The Employment of Emergency Medical Units of the National Medical Stockpile

Canada has a good National Medical Stockpile valued at 21 million dollars and consisting of packaged emergency medical units ready for use in peacetime or wartime disaster. These units are available for release to provinces for pre-positioning in selected communities provided that certain storage conditions are met and that physicians and other key health workers are prepared to take operational charge of the equipment. The major packaged units are the Emergency Hospital with a capacity of 200 beds, the Advanced Treatment Centre with equipment to give emergency medical care to 500 casualties, the Casualty Collecting Unit with equipment to give first-aid care to 500 casualties, the Emergency Blood Depot, the Emergency Clinic and the Emergency Public Health Laboratory. In addition, training equipment, supplies and units are provided.

The value of the stockpile has already been demonstrated in disasters occurring inside and outside Canada. Ten Emergency Hospitals have been shipped to South Vietnam for civilian use. A similar Emergency Hospital was flown to Yellowknife, N.W.T., within 24 hours of the destruction, by fire, of the Stanton Yellowknife Hospital in May 1966.

     

Emergency Blood Services

The prime and essential function of any emergency blood service is to provide ample supplies of blood and blood derivatives to the medical services operating in the post-nuclear disaster period with as much despatch and precision as possible. To meet these needs, a plan has been devised in Canada whereby 600,000 units of whole blood may become available for the treatment of an estimated 200,000 living casualties in the two- to three-week period immediately following a national disaster. The disaster organization is based upon the existing Canadian Red Cross Blood Transfusion Service which is currently providing blood and blood fractions to all hospitals, coast to coast, through its 16 depots.

The key to the emergency operation is the establishment of shadow depots in preselected sites 50 to 75 miles from the existing depots and in places free of fallout.

Stockpiling of essential blood transfusion supplies and equipment, along with a peace-time training program of essential personnel, is a prerequisite for the success of the plan.

     

Perforated Peptic Ulcer

Because no large series of perforated peptic ulcers has been reported from Canada, 402 cases from the Ottawa Civic Hospital were reviewed to study this dramatic disorder.

The incidence was 15 per 100,000 population annually, or one in every 1000 hospital admissions.

The incidence in females and the elderly in this series was higher than reported elsewhere. The risk of perforation increased with age, being greatest after 55; this was not due to an excess of chronic ulcers in older patients, indicating that ageing is an etiological factor.

As the mortality of perforated peptic ulcer—20%—had remained unchanged over the years, fatal cases were studied to see if changes should be made in the management of this condition. The mortality for patients undergoing operation was 7.5%. Patients treated conservatively because their general condition was poor, died. Fifteen patients, in whom an incorrect diagnosis was made, died. More aggressive therapy and greater efforts at diagnosis might have saved some of these patients.

     

Resuscitation from cardiac arrest: assessment of a system providing only basic life support outside of hospital

Resuscitation outside of hospital of victims of cardiac arrest is a major challenge to our emergency care system. Most cities in Canada do not have a mobile advanced life support service; instead they rely on basic life support outside of hospital. The outcome in such cases and the factors affecting the outcome are largely unknown. Thus, it is difficult to estimate the lifesaving potential of adding advanced life support to the existing measures available for care outside of hospital.

A prospective study of all resuscitation attempts begun outside of hospital was conducted during 18 consecutive months in 1977-78 in Winnipeg; at that time only basic life support was available outside of hospital. Resuscitation was attempted 849 times, and 33 patients (4%) survived to be discharged from hospital. Data analysis revealed that: (a) none of the 58% of patients in asystole at the time of arrival at a hospital survived to be discharged, but 11% of the patients with ventricular fibrillation or tachycardia (27% of the entire group) survived; (b) the survival rate was lower when the interval from the emergency telephone call to the patient's arrival at the hospital exceeded 10 minutes; and (c) basic life support was begun immediately in 29% of the patients with ventricular fibrillation or tachycardia, and increased the survival rate fivefold.

The training of private citizens in basic life support is a vital component of total emergency cardiac care. A mobile advanced life support service will be effective in saving lives if it reduces the delay before definitive care is instituted, preferably to less than 10 minutes.

     

Canadian-Trained Basic Medical Scientists, 1946-47—1963-64

The number of master's and doctoral degree holders who obtained their degree in a basic medical science under the supervision of a Canadian medical faculty between 1946-47 and 1963-64 was obtained from the medical schools. Of the total degree holders, 69% are currently residing in Canada, 23% in the U.S.A., and the remaining 8% in overseas countries.

Questionnaire returns from doctoral degree holders revealed that citizenship status at the time of graduation is positively related to migration; migration rates were lowest for Canadian-born and highest for landed immigrants and foreign students. Geographic mobility during training was also found to be a significant factor which increased the propensity to migrate. One-half of those who took further postdoctorate training in the United States are currently living in the United States, compared to 15% of those who received all their training in Canada. Information on current type of employment revealed that only a quarter of the Ph.D. respondents are in a basic science teaching position in Canada.

