The paramedic ambulance: a Canadian experience.

Prehospital critical care provided by specially trained ambulance attendants in New Westminster, BC during a 27-month period was studied. Although the most important benefit of the improved care was the prevention of sudden death in a large proportion of persons with crises due to coronary artery disease, the skills learned to provide basic life support are applicable to a wide variety of other disorders that can result in death before the patient reaches hospital.     

A Canadian hospital's experience with the automatic implantable cardioverter/defibrillator.

The automatic implantable cardioverter/defibrillator is a device that can be implanted in patients for treatment of recurrent ventricular tachycardia and ventricular fibrillation. It was recently approved for clinical use in Canada. The authors describe their experience with 12 patients (mean age 51.3 years) who underwent implantation of a defibrillator. All 12 patients had a history of documented ventricular fibrillation, which was idiopathic in 3 and due to ischemic heart disease in 9. Electrophysiologic testing revealed inducible ventricular tachycardia or ventricular fibrillation in 8 of the 10 patients tested. An important criterion for selection for implantation was failure of pharmacologic therapy to suppress ventricular arrhythmias induced during electrophysiologic testing. Of the 12 patients, 1 died within 24 hours after implantation. During a mean follow-up period of 15.5 months there were no further deaths. All the surviving patients expressed satisfaction with the device; five of the seven under the age of 60 years have returned to work, and one has returned to school. This initial favourable experience with the automatic implantable cardioverter/defibrillator suggests that future increases in the availability of the device and improvements in its function will lead to much more widespread use, as the population of patients at risk of sudden cardiac death is large.     

Ruptured uterus in pregnancy: a Canadian hospital's experience.

Between 1966 and 1985, 15 cases of complete rupture of the uterus in pregnancy were identified among 52,854 deliveries at Foothills Provincial General Hospital, Calgary, for an incidence rate of 0.3 per 1000 deliveries. Previous cesarean section (in seven patients) was not the only predisposing factor: a history of dilatation and curettage (in two patients) or laparoscopy (in one) were also implicated. Long, obstructed labour did not appear to be a factor. Rupture also occurred in patients at low risk. The most frequent immediate complication was hypotension, in five patients. The rupture site was repaired in 11 of the patients; the other 4 underwent hysterectomy. Close surveillance and prompt intervention are the keys to good fetal and maternal outcome.     

Recent trends in neonatal mortality: the Canadian experience.

In Canada between 1958 and 1977 the neonatal mortality dropped by more than 50%. the decline was most prominent from 1963 and was almost entirely due to an improvement in neonatal birthweight-specific mortality, which suggests an improvement in perinatal medical care. The timing and pattern of the decline are similar to those reported for the United States. There was a transient increase in the incidence of low and very low birthweight in both countries in the late 1960s. The cause of this increase remains unexplained.     

Assessment of clinical competence using objective structured examination.

To avoid many of the disadvantages of the traditional clinical examination we have introduced the structured clinical examination. In this students rotate round a series of stations in the hospital ward. At one station they are asked to carry out a procedure, such as take a history, undertake one aspect of physical examination, or interpret laboratory investigations in the light of a patient''s problem, and at the next station they have to answer questions on the findings at the previous station and their interpretation. As they cannot go back to check on omissions multiple-choice questions have a minimal cueing effect. The students may be observed and scored at some stations by examiners using a check list. In the structured clinical examination the variables and complexity of the examination are more easily controlled, its aims can be more clearly defined, and more of the student''s knowledge can be tested. The examination is more objective and a marking strategy can be decided in advance. The examination results in improved feed-back to students and staff.     

Canadian experience in cytology proficiency testing

The mandatory Laboratory Proficiency Testing Program (LPTP) of the province of Ontario as applied to cytology laboratories is briefly described. LPTP evaluates reporting of test slides to identify laboratories that have deficiencies. Such laboratories receive an on-site visit, followed by recommendations on means of improvement (especially educational) and subsequent monitoring. Most of the 18 cytology laboratories visited to date have shown an improved level of performance on later tests.     

