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Catastrophic injuries require novel approach by our plastic surgery team
It was January 23, 2012, when Karen Toop was rushed into our Trauma Centre after being hit by a snowplow. The extent of her injuries and the complex care she would need to survive was something her care team would never forget.
Category: Trauma
Dr. Kirsty Boyd was six weeks into her medical career when a patient with catastrophic injuries was rushed to The Ottawa Hospital Trauma Centre. Karen Toop had been hit by a snowplow while crossing the street on her way home from work — half her pelvis was missing when she arrived at our hospital. A multi-disciplinary team that included reconstructive plastic surgery, would not only work to save her life and get her back to her family but would also implement a unique idea to drastically improve her quality of life.
From the moment the accident happened, Karen knew her injuries were devastating. She remembers thinking about her five-year-old son at home as she lay helplessly on the road. "I kept thinking 'I can't leave him without a mother'."
Karen lost consciousness briefly and she remembers waking up in the ambulance and speaking to the paramedic. "I asked him to tell my son I love him because I really did think I was going to die. And then he said to me 'No, no, you tell him' and I didn't say anything back."
"The injury Karen had was the kind of thing we will see once in our career. It's not a typical day for us to see that kind of an injury."
— Dr. Kirsty Boyd
Ready for the most challenging cases
It was January 23, 2012, when Karen was rushed into our Trauma Centre. Dr. Boyd will never forget the day. "The injury Karen had was the kind of thing we will see once in our career. It's not a typical day for us to see that kind of an injury."
Karen Toop was treated for severe injuries at The Ottawa Hospital after being hit by a snowplow.
Her injuries were devastating. She lost one leg, her left pelvis, and several internal organs. It took the vascular, general, and trauma surgical teams to stabilize her. Two days later, the 40-year-old would be wheeled back into the operating room (OR) for plastic surgery for the first time. "I was very much a small part of a big team of people looking after Karen. Dr. Murray Allen, my mentor who's now retired, was an integral part of the case. I was relatively new on staff when she came in and was originally consulted by the other surgical services for assistance with her wound care because she had a fairly large soft tissue deficit following her injury," explains Dr. Boyd.
This was the beginning of a long road to recovery, including multiple surgeries over the many months. Karen spent two-and-a-half months in the Intensive Care Unit. While she recalls some scary moments, she also remembers the healthcare team surrounding her and helping her — each hour, each day. "They were phenomenal. I had this one nurse, Lynne, who was such a strong advocate for me — always looking out, making sure I was as comfortable as I could be — she really helped me."
Karen's most significant reconstruction surgery didn't happen until October 18, 2012. It took months of planning by the plastic surgery team and required combining existing reconstructive techniques in a novel way to rebuild Karen's pelvis and restore her independence.
Losing a portion of her pelvis in the accident meant Karen couldn't sit up. "I wasn't able to sit up more than 20 degrees from my bed. I had to eat like that, and drink like that and do everything from that position," remembers Karen.
Dr. Kirsty Boyd
"We explored a lot of options; we reached out to colleagues from all across the country. I mean, this was something that I don't think had ever been done or described before."
This is when the surgical team started to think outside the box to find a way to give Karen an improved quality of life, and to get her back home to her husband and son. Drs. Allen and Boyd worked closely with Dr. Nancy Dudek from the Rehabilitation Centre, and Dr. Allan Liew from orthopedic surgery, to think of a way to get Karen a new pelvis — what's called a neo-pelvis.
"Karen lost one leg and part of her pelvis in the accident. The other leg had all kinds of issues including poor blood flow, a loss of sensation, and significant nerve damage to the extent she couldn't move that leg. While the leg was still attached it wasn't functional," explains Dr. Boyd. She adds they spent quite a bit of time in consultation with Karen and her family before the decision was made to amputate.
For Karen, it meant putting her complete trust in her care team. "The lengths they went to save my life were incredible. They asked for input from experts around the world. Everyone came together."
Karen Toop with her son, Ryan, following her accident in 2012.
The role of reconstructive surgery in trauma
The surgery was long and complicated — almost 14 hours. "We rearranged the bone of her right leg to make a pelvis while keeping the bones attached to their soft tissue. I think origami is a very good description; you're just rearranging things and moving them into locations close to them," says Dr. Boyd.
"They were so kind, compassionate, and helpful."
