Unfortunately there are those who will undermine the physician-patient relationship. Physicians cannot allow this to cause distrust in future relationships, nor should it force physicians to practice more defensive medicine. Physicians must continue to practice the art of medicine and accept that “performance” is a part of the job.

The influence of feeds containing varying dietary cation–anion differences (DCADs) with and without supplements of 25-hydroxyvitamin D (25(OH)D) on urine pH and excretion of macro minerals was determined in fistulated crossbred steers (mean live weight 315 ± 45 kg). A basal forage diet comprising lucerne hay and wheat chaff was used, to which varying quantities of MgCl2 or K2CO3 were added to achieve four levels of DCAD: −300, 50, 150 or 250 mEq/kg dry matter (DM). Steers were allocated to one of six treatments, one treatment for each diet and a further treatment for both the 50 and 150 mEq/kg DCAD diets, which were supplemented with 25(OH)D at a rate of 3 mg/steer per day. Urine pH from steers offered the diets comprising DCADs of 50, 150 and 250 mEq/kg ranging from 8.3 to 8.8. In treatments not containing 25(OH)D with DCADs of 50 to 250 mEq/kg, there were no significant differences in urine pH or Ca excretion. However, steers offered the diet with a DCAD of −300 mEq/kg DM produced urine with a significantly lower pH (6.5 to 7.5). Daily output of Ca in urine was also significantly higher from steers given this diet. Supplementation with 25(OH)D significantly increased urinary Ca excretion from steers offered diets of DCADs 50 and 150 mEq/kg DM. Estimates of daily urinary Ca excretion, calculated using the ratio of creatinine to Ca in ‘spot’ urine samples, were less variable than those based on total collection (residual mean square of 0.54 and 0.63, respectively).

A total of 14 known fatty acids and one unknown fatty acid were detected in the third instar, fourth instar, prepupa, and female and male pupae of the eastern hemlock looper, Lambdina fiscellaria fiscellaria. The C8:0,3 C10:0, C22:1, and C24:0 fatty acids and an unknown fatty acid were not detected in the third instar larvae, and the unknown was also absent from the fourth instar larvae. The C24:0 fatty acid was absent from the prepupae and both the male and female pupae. The C22:1 fatty acid was absent from the prepupae. Otherwise, developmental stages contained the C8:0, C10:0, C14:0, C15:0, C16:0, C18:0, C18:1, C18:2, C18:3,C20:0, C20:1, C22:0, C22:1, and the C24:0 fatty acids and the unknown fatty acid. In general, the level of a given fatty acid decreased with succeeding developmental stages. The lipid level was also determined for each developmental stage.

Five types of hemocytes (plasmatocytes, granular cells, spherule cells, oenocytoids, and prohemocytes) were identified in the larval, prepupal, and pupal stages of the spruce budworm, Choristoneura fumiferana (Clem.). Hemocyte numbers (total hemocyte counts and absolute hemocyte counts) increased during larval development. The absolute counts were greater in female larvae than in the male larvae during the fourth instar but were higher in the males during the fifth and sixth instars. Hemocyte numbers peaked in the prepupal stage in females and in the early pupal stage in males. The plasmatocytes and granular cells were the predominant hemocytes in both sexes. The plasmatocytes decreased and the granular cells increased throughout larval development of both sexes. There were more plasmatocytes in the males than in the females in all stages of development. There were more granular cells in the males than the females until the sixth instar when the reverse occurred.