Set up and run an objective structured clinical exam.

Objective structured clinical exams are increasingly used as a way of assessing a range of clinical skills at both undergraduate and postgraduate level. To those planning to introduce such assessments, this article provides basic guidance on their development and structure and the personnel required. For those already using the assessments, our article may provide new ideas or be the impetus for an exchange of ideas. For those who are facing such formal assessment as candidates, we hope this article shows the efforts that are made to achieve the necessary structure and objectivity in this type of examination.     

Therapeutic abortion and its psychological implications: the Canadian experience.

Approximately 9 months after a legal therapeutic abortion, 188 Canadian women were interviewed. One half were single and the rest were married, separated or divorced. They were matched closely for a number of demographic variables with control women who had not had abortions. Neurotic disturbance in several areas of personality functioning was assessed from questionnaire responses. Out of 27 psychological scales, differences between the abortion and control groups were found on only 3: in general, women who had had abortions were more rebellious than control women, abortion tended to be associated with somewhat greater depression in married women, and single women who had had abortions scored higher on the shallow-affect scale. However, all the personality scores were well within the normal range. Perceived social support was strongly associated with favourable psychological reactions after abortion. Use of contraceptives improved greatly after the abortion, when over 90% of women reported using contraceptives regularly.     

Wetland mitigation and compensation: Canadian experience

Since Canada’s accession to the Ramsar Convention on Wetlands in 1981, the nation’s commitment to wetland conservation and management has increased significantly. This includes the adoption of one of the World’s first national wetland conservation policies by the Government of Canada, and the adoption of complementary policy and legislative initiatives by most of the 13 provincial and territorial jurisdictions. Numerous habitat ‘no net loss’ and environmental assessment policies, regulations and guidelines for incorporating mitigation processes into development decisions affecting wetland resources are used throughout Canada. The governments of Canada and six provinces have so far adopted wetland mitigation measures. These are in addition to comprehensive wetland fish and wildlife habitat initiatives, such as the species and habitat joint ventures delivered in Canada through the North American Waterfowl Management Plan by all jurisdictions and numerous non-government partners. This paper examines the current policies, regulations and programs, as well as past implementation experience with wetland mitigation and compensation in Canada.     

Changes in timing of fertility--a Canadian experience

This paper examines the patterns of timing of births of women using data from the Canadian Fertility Survey of 1984. Semi-Markovian schemes are applied to the maternity histories of the 5315 sample women in their reproductive ages in order to measure the intensity and timing of childbearing. Age-and-duration-specific transition probabilities are found to have substantially changed for the more recent birth cohorts compared to the older cohorts.     

Accuracy of clinical diagnosis in a Canadian teaching hospital.

Two hundred autopsies were investigated to determine the correlation between the clinical and pathological diagnoses in three categories--major underlying disease, cause of death and significant incidental pulmonary findings. There was concurrence in diagnosis of the major underlying disease in 76% of cases, with 12% of disagreements being considered minor and 12% major. In only three cases might different management have affected the outcome had the correct diagnosis of the major underlying disease been made during life. There was concurrence of the diagnosis of the cause of death (which was often different from the underlying disease) in 64% of cases, and in 10% of cases the outcome might have been different had the clinical diagnosis been accurate. The clinical opinion that lung disease was the cause of death was confirmed at autopsy in 54% of cases, and 45% of the pulmonary causes of death as determined at autopsy had been recognized clinically. Major incidental pulmonary findings diagnosed clinically were confirmed in 76% of cases, and major pulmonary findings diagnosed at autopsy had been recognized clinically in 83%. The major sources of these discrepancies were pulmonary embolism and pneumonia. If autopsies are to play a role in patient management, clinicians will have to be made aware of discrepancies between clinical and autopsy diagnosis. The real test of efficacy would be modification of patient management for the good.