— Karen Toop
It was a unique approach to a complicated case, but Karen's team saw it as the best chance to help her in the years ahead. "We explored a lot of options; we reached out to colleagues from all across the country. I mean, this was something that I don't think had ever been done or described before," explains Dr. Boyd.
The surgical expertise and collaborative effort was transformational for Karen's future. "After the surgery, I was able to sit up using a chair. I mean that happened slowly. I got the chance to do a lot of physical rehab and I started on the hand bike and doing exercises, weights, and they got me back to the point where I could sit in the chair," says Karen.
Outstanding compassionate care
Karen Toop and her son Ryan today.
In addition to her physical rehab, Karen won't soon forget the compassionate care she received throughout her recovery. "They were so kind, compassionate, and helpful. The nurses would write out the plans the doctors were making so I could visualize it better. One of my trauma members, Dr. Jacinthe Lampron, baked me a birthday cake, which she said was made with love, and nurses made cupcakes for my birthday."
"Thank you to the doctors and nurses at The Ottawa Hospital who saved my mom's life."
— Ryan Toop
Strengthening Karen's mental health and dealing with the trauma of the accident were also integral parts of her journey "They care for your emotional health through the psychologist, the physiotherapist, the physiotherapist assistants, and my personal support workers — they were all fantastic. It was incredible teamwork and just such giving people."
Going home to her family
After 11 months in the hospital and nine months at the Rehabilitation Centre, where she learned a whole new way of living, Karen moved into a retirement home until her new, accessible home was ready.
"It was really at the beginning that I knew that I was going to put The Ottawa Hospital in my will, because the hospital gave my son his mother, and that was so powerful."
But the most unforgettable part was being reunited with her family. "It was amazing. I can't describe how happy we all were, to be together again," she says.
Even more amazing was for her son, Ryan, to have his mom home. Now 14, he's grateful to have her by his side. "Thank you to the doctors and nurses at The Ottawa Hospital who saved my mom's life."
Leaving a gift in her will
The whole experience left Karen enjoying the small things in life, like hugging her family or going to watch Ryan play soccer — things she will never take for granted. It also left her reflecting on those who saved her life and fought so hard to give her a good quality of life. "My accident happened in a flash. You never know when you'll need the hospital. I went from being able-bodied to losing both my legs, so you know other things happen that maybe aren't as drastic, but you still need the hospital."
It's the specialized team who were ready for Karen when she faced critical injuries, that made her decide to leave a gift in her will to The Ottawa Hospital. "It was really at the beginning that I knew that I was going to put it in my will, because the hospital gave my son his mother, and that was so powerful."
Karen and Ryan enjoying time together at their home.
She believes she's truly fortunate to have had access to the care she received. "I got world-class healthcare, with the new technology — for example, a VAC (Vacuum-Assisted Closure) dressing. If I didn't have that, I don't think I would have survived because I would have gotten too many infections. There was also the hyperbaric chamber. I went there when my wounds weren't healing and then my wounds healed."
Karen is also thankful for the care her husband, Harvey, received at The Ottawa Hospital when he became ill — care she witnessed from the perspective of a family member this time. Sadly, Harvey passed away in November 2017.
And so, by leaving a gift in her will, she's helping patients who will come through the doors in the future and she encourages others to consider doing the same. "It's important for people in the community to support the hospital, especially when it comes to developing new technology and the new campus that's going to be built. That's an incredible endeavor for the hospital, and they need the support of the people in the community to be able to realize these goals."
For Karen, she feels it's the least she can do for the team who allowed her to realize her goal of watching her young son grow into a young man.
Two-time winner of the Show Jumping World Cup and Olympic equestrian silver medalist Ian Millar knows his way around horses. His long and storied career even led to his nickname, Captain Canada. But after a rare accident on his farm in Perth, he was rushed to The Ottawa Hospital Trauma Centre with a severe arm injury. Ian was quickly losing blood, causing deep concern for his life.
"My main barn guy, who has medical training, rushed to help along with my family. They thought I was in big trouble because of the amount of blood I was losing."
– Ian Millar
In late October 2020, Ian was riding a young mare when something startled her. She reared up on her hind legs, and then came down hard and spun around, causing Ian to be tossed over her head and onto the ground. "I was sailing through the air; I knew exactly what I was going to do in terms of landing to make sure there was no damage. Normally, the horse will do what it can to avoid stepping on you, but this one came down on me three times," says Ian.