     

The Epidemiology of Cerebral Vascular Disease in Canada: An Analysis of Mortality Data

Mortality data for cerebral vascular disease in Canada and its provinces were analysed as an initial approach to the understanding of the epidemiology of this disease. Since 1950, there has been a decline in mortality attributed to vascular lesions of the central nervous system. This decline has been more pronounced in females. Five-year average age-sex-specific rates (1960-64) showed an almost constant proportional increase with age. The highest mortality rates tended to occur in the Eastern Provinces.

From 1950 to 1964 there was a 21% decline in mortality due to intracranial hemorrhage and a concomitant 53% decline in mortality attributed to hypertensive disease. Over the same period there was a 24% increase in mortality attributed to cerebral embolism and thrombosis, and an 8% increase in mortality due to arteriosclerotic heart disease. Areal correlations offered only inconsistent support for the hypothesis that these associated trends are due to common etiologic determinants.

Evidence presently available does little to clarify to what extent these trends and differences can be attributed to coding, certification and diagnostic practices, and to what extent to changing and differing incidence and prognosis.

     

The Magnitude of the Lung Cancer Problem in Canada

Available statistics were studied to define the extent of the lung cancer problem in Canada. Because of the low overall survival in treated and untreated cases at one year, mortality figures provide a rough index of morbidity from this disease.

Male lung cancer death rates rose steadily from 3.0 to 24.6, and female rates from 1.6 to 4.0 per 100,000 population between 1931 and 1961. In males, the greatest increase occurred in the 70-74 year age group (eighteen-fold) and in females in the 80-84 year age group (seven-fold).

Lung cancer caused 2774 deaths in Canada in 1961, and was the leading cause of cancer deaths for males in all age groups from 40 to 79 years. It accounted for approximately 1 in 5 of all cancer deaths in males and 1 in 26 in females.

Lung cancer mortality in Canada has not increased to the same extent as in certain other countries, but to counter the rising trend, changes in the smoking habits of the population are required as well as community and industrial control of atmospheric carcinogens.

     

Alberta Northern Field Work, 1966: Rheumatic Heart Disease in LaCrete and Paddle Prairie

A sociologic and medical study was undertaken of the incidence of rheumatic heart disease in an isolated Mennonite colony in Northern Alberta, Canada. A group of Métis in a nearby settlement was used as a control. A total of 1294 individuals were examined, and evidence of carditis was found in 42 Mennonites.

This project is one of a series of student summer research programs sponsored by the Department of Community Medicine, University of Alberta, and supported by grants from the Provincial Department of Health during the past three summers.

The students - medical and dental - receive in Edmonton a seven- to 10-day orientation and indoctrination course dealing with the sociological, anthropological and medical problems likely to be met with in the North. Research protocol and methodological techniques are prepared and devised with student participation. A minimum of supervision is given in the field to encourage the undergraduates to adapt and adjust to a changed environment. Student response to this type of learning experience has been most encouraging.

     

Comparison of the effects of treatment of acute myocardial infarction in a coronary unit and on a general medical ward

During 1968, 400 cases of proven acute myocardial infarction were admitted to the Toronto General Hospital (mortality 25.0%).

Approximately half the patients who survived their stay in the Emergency Department were admitted to the Coronary Unit (mortality 15.6%) while the other half, because of lack of beds in the Coronary Unit, were treated on a general medical ward (mortality 26.5%). More elderly patients (> 70) were admitted to the medical wards and contributed to the higher mortality.

The frequency of successful resuscitation following cardiac arrest was twice as great in the Coronary Unit as on the medical wards. Antiarrhythmic drugs given in the Coronary Unit with the assistance of the electrocardiographic monitor did not influence the early mortality. Digitalis was used more frequently on the medical wards, but did not appear to exert an unfavourable effect on survival.

     

Attainment of Optimum Health

The history of the worker in public health is reviewed, his present activities are assessed, and predictions are made concerning his future role. It is emphasized that the public health specialist is but one member of the total health team in the community. His interdependence with other disciplines must be accepted if optimal health care is to be provided.

Although prepared specifically for public health workers, this article has direct relevance to the future of the medical profession as a whole. In view of the present intense interest in the future pattern of health care in Canada, the viewpoint of a physician with a dual background in public health and medical school administration and teaching is considered to be particularly pertinent.

     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association's activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.

Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.

Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.

There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.

     

Treatment and Mortality of Perforated Peptic Ulcer: A Survey of 852 Cases

All proved cases of perforated peptic ulcer occurring in the Greater Vancouver area during the decade 1959-1968 have been studied. The incidence of perforation was approximately 10 per 100,000 population. The mean age was 55 years and the peak age incidence was in the fifth decade. The site of perforation was pyloroduodenal in 88% of cases and simple closure was the treatment employed in 81%. The overall mortality rate was 18.3% and one-third of these fatalities were due to misdiagnosis. The operative mortality rate was 9%.

The overall mortality rate was significantly greater among women and the elderly, in gastric perforations, and in perforations occurring between 11 p.m. and 8 a.m.

A close correlation was found between operative mortality rate and the time interval between perforation and operation. This elapsed time was found to be significantly greater among women and the elderly, in gastric perforations and in perforations occurring during the night.

     

Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization.

CONTEXT: For many elderly patients, an acute medical illness requiring hospitalization is followed by a progressive decline, resulting in high rates of mortality in this population during the year following discharge. However, few prognostic indices have focused on predicting posthospital mortality in older adults. OBJECTIVE: To develop and validate a prognostic index for 1 year mortality of older adults after hospital discharge using information readily available at discharge. DESIGN: Data analyses derived from 2 prospective studies with 1-year of follow-up, conducted in 1993 through 1997. SETTING AND PATIENTS: We developed the prognostic index in 1495 patients aged at least 70 years who were discharged from a general medical service at a tertiary care hospital (mean age, 81 years; 67% female) and validated it in 1427 patients discharged from a separate community teaching hospital (mean age, 79 years; 61% female). MAIN OUTCOME MEASURE: Prediction of 1-year mortality using risk factors such as demographic characteristics, activities of daily living (ADL) dependency, comorbid conditions, length of hospital stay, and laboratory measurements. RESULTS: In the derivation cohort, 6 independent risk factors for mortality were identified and weighted using logistic regression: male sex (1 point); number of dependent ADLs at discharge (1-4 ADLs, 2 points; all 5 ADLs, 5 points); congestive heart failure (2 points); cancer (solitary, 3 points; metastatic, 8 points); creatinine level higher than 3.0 mg/dL (265 micromol/L) (2 points); and low albumin level (3.0-3.4 g/dL, 1 point; <3.0 g/dL, 2 points). Several variables associated with 1-year mortality in bivariable analyses, such as age and dementia, were not independently associated with mortality after adjustment for functional status. We calculated risk scores for patients by adding the points of each independent risk factor present. In the derivation cohort, 1-year mortality was 13% in the lowest-risk group (0-1 point), 20% in the group with 2 or 3 points, 37% in the group with 4 to 6 points, and 68% in the highest-risk group (>6 points). In the validation cohort, 1-year mortality was 4% in the lowest-risk group, 19% in the group with 2 or 3 points, 34% in the group with 4 to 6 points, and 64% in the highest-risk group. The area under the receiver operating characteristic curve for the point system was 0.75 in the derivation cohort and 0.79 in the validation cohort. CONCLUSIONS: Our prognostic index, which used 6 risk factors known at discharge and a simple additive point system to stratify medical patients 70 years or older according to 1-year mortality after hospitalization, had good discrimination and calibration and generalized well in an independent sample of patients at a different site. These characteristics suggest that our index may be useful for clinical care and risk adjustment.     

Studies of Male Survivors of Myocardial Infarction: IX. Mortality Experience and Insurability

The mortality of a group of Canadians who survived myocardial infarction for at least three months was compared with the mortality of medically selected lives insured in Canada at standard rates. The results were expressed as the ratio of the actual deaths incurred in the infarction group to the deaths expected according to the insured table. There were 120 men, approximately 25 in each decade from the fourth to the eighth inclusive, with no condition other than coronary disease which might affect survival. The severity and number of infarcts did not influence selection.

Calculating from the date of entry into the study the mortality ratio after 10 years was 530%. Calculating from the date of first infarction, the mortality ratio from 0 to five years was 980%, from six to 10 years 510% and after 10 years 320%. The mortality ratio was greatest in the fourth decade, 9400%, and decreased progressively: fifth, 2400%; sixth, 1300%; seventh, 400%; eighth, 230%. In the younger groups the high mortality ratios were due to the small number of expected deaths at young ages, not to an increase in the absolute number of actual deaths. In each age group the mortality ratio decreased with time but remained substantially increased even after 10 years. The mortality experience of this coronary group was worse than that of more rigidly selected, insured coronary groups.

     

A Prospectus for Canadian Studies in Medical Education

The need for factual information on all phases of medical education is widely recognized. In the United States the Association of American Medical Colleges has initiated an extensive program of research in medical education. No comparable program exists in Canada.

On the basis of studies of medical students at the University of British Columbia and the University of Saskatchewan, a prospectus for Canadian studies in medical education is suggested. Such studies might include an annual census of Canadian medical students as well as detailed studies of specific problems. Until such studies have been undertaken in Canada, only an incomplete picture of the various problems in medical education will be available.

     

Candidemia at selected Canadian sites: results from the Fungal Disease Registry, 1992-1994

BACKGROUND: Candida species are important bloodstream pathogens that are being isolated with increasing frequency. Despite the availability of effective antifungal therapy, the mortality rate associated with Candida infection remains high. With the objective of describing the epidemiology of candidemia, the Canadian Infectious Disease Society conducted a study of candidemia in Canada. METHODS: Fourteen medical centres across Canada identified all patients with candidemia from March 1992 to February 1994 through blood culture surveillance for Candida spp. Patient-related data for invasive fungal infection were compiled retrospectively by chart review using a standardized data-recording form developed for the Fungal Disease Registry of the Canadian Infectious Disease Society. Cases of Candidemia were studied in relation to underlying medical conditions, predisposing factors, concurrent infection, antimicrobial agents, antifungal treatment and deaths. RESULTS: In total, 415 cases of candidemia were identified, 48 (11.6%) in children and 367 (88.4%) in adults. The causative pathogens were C. albicans in 286 cases (68.9%), C. parapsilosis in 43 (10.4%), C. glabrata in 34 (8.2%), C. tropicalis in 27 (6.5%) and other Candida species in 18 (4.3%); polymicrobial candidemia occurred in 7 cases (1.7%). The overall mortality rate was 46%, and the rate of deaths clinically related to candidemia was 19%. However, only 13 (27%) of the children died. A univariate analysis indicated that significant risk factors for death were age greater than 60 years, therapy for concomitant bacterial infection, stay in an intensive care unit, concurrent malignant disease, cytotoxic chemotherapy and granulocytopenia, although only age and stay in an intensive care unit emerged as significant risk factors in the multivariate analysis. After adjustment for other predictors of death, only infection with C. parapsilosis was associated with a lower mortality rate than infection with C. albicans. Treatment was given in 352 (84.8%) of cases. Amphotericin B was the preferred agent in 244 cases (69.3% of those treated); fluconazole was used in 101 cases (28.7%) and ketoconazole in 5 cases (1.4%). INTERPRETATION: Candidemia in Canada is caused predominantly by C. albicans. The mortality rate associated with candidemia is high, but it varies with the species of Candida and is lower in children than in adults. Age greater than 60 years and stay in an intensive care unit were the most significant risk factors for overall mortality.     

CHEST INJURIES IN BATTLE CASUALTIES

Battle casualties treated as indoor patients at a military hospital between December 89 and December 94 were prospectively evaluated. Out of 3640 patients, 388 (10.7%) had chest injuries. Among the 388 patients 190 (48.9%) had haemothorax. Pleurocentesis was the fastest and the most reliable means of establishing the diagnosis of haemothorax. Thoracostomy with supportive care was adequate to manage 75 per cent of these cases which included more than 50 per cent of those with massive haemothorax. Twelve patients out of the 190 cases (6.3%) who presented with haemothorax needed thoracotomy. The overall mortality in this series was 7 per cent.KEY WORDS: Chest injury, Haemothorax, Pleurocentesis, Thoracostomy, Thoracotomy     

卫生运输船卫生人员合理配置的研究

目的 探讨卫生运输船需要配置的卫生人员人数及人员的专业、职称分布问题.方法 在远洋训练舰训练中,模拟战时可能收治不同数目的伤病员,确定不同收治规模至少需要配置的卫生人员及人员专业、职称分布.结果 通过卫勤演练,发现展开100张床位的卫生运输船,至少需要配置17名卫生人员,如果超过100名伤病员,只需在重要的岗位适当增加少量的卫生人员.结论 本研究提出的卫生人员配置方案,符合卫生运输船伤病员的救治特点,可为以后卫生运输船的卫勤保障提供参考依据.     

Current management of unstable angina

The patient with unstable angina (angina of recent onset, of changing pattern or occurring at rest) is at high risk of myocardial infarction and sudden death. Patients with simple angina of recent onset can generally be managed out of hospital. Those with progressive angina or angina at rest should be admitted to a coronary care unit, kept at bed-rest, and given propranolol and long-acting nitrates when such therapy is indicated. With these approaches the rate of infarction within 1 to 3 months after the onset of unstable angina is about 12% (as compared with 40% before 1970); the mortality in the same period is less than 2% (as compared with 17% before 1970), though during the first year it is about 17%, much higher than in patients with stable angina and in survivors of acute myocardial infarction.

Urgent aortocoronary bypass grafting has proven to be unnecessary and probably undesirable for most patients with unstable angina, and is now generally reserved for patients who continue to have angina in hospital while receiving full medical therapy. The ongoing management of patients whose angina is controlled during the acute phase remains controversial. The main options are to operate on every possible patient, to operate only on those with certain distributions of coronary artery lesions, and to operate only on those who have recurrent symptoms. Further studies are required to delineate the etiology and the Optimal management of unstable angina.