BackgroundThe International Federation for Emergency Medicine (IFEM) published its model curriculum for medical student education in emergency medicine in 2009. Because of the evolving principles of emergency medicine and medical education, driven by societal, professional, and educational developments, there was a need for an update on IFEM recommendations. The main objective of the update process was creating Intended Learning Outcomes (ILOs) and providing tier-based recommendations.MethodA consensus methodology combining nominal group and modified Delphi methods was used. The nominal group had 15 members representing eight countries in six regions. The process began with a review of the 2009 curriculum by IFEM Core Curriculum and Education Committee (CCEC) members, followed by a three-phase update process involving survey creation [The final survey document included 55 items in 4 sections, namely, participant & context information (16 items), intended learning outcomes (6 items), principles unique to emergency medicine (20 items), and content unique to emergency medicine (13 items)], participant selection from IFEM member countries and survey implementation, and data analysis to create the recommendations.ResultsOut of 112 invitees (CCEC members and IFEM member country nominees), 57 (50.9%) participants from 27 countries participated. Eighteen (31.6%) participants were from LMICs, while 39 (68.4%) were from HICs. Forty-four (77.2%) participants have been involved with medical students' emergency medicine training for more than five years in their careers, and 56 (98.2%) have been involved with medical students' training in the last five years. Thirty-five (61.4%) participants have completed a form of training in medical education. The exercise resulted in the formulation of tiered ILO recommendations. Tier 1 ILOs are recommended for all medical schools, Tier 2 ILOs are recommended for medical schools based on perceived local healthcare system needs and/or adequate resources, and Tier 3 ILOs should be considered for medical schools based on perceived local healthcare system needs and/or adequate resources.ConclusionThe updated IFEM ILO recommendations are designed to be applicable across diverse educational and healthcare settings. These recommendations aim to provide a clear framework for medical schools to prepare graduates with essential emergency care capabilities immediately after completing medical school. The successful distribution and implementation of these recommendations hinge on support from faculty and administrators, ensuring that future healthcare professionals are well-prepared for emergency medical care.

Development of a successful research program can seem daunting when looked at from the starting line. It will take years if not decades to succeed and become sustainable. It requires local partnerships and mentoring; it mandates the establishment of review boards; it requires national health policies to allow for protected time for research in salaries and for fund granting agencies to be set up; it requires training of researchers and support staff as well as a change in the mindset of clinical staff on the floor. It will almost inevitably require international support of some kind for low- and middle-income country researchers, be it university programs or other academic or private institutions. Success can occur; most likely it will occur by partnering with local research experts outside of emergency medicine in some combination with international networks and mentoring. Perhaps the most critical elements to success are intellectual curiosity and a burning flame of passion - and neither of those carry a financial cost.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Opioid use disorder risk assessment tools cannot be used in isolation. In combination with standardized clinical examination, and, when indicated, urine drug screening, a validated risk assessment tool, improves the ability to detect opioid misuse. Even though no single tool has been shown to have both high interobserver reliability and high sensitivity, the standardized approach has still been shown to be superior to subjective care giver assessment. This article will provide a global approach to risk assessment in addition to reviewing the available tools.

OBJECTIVE:The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system. METHODS:This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management. RESULTS:Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care. CONCLUSION:Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

OBJECTIVES:With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.METHODS:We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).RESULTS:We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25-60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2-7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).CONCLUSIONS:Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

This review article provides an overview of acute pain management. It highlights the need to provide balanced pain care while limiting harm from opioids as per the World Health Organization (WHO) recommendations for balanced pain care. Opiophobia and its impact on the use of opioids for acute severe pain are discussed. Interventions that can improve global pain care and the role of pain scales in the management of acute pain are discussed. Newer trends in acute pain management in the emergency department (ED) are also reviewed and include: low dose ketamine, intravenous lidocaine, ultra-sound guided regional anesthesia, intravenous paracetamol, and patient controlled analgesia.

Los Servicios de Urgencia han sido testigos de múltiples cambios de paradigma en un período muy corto. Es muy probable que el envejecimiento de la población produzca el cambio más grande hasta la fecha. A medida que el número de población sobre los 75 años aumenta, es muy probable que suceda lo siguiente: riesgo de colapso de las unidades de urgencia en el manejo de lesionados y enfermos agudos, debido a la poca disponibilidad de equipos geriátricos multidisciplinarios para manejar los complejos problemas no médicos de éstos. La congestión de pacientes podría escaparse de control provocando peores resultados en las unidades de urgencia. Será crucial anticiparse a la avalancha geriátrica que se viene y preparar un sistema de atención de salud tanto dentro como fuera del hospital. Si se construye una unidad de urgencia geriátrica en forma aislada se corre el riesgo de que los gobiernos designen la unidad de emergencia como el portal de entrada de todas las necesidades geriátricas, que sólo pueden comprometer un cuidado aún más agudo, un cuidado amenazado por presupuestos más restringidos, costos de salud cada vez más altos, y recursos comunitarios insuficientes.

The Emergency Department has witnessed multiple paradigm shifts within a very short period of time. It is likely that the aging of the population will create the greatest shift to date. As the number of people over age 75 swells, the demands on the emergency department to have available multi-disciplinary geriatric capabilities to manage their complex non-medical problems risk overwhelming the ability of the department to manage the acutely ill and injured as is its mandate. Crowding could spiral out of control, resulting in worsening outcomes for emergency department patients. Anticipating the geriatric tsunami and preparing a health care system, both in and outside of a hospital will be critical. Creating a geriatric emergency department in isolation risks having governments designate the emergency department as the portal of entry for all community geriatric needs, which can only compromise further acute care, care already threatened by tightened budgets, increasing health care costs and insufficient community resources.

Objective We sought to conduct a major objective of the CAEP Academic Section, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools. Methods We developed an 84-question questionnaire, which was distributed to academic heads. The responses were validated by phone by the lead author to ensure that the questions were answered completely and consistently. Details of pediatric emergency medicine units were excluded from the scan. Results At eight of 17 universities, emergency medicine has full departmental status and at two it has no official academic status. Canadian academic emergency medicine is practiced at 46 major teaching hospitals and 13 specialized pediatric hospitals. Another 69 Canadian hospital EDs regularly take clinical clerks and emergency medicine residents. There are 31 full professors of emergency medicine in Canada. Teaching programs are strong with clerkships offered at 16/17 universities, CCFP(EM) programs at 17/17, and RCPSC residency programs at 14/17. Fourteen sites have at least one physician with a Master’s degree in education. There are 55 clinical researchers with salary support at 13 universities. Sixteen sites have published peer-reviewed papers in the past five years, ranging from four to 235 per site. Annual budgets range from $200,000 to $5,900,000. Conclusion This comprehensive review of academic activities in emergency medicine across Canada identifies areas of strengths as well as opportunities for improvement. CAEP and the Academic Section hope we can ultimately improve ED patient care by sharing best academic practices and becoming better teachers, educators, and researchers.

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

ObjectiveTo explore bibliometric markers in a worldwide sample of emergency physician investigators to define global, continental and individual patterns over time.MethodsWe evaluated the number of papers published, citations received, cumulative impact factor and h-index of editorial board members of six international emergency medicine journals. We calculated the individual values for every year of each author's career to evaluate their dynamic evolution. We analysed the results by researcher world area and growth rate.ResultsWe included 107 researchers (76 American, 21 European and 10 Australasian; 46 slow-rate -group C-, 43 medium-rate -group B- and 18 fast-rate growth -group A-). The median experience was 18 (IQR: 12) years, without subgroups differences. Dynamic analysis over time showed good fit with quadratic function in all individual researchers and for all bibliometric markers (R2: 0.505–0.997), with the h-index achieving the best R2. The combined analysis of the h-index of the 107 investigators also fit the quadratic model (R2=0.49). Analysis by predefined continental and growth-rate subgroups allowed defining specific patterns (R2between 0.46–0.54 and 0.80–0.86, respectively): by continents, American researchers' h-index increased 0.632 points per year, European 0.417 and Australasian 0.341; by growth rate, researchers from group A, B and C increased 1.239, 0.683 and 0.320, respectively.ConclusionsDynamic analysis of every individual author indicator over time has a very good fit with a quadratic model, with the h-index achieving the best R2. It is also possible to construct models based on continent and rate of growth that could help to predict future expected outcomes of researchers in a particular subgroup and to classify new emerging researchers by growth rate.

Objective We assessed the relationship between the size of the 39 Journal Citation Reports (JCR) medical categories and impact factor (IF) of journals in these categories, and the implications that it might have for emergency medicine (EM) journals. Materials and methods Using the 2010 JCR database, we calculated the mean IF, 5-year IF (5y-IF), Eigenfactor (EF), and Article Influence (AI) scores including all journals for each category. We also calculated a 'weighted IF' for all journals by dividing each journal IF by the mean IF of its category. We ranked EM journals according to IF and 'weighted IF' into all the journals included in the 39 categories. We assessed the relationship between category size and bibliometric scores by linear regression. Results Category size varied from 252 journals (Pharmacology and Pharmacy) to 14 (Primary Healthcare), EM category occupying the 36th position (23 journals). The mean IF of EM category ranked in 34th position, 5-yIF in 32nd, EF in 34th, and AI in 34th position. Category size had a direct and significant association with mean IF, 5y-IF, and AI but not with mean EF. When the EM journals were ranked among all the journals according to their IF, only two (9%) were placed into the first quartile and raised up to eight (35%) when 'weighted IF' was considered. Conclusion There is a negative relationship between JCR size category and IF achieved by the journals. This places EM journals at a clear disadvantage because they represent one of the smallest clinical medical research disciplines.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

See also pp. 120–126 In this issue, Doherty et al. presented the results of a major national effort to improve ED pain management.1 Using a large group of hospitals from across Australia, the study unfortunately concentrated primarily on surrogate markers for most of their outcomes, rather than on actual patient impact. In the sole patient outcome marker of the study, and despite a ‘multifaceted intervention strategy’, there was no improvement in pain relief for patients assessed 1 h after arrival when compared with historical controls. There were improvements in surrogate markers for pain management: time to analgesia and documentation of pain scores. Pain management is related to mindset and attitudes, not objective markers such as those studied. It is of no value, for example, to document that over 90% of the time an ‘appropriate parenteral narcotic’ was used if the weight-based dose and degree of titration are not also measured. A patient might receive 10 mcg of fentanyl and thus score positive for the study point of appropriate parenteral opioid (we do not give patients narcotics as that would be a felony in most countries, but that is for another discussion). Opioids, as a class, are titratable analgesics, yet O'Connor et al. demonstrated in their study that only 21% of those who received an opioid had any titration at all.2 This poor titration had the expected result: more than half of the patients wished to receive more analgesics. Herein lies the second problem: most healthcare providers do not titrate opioids to what the patient wishes; rather, they titrate – if they titrate at all – to either a pain score that in their minds is ‘low enough’ or to a set amount of medication they feel is safe or sufficient. It is rare to have a caregiver titrate to the only appropriate patient endpoint, that of not requiring or requesting any more analgesic. There is no information about titration of opioids in the Doherty et al. study, so we cannot know what end-point was targeted by staff. We have become too focused on pain scales, corrupting their original purpose. In the United States, the Joint Council mandated measurement of pain in patients both at arrival and prior to discharge from the ED.3 That well-intentioned decree has perhaps had the opposite effect to that intended: Weng et al. demonstrated that increased use of pain scales actually decreased the use of analgesics in children with long bone fractures.4 Pain scales were developed primarily for research purposes to allow comparisons and to best measure the impact of novel medications when compared with placebo. They were meant to allow the patient to report their pain level rather than having the caregiver guess how much pain they had. For the pain scale to work as originally desired, caregivers have to believe the patient's score and also believe there is no underlying secondary gain involved. Lack of belief in patient reporting, unfortunately, seems widespread. Worse, we seem to fail to respond to a reported pain score even when we believe it: Jadav et al. found no relationship between pain scores in children with long bone fractures and time to analgesia or even whether analgesics were given or not.5 Too often in emergency medicine, we do not believe the patient's reported score; too often we do not verify that the dose of opioid given has achieved the (patient's) desired result. Todd et al. found that 42% of patients wishing to receive an analgesic did not get one.6 Singer et al. found that almost half of patients scoring an average of 7.2/10 did not wish to receive an analgesic.7 Marking the pain score on large graph at the foot of the bed every 10 min made no difference in pain scores at 2 h when compared with no documentation of pain levels, even though analgesia was initiated earlier.8 The authors stated in the title of their article that pain care was improved, because analgesics were given earlier – as happens too often in pain research, they followed the surrogate markers and essentially ignored actual patient outcomes. After all these publications, how can we still believe that use of a pain scale in the ED will lead to better pain relief? It is not the patient using the scale that is flawed, however; despite what we think, patients for the most part do not exaggerate their pain score. Rather, it is we the caregivers that are the problem, in that too often we do not trust the result. Worse, we often ignore it, treating any one patient the way we treat all patients – with a set dose that we think ‘works’ for most patients. Titrating to a specific pain score is irrational. As Singer et al. showed, there is no score where all patients will want an analgesic; similarly, there are lower scores where most patients will not wish to receive any pain relief, but some patients will. Patient activities will determine their preferred level of pain relief to some degree: a mother caring for three children may not wish to have any drowsiness, preferring to have a higher level of pain. Patient barriers and cultural backgrounds will also play roles in having a patient determine if or when he/she wishes to receive an analgesic. It may thus well be that the pain level achieved at 1 h in the study by Doherty et al. is indeed the best we can do. They did not ask the patients’ opinions; until we do, we cannot know what the ‘right’ pain score is. It comes back to attitude and mindset. In a most telling study from 2012, only 10% of children admitted with long bone fractures received adequate analgesia during their stay in the ED.9 Twenty-nine percent received no analgesic, while 80% of those who did receive an analgesic were given acetaminophen or a non-steroidal anti-inflammatory drug. In this age group, there was no concern about secondary gain, yet almost no child received proper pain care. We believe children cry because they are afraid, not because they are in pain; we believe opioids are dangerous in children. It almost seems as if we will rely on any excuse in order to not provide proper pain relief with opioids. Educational endeavours as in this study are critical, but pain education needs to start from day 1 in medical or nursing school. We have to start listening to our patients better by asking the simple question: ‘Do you wish to receive medication to relieve your pain?’ While titrating an opioid intravenously, we should be asking at set intervals: ‘Do you wish to receive more medication?’ If a patient says no, another simple question ensues: ‘Why not?’ A negative response from some patients may be because of adverse effects or their personal pain barriers, but we would not know unless we ask. This solution is very simple, but it requires us to believe our patients. It is a safe approach because the patient has to be talking to us to get another dose. It will require setting aside the mandate of pain scales everywhere but in triage; a pain scale there will prioritise people in severe pain. Research will have to change its measured outcomes to terms like ‘adequate pain relief’, ‘satisfaction with pain care’ and ‘timeliness of pain relief’. In the end, it changes our mindset to where it should be: a qualitative caring one, rather than a quantitative, objective, distrustful one. Anything less will leave us wondering yet again why we are not doing better at taking care of our patients’ pain.