Significant blood loss
The 74-year-old could feel pain through his ribs and one leg. However, the real concern was the damage to his left arm, just above the elbow. "I tried to get up but the bleeding was significant. The wound was about eight inches in length and I could see the nerves and muscles. My main barn guy, who has medical training, rushed to help along with my family. They thought I was in big trouble because of the amount of blood I was losing."
"They were beyond words. I want to say there were about six team members there when I arrived, and they were ready to rock and roll."
A tourniquet was quickly created to stop the bleeding while a call went out to 9-1-1 for help. Within minutes, paramedics arrived and whisked him to Carleton Place, where the helicopter was waiting to fly him to our Trauma Centre.
Ian remained conscious the entire time and says the air ambulance paramedics were fantastic as they helped control the bleeding and keep him calm until they arrived at the hospital. When wheeled into the Trauma Centre, Ian says an exceptional team awaited him. "They were beyond words. I want to say there were about six team members there when I arrived, and they were ready to rock and roll."
Ian Millar, ©Millar Brooke Farm
Trauma Centre serving eastern Ontario
With the uncertainty over the extent of damage to Ian's arm, he would need the most advanced treatment options available. Our hospital has the only Level 1 Trauma Centre in eastern Ontario — this is where the most critically injured patients from across the region, including Québec in some cases, come to for lifesaving care, often bypassing smaller community hospitals.
"I had just walked into the resuscitation bay when we received the call that an ORNGE air ambulance was on the way, and there was the risk of the life-threatening arterial bleed."
– Dr. Edmund Kwok
Today, when patients like Ian arrive by air ambulance to the Civic Campus, they need to be rushed across busy Carling Avenue from the helipad to the hospital. All that will change when the new Civic development site on Carling Avenue is complete in 2028. Our new hospital campus will save crucial time with dedicated high-speed elevators that will bring critically ill and severely injured patients directly from the rooftop helipad to a trauma bay.
Specialized teams ready
When Ian arrived, Dr. Edmund Kwok, an Emergency Department (ED) physician and Director of Quality Improvement Unit for the ED at our hospital, was waiting. He still vividly remembers that day. "It was the beginning of my shift. I had just walked into the resuscitation bay when we received the call that an ORNGE air ambulance was on the way, and there was the risk of the life-threatening arterial bleed," recalls Dr. Kwok.
With that call, Dr. Kwok and his team prepared the trauma bay for the patient's arrival. "When it's an ORNGE ambulance we know it's more severe. Our team, including physicians like myself, the nurses, and respiratory therapists are ready."
Ian was conscious, stable, and after a full assessment, the main concern remained his arm. Dr. Kwok and his team had to determine if the injury was an arterial or venous bleed — one being much more challenging than the other is. "The arterial injuries can bleed out very quickly. Therefore, it is a potentially life-threatening situation. It's like plumbing. When we release the pressure it has to be done in a very controlled manner," explains Dr. Kwok.
Dr. Edmund Kwok is a physician in the Emergency Department at The Ottawa Hospital
Expert team collaboration
Once they removed the tourniquet, Ian started to bleed out. "We put a call out to vascular, orthopaedic, and plastic surgeons. We needed these specialists involved, and their response was prompt. We had the vascular team at the bedside before Ian's imaging was completed."
"Before this, I didn't know the Civic Campus was the only trauma centre in our region. The care I received was unbelievable. We're fortunate to have that team of experts ready for any injury. It seemed to me every specialty was waiting and ready to help."
Ultimately, the vascular physician determined it was not an arterial bleed and repaired the damage to the veins before handing it off to the plastic surgeon to close the wound. It all happened very quickly, but Dr. Kwok is quick to point out this is a perfect example of having access to each specialty to ensure a positive outcome for the patient. "This is a classic example of an injury which involved different specialists. Vascular and plastic surgeons provide highly specialized services, and to have them all in one location and able to respond promptly made a huge difference in this patient's outcome because the tourniquet couldn't have been left on for much longer."
The damage to Ian's arm put him at high risk for bone injury, and that's why it was essential to have orthopaedics on site. The vascular team stopped the bleeding by tying off vessels right at the bedside while Ian awaited a CT scan and angiogram.
