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Introduction: The emergency department (ED) in rural communities is essential for providing care to patients with urgent medical issues and those unable to access primary care. Recent physician staffing shortages have put many EDs at risk of temporary closure. Our goal was to describe the demographics and practices of the rural physicians providing emergency medicine services across Ontario in order to inform health human resource planning. Methods: The ICES Physician database (IPDB) and Ontario Health Insurance Plan (OHIP) billing database from 2017 were used in this retrospective cohort study. Rural physician data were analysed for demographic, practice region and certification information. Sentinel billing codes (i.e., a billing code unique to a particular clinical service) were used to define 18 unique physician services. Results: A total of 1192 physicians from the IPDB met inclusion as rural generalist physicians out of a total of 14,443 family physicians in Ontario. From this physician population, a total of 620 physicians practised emergency medicine which accounted for 33% of their days worked on average. The majority of physicians practising emergency medicine were between the ages of 30 and 49 and in their first decade of practice. The most common services in addition to emergency medicine were clinic, hospital medicine, palliative care and mental health. Conclusion: This study provides insight into the practice patterns of rural physicians and the basis for better targeted physician workforce-forecasting models. A new approach to education and training pathways, recruitment and retention initiatives and rural health service delivery models is needed to ensure better health outcomes for our rural population.

Résumé Introduction: Le service d'urgence des communautés rurales est essentiel pour la prise en charge des patients présentant des problèmes médicaux urgents et de ceux qui ne peuvent accéder aux soins primaires. En raison de la récente pénurie de médecins, de nombreux services d'urgence risquent de fermer temporairement. Notre objectif était de décrire les caractéristiques démographiques et les pratiques des médecins ruraux qui fournissent des services de médecine d'urgence en Ontario afin d'éclairer la planification des ressources humaines en santé. Méthodes: La base de données des médecins de l'ICES (IPDB) et la base de données de facturation de l'assurance-santé de l'Ontario (OHIP) de 2017 ont été utilisées dans cette étude de cohorte rétrospective. Les données sur les médecins ruraux ont été analysées pour obtenir des renseignements sur la démographie, la région de pratique et la certification. Les codes de facturation sentinelle (c'est-à-dire un code de facturation unique pour un service clinique particulier) ont été utilisés pour définir 18 services médicaux uniques. Résultats: Sur un total de 14 443 médecins de famille en Ontario, 1 192 médecins de l'IPDB ont été inclus en tant que médecins généralistes ruraux. Parmi cette population de médecins, 620 pratiquaient la médecine d'urgence, ce qui représentait 33% de leurs jours de travail en moyenne. La majorité des médecins qui pratiquaient la médecine d'urgence étaient âgés de 30 à 49 ans et en étaient à leur première décennie de pratique. Les services les plus courants en plus de la médecine d'urgence étaient la clinique, la médecine hospitalière, les soins palliatifs et la santé mentale. Conclusion: Cette étude permet de mieux comprendre les modes de pratique des médecins ruraux et de jeter les bases de modèles de prévision des effectifs médicaux mieux ciblés. Une nouvelle approche des parcours d'éducation et de formation, des initiatives de recrutement et de rétention et des modèles de prestation de services de santé en milieu rural est nécessaire pour garantir de meilleurs résultats en matière de santé pour notre population rurale. Mots-clés: Médecine d'urgence, médecins ruraux, planification des ressources humaines en santé.

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OBJECTIVES: We aimed to determine the rate of adverse events during interfacility transport of cardiac patients identified as low risk by a consensus-derived screening tool and transported by primary care flight paramedics (PCP(f)). METHODS: We conducted a health records review of adult patients diagnosed with a cardiac condition who were identified as low risk by the screening tool and transported by PCP(f). We excluded patients transported by an advanced care crew, those accompanied by a clinical escort from hospital, and those transported from a scene call, by rotary wing or ground vehicle. We recorded patient and transportation parameters using a piloted-standardized collection tool. We defined adverse events during transport a priori. We report descriptive statistics using mean (standard deviation), [range], (percentage). RESULTS: We included 400 patients: mean age 66.9 years old, 66.5% male. Mean transport duration was 136.2 (74.9) minutes. Most common comorbidities were hypertension (50.3%) and coronary artery disease (39.5%). Most transports originated out of Northern Ontario and were for cardiac catheterization (61.8%) or coronary artery bypass grafting (26.8%). Overall, the adverse event rate was low (0.3%), with no serious event such as cardiac arrest, death, or airway intervention. CONCLUSIONS: A screening tool can identify cardiac patients at low risk for clinical deterioration during air-medical transport. We believe patients screened with this tool can be transported safely by a PCP(f) crew, leading to potentially significant resource savings.

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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.

OBJECTIF: Compte tenu de la régionalisation des soins en traumatologie, la durée des transports pour raison médicale peut être prolongée, ce qui oblige les ambulanciers paramédicaux à traiter les symptômes et à donner des soins. L'étude visait donc à évaluer le soulagement de la douleur durant le transport aérien des polytraumatisés. MÉTHODE: L'étude consistait en un examen de dossiers électroniques d'ambulanciers paramédicaux, provenant d'une agence provinciale de transport de blessés en phase critique, sur une période de 12 mois. Les critères d'inclusion comprenaient un âge ≥ 18 ans et le transport aérien vers un centre de traumatologie; et les critères d'exclusion, un score < 14 sur l'échelle de Glasgow, l'intubation ou l'accompagnement d'un médecin ou d'une infirmière. La collecte d'éléments factuels se composait de données démographiques, de renseignements sur les blessures et de paramètres relatifs au transport. Les résultats étudiés comprenaient l'évaluation de la douleur sur une échelle numérique de 11 points, les modes d'administration des analgésiques et les événements indésirables liés à l'analgésie. Les résultats sont exprimés sous forme de moyenne ± l'écart type [fourchette], (pourcentage). RÉSULTATS: Ont été retenus dans l'étude 372 patients : âge : 47,0 ans; hommes : 262; contusions : 361. La durée de transport était de 82,4 ± 46,3 minutes. Parmi les 232 patients (62,4%) qui ont reçu des analgésiques, la douleur au départ s'élevait à 5,9 ± 2,5 sur l'échelle numérique. Le médicament le plus souvent administré était le fentanyl, à raison de 44,3 µg [25­60]. Une diminution de l'intensité de la douleur de 1,1 [-2­7] sur l'échelle numérique a été enregistrée après la première dose d'analgésique; par la suite, 171 patients (73,7%) ont reçu 2,4 doses additionnelles [1­18]. De leur côté, 44 patients (23,4%) n'ont noté aucun changement sur l'échelle numérique après la première dose d'analgésique, et les doses suivantes n'ont rien changé à l'évaluation de la douleur chez plus de 65% des patients. Enfin, 43 événements indésirables ont été enregistrés, dont le plus fréquent était les nausées (39,5%). CONCLUSIONS: Les doses initiales et subséquentes d'analgésiques ont eu peu d'effets sur le soulagement de la douleur, selon l'évaluation faite sur l'échelle numérique, probablement en raison d'un dosage inadéquat, du moins en partie. Aussi faudrait-il mener des études sur les obstacles à l'administration d'une analgésie appropriée et sur la manière de les vaincre.

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We report a passively Q-switched all-fiber laser using a large mode area (LMA) Yb(3+)-doped fiber cladding-pumped at 915 nm and an unpumped single-mode Yb(3+)-doped fiber as the saturable absorber (SA). The saturable absorber fiber and gain fiber were coupled with a free-space telescope to optimize the coupling efficiency between the disparate fibers, preferentially bleaching the SA fiber before gain depletion in the pumped fiber. Using this scheme we first demonstrate a Q-switched oscillator with 40 µJ 79 ns pulses at 1026 nm, and show that pulses can be generated from 1020 nm to 1040 nm. The associated peak power of the oscillator alone is more than two orders of magnitude larger than that reported in previous experimental studies using an Yb(3+)-doped fiber as a saturable absorber. We further demonstrate an amplified pulse energy of 0.4 mJ using an Yb(3+)-doped cladding pumped fiber amplifier. Experimental studies in which the saturable absorber length, pump times, and wavelengths are independently varied reveal the impact of these parameters on laser performance.

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We report a design for a power-scalable all-fiber passively Q-switched laser that uses a large mode area Yb-doped fiber as a gain medium adiabatically tapered to an unpumped single-mode Yb-doped fiber, which serves as a saturable absorber. Through the use of a comprehensive numerical simulator, we demonstrate a passively Q-switched 1030 nm pulsed laser with 14 ns pulse duration and 0.5 mJ pulse energy operating at 200 kHz repetition rate. The proposed configuration has a potential for orders of magnitude of improvement in both the pulse energies and durations compared to the previously reported result. The key mechanism for this improvement relates to the ratio of the core areas between the pumped inverted large mode area gain fiber and the unpumped doped single-mode fiber.

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In addition to fiber nonlinearity, fiber dispersion plays a significant role in spectral broadening of incoherent continuous-wave light. In this paper we have performed a numerical analysis of spectral broadening of incoherent light based on a fully stochastic model. Under a wide range of operating conditions, these numerical simulations exhibit striking features such as damped oscillatory spectral broadening (during the initial stages of propagation), and eventual convergence to a stationary, steady state spectral distribution at sufficiently long propagation distances. In this study we analyze the important role of fiber dispersion in such phenomena. We also demonstrate an analytical rate equation expression for spectral broadening.

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A real-time, noninvasive approach for detecting trace amounts of vapor-phase mercuric chloride (HgCl(2)) in combustion flue gas is demonstrated using a near-infrared pulsed fiber amplifier that is frequency converted to the ultraviolet. Excitation of the HgCl(2) ([see text]) transition at 213 nm generates 253.7 nm emission from the Hg (6(3)P(1)) photoproduct that is proportional to the concentration of HgCl(2). A measured quadratic dependence of the HgCl(2) photofragment emission (PFE) signal on the laser irradiance indicates that the photodissociation process involves two-photon excitation. Additionally, low concentrations of HgCl(2) are detected with the PFE approach in an environment characteristic of coal-fired power-plant flue gas using this compact solid-state laser source. A detection limit of 0.7 ppb is extrapolated from these results.

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We report a multimode, double-clad, Yb-doped fiber amplifier that produces diffraction-limited, 0.8-ns pulses with energies of 255 muJ and peak powers in excess of 300 kW at a repetition rate of ~8 kHz . Single-transverse-mode operation was obtained by bend-loss-induced mode filtering of the gain fiber.