Going home six hours later
Remarkably, Ian went home about six hours after he was rushed into hospital. Dr. Kwok says it was an extraordinary case. "I'm glad we were able to help get Ian back home so quickly. He got really lucky. Had this happened to his head, the outcome could have been very different."
Even more amazing, there were no broken bones, only a dislocated rib and a superficial leg wound. For Ian, it was an eye-opening experience. "Before this, I didn't know the Civic Campus was the only trauma centre in our region. The care I received was unbelievable. We're fortunate to have that team of experts ready for any injury. It seemed to me every specialty was waiting and ready to help."
As an emergency medicine physician, Dr. Kwok admits it's wonderful to see a story like Ian's have this kind of ending. "No words can explain how positive it is to see Ian's outcome. It rejuvenates our team and it reminds us we are making a difference."
The Olympian was back riding within a couple of weeks with full use of his arm. And for that, he's grateful for the team that cared for him. "They were a well-oiled machine. It made me proud to be a Canadian."
When Casey Delaney was struck by an out-of-control personal watercraft two years ago, her life came to a sudden stop. Having sustained a severe traumatic brain injury, doctors weren't sure if she'd be able to walk, talk or return to her passion for teaching, ever again. But thanks to specialized rehab therapy at The Ottawa Hospital's Rehabilitation Centre, Casey was given the opportunity to get her life back on course.
The accident that changed everything
On Canada Day in 2018, Casey and her friends were sitting on an inflatable raft near the Gatineau River shoreline when the driver of a nearby personal watercraft lost control, hitting Casey and leaving her immediately unconscious.
Casey in the hospital.
Her boyfriend at the time, Scott, performed CPR until the paramedics arrived and Casey was rushed to a local hospital. However, her injuries were extensive and complex, so she was quickly transferred to our Trauma Centre at the Civic Campus for lifesaving treatment.
To reduce swelling in her brain, doctors carefully removed the left half of Casey's skull – which was later replaced with titanium mesh – and put her in a medically-induced coma. Casey was diagnosed with a severe traumatic brain injury and her medically induced coma was extended for two weeks. Her doctors weren't sure if she'd ever be able to walk, use her arms, or remember her loved ones. But when Casey woke up, there was hope.
"I had issues with walking at first, but I was getting up as soon as I could, and that's pretty lucky," says Casey, who was just 26 at the time. Lucky as she was, Casey wasn't left completely unscathed. She had newfound weaknesses on the right side of her body and issues with memory and balance that required special care.
But our experts were ready to help Casey work through these challenges and give her the chance to return to life as she knew it.
A long road ahead
In August 2018, Casey was transferred to our specialized brain injury rehabilitation program, one of only a handful like it in Ontario, that treats patients from all over eastern Ontario and as far as Nunavut. It was there that Casey participated in two months of intensive therapy, followed by what was expected to be years of outpatient rehab.
Those who survive a traumatic brain injury are often faced with life-long side effects – both physical and cognitive, that can prevent them from living independently or participating in social activities, and can cause changes in personality and behaviour. Rehabilitation can help a person regain function in these areas, and our specialists work with patients for the duration of what can be a long road to recovery.
Casey recovering in hospital.
"If you break your leg, you might expect recovery to take about three months. Brain injury is probably one to two years of ongoing recovery," explains Dr. Shawn Marshall, physiatrist and division head of physical medicine and rehabilitation, who worked closely with Casey throughout her care. "Because Casey had a severe traumatic brain injury, her prognosis for return to full-time work was less than 50 percent."
Casey, a passionate kindergarten teacher, wasn't going to let this prognosis hold her back from getting back to life, and the classroom, as soon as she could.
"I was like, 'They're wrong. I'm going back to teaching in September,' which to be clear, I was not back in September," says Casey. But, she was ready to give it her all.
Setting the stage for recovery
For patients like Casey, their care in the Trauma Centre sets the stage for their journey to recovery. Ongoing research happening right here at our hospital can help inform and improve this care.
At the time of her admission, Dr. Shane English, an ICU physician and researcher at The Ottawa Hospital, was recruiting participants for an international research trial that was investigating how to manage low blood levels in patients with a brain injury – and Casey was the perfect candidate.
"This study was brought here to truly provide the best care possible to our patients."
– Dr. Shane English
Casey with her father during recovery.
Typically, blood transfusions are only given to trauma patients with very low red blood cell levels (anemia). However, those with brain injuries are more susceptible to low hemoglobin levels and researchers were examining whether transfusions should be given more liberally to prevent significant anemia and how this might lead to improved outcomes.
"Our job is to preserve everything we can to give them the best chances of a recovery later," says Dr. English. "We've been really active in brain injury and trauma research and this study was brought here to truly provide the best care possible to our patients."
Getting back on her feet
Throughout her rehabilitation, Casey was fortunate not only to have access to the latest cutting-edge treatments, but also to be cared for by an extensive and collaborative care team of experts, including nurses, physiotherapists, occupational therapists, psychologists, social workers, speech-language pathologists, and physiatrists.
"The most effective therapies are the ones that are meaningful to you, that engage you, and that are practical to you. Rehabilitation is about getting your life back."
– Dr. Shawn Marshall
These experts, many of whom are involved in establishing the guidelines and best practices for traumatic brain injury care and management in Ontario, helped Casey through daily, three to five-hour intensive therapy sessions. Because no two brain injuries are alike, Casey's care team developed a highly customized rehabilitation program that focused on improving areas where her injury caused difficulties so she could regain function and return home.
Casey preparing to go to the Rehabilitation Centre.
Casey during a day pass while in recovery.
In some of her therapy sessions, Casey was taken into specialized rooms that mimicked areas of a home, like a bathroom and kitchen, to learn strategies to overcome her injury. Looking back, Casey remembers being surprised by some of the therapy sessions she participated in, which included activities like cooking and woodworking.
"Dr. Marshall was amazing and always had the next step ready to go. That's what my brain needed."
– Casey Delaney
"I had fine motor type classes, which seemed silly to me at the time. I teach my kindergarten students fine motor skills, but looking back, that was something I struggled with," says Casey with a laugh. "I remember being so proud that I was able to bring home a meal I'd cooked and present it to Scott, which I hadn't done in ages."
While activities like cooking may seem simple, our experts say they are complex tasks for the brain and played an integral role in Casey's rehabilitation. "When you do therapy, the most effective therapies are the ones that are meaningful to you, that engage you, and that are practical to you," explains Dr. Marshall. "Rehabilitation is about getting your life back."
An exceptional recovery
After only two months of therapy, Casey had made great progress in her rehabilitation and was ready to take the next step – going home. "By September I was out of the hospital and at home. That was huge," says Casey. There was even more reason to celebrate when Scott, who had been by Casey's side throughout her recovery, proposed.
Casey with her fiancé, Scott.
Casey continued with daily therapy at our hospital, which became less frequent as she improved. Amazingly, by the following September, Casey was back to work full-time, doing the things she loves and no longer needed therapy.
In addition to support from her family, Casey credits her care team for giving her the tools and care she needed to bounce back, beat her prognosis, and have the opportunity for a healthy future. "Dr. Marshall was amazing and always had the next step ready to go," says Casey. "That's what my brain needed."
For our experts, her recovery was nothing short of exceptional.
"The take-home of her case is how you can be drifting on a river and one second later your life is turned over and affected for the rest of your life. Casey's story is one of someone who's really worked hard," says Dr. Marshall. "She progressed to getting back to the things she loves, to her family, and impressively, back to teaching on a full-time basis, which is pretty remarkable."
The Ottawa Hospital is a leading academic health, research, and learning hospital proudly affiliated with the University of Ottawa.
"We are the only Level 1 Trauma Centre in eastern Ontario, so we see the most critically injured patients from all across the region, including Quebec in certain circumstances. Our team has the capacity to handle almost any injury."
– Dr. Maher Matar
As darkness falls over the city and most are sleeping, that's when many of our patients arrive at the Trauma Centre. My name is Maher Matar, I'm a trauma surgeon at The Ottawa Hospital, and it's not unusual to be jolted out of a sound sleep in the middle of the night after a Code One is called. I have just minutes, 20 minutes to be exact, to pull myself together, arrive at the Emergency Department (ED) of the Civic Campus, and join the rest of the trauma team that has assembled. All of us are ready and functioning at 110%. Lives depend on it.
Dr. Maher Matar, trauma surgeon at The Ottawa Hospital.
The only Level 1 Trauma Team in the region
We are the only Level 1 Trauma Centre in eastern Ontario, so we see the most critically injured patients from all across the region, including Québec in certain circumstances. Our team has the capacity to handle almost any injury.
Our team includes a trauma team leader like myself, as well as an anesthesiologist, a team of emergency nurses, a group of resident physicians, and respiratory technicians — this allows us to be ready for the wide variety of complex cases that we handle, or when a Code One is called.
A Code One means a patient with significant injuries is coming to the hospital and we need all resources gathered at the ED. It could be a few patients involved in a high-speed motor vehicle collision or a single patient that fell down the stairs. By contrast, a large-scale incident like the Westboro bus crash or any other community disaster results in a Code Orange being called.
Snowmobile crash brings life-threatening injuries
Back on January 18, 2020, I was jolted awake from the comfort of my warm bed, when I got a call in the middle of the night from a nearby Québec hospital. They had a patient with a transected aorta – that means the aorta, the main blood vessel that travels from the heart, had ruptured or torn. When I heard that, I knew the patient's chances of making it to our hospital were slim.
His name was Cody Howard, and while visiting from Arizona, he had been in a snowmobile crash in Ripon, Québec, about 70 minutes from Ottawa. The fact that he made it to the first hospital was hopeful, but with this type of injury, he could suddenly crash. Cody needed our expertise to help save him.
Doctors, nurses, and specialists work on a trauma patient in an intense training simulation in the trauma bay at The Ottawa Hospital.
I began caring for Cody on that phone call, explaining to the team on the other end of the phone what medications should be started and how Cody should be transferred to our Trauma Centre.
"The patient was lying flat and, incredibly, he was awake and alert. He knew he was in a very precarious situation."
As I drove to the hospital, I called Cheryl Symington, a charge nurse who was working in the ED that night. She's a team lead and she's amazing. I told her "This is a bad one. I need everyone on deck."
The trauma team is ready
I immediately called the vascular surgery team and told them to be on standby as soon as Cody arrived.
Cody made it to the Trauma Centre with his younger brother, Trevor Howard, who had not been involved in the crash. Cody was lying flat and incredibly, he was awake and alert. He knew he was in a very precarious situation. In fact, even a small movement could have been fatal. We did our assessment from A to Z, the same way we do it every single time, making sure we don't miss any injuries. As this is happening, I'm on the phone with Dr. Prasad Jetty, a vascular surgeon. He also consulted with a cardiac surgeon, Dr. Fraser Rubens. You know, we're lucky to have that kind of skill close by at the University of Ottawa Heart Institute.
"In my 30 plus years as an ED nurse, that was by far the most difficult yet most rewarding night. Dr. Matar, Dr. Jetty, and Dr. Reubens are each highly skilled specialists in their fields. Together they are a team beyond description. The stars aligned that night."
– Cheryl Syminton
Dr. Rubens came to the trauma bay – a cardiac surgeon rarely comes to the trauma bay – that's an indicator of the severity of this injury. At this point, the three of us were discussing the patient and we agreed he had a very high chance of dying on the operating table; there was also the potential for paralysis. Everything happened fast – this all took place in the first 30 minutes of Cody arriving.
Making the difficult call to the family
I then called the patient's father in Arizona who also happens to be a doctor. I had to tell him the grim news. However, I promised him the people taking care of his son were the best in the entire region. I told him to focus on getting to Ottawa and that we'll take care of the rest.
It's never easy making those calls. Breaking bad news to family members or letting someone know their loved one is going in for a very serious surgery – it weighs on you. Thankfully, social workers at our hospital are always there to help. If I'm busy caring for the patient, a social worker receives the family and updates them on what's going on. They play an immense role in our ED.
More injured patients arrive
As Cody's surgery plan was being made, his brother, Trevor, came up to me and said, 'there are two more of us' I said, 'excuse me?' I was shocked! He explained that another brother, Bret, and his brother-in-law were also injured in the snowmobile crash and were still at a nearby hospital in Québec.
"I promised him the people taking care of his son were the best trained in the entire region. I told him to focus on getting to Ottawa and we'll take care of the rest."
That's when the compassionate side of caring plays a key role in the work we do – in the work we all do. We can't have the family arrive in Ottawa and have to go back and forth between two hospitals, worried about their injured kids. They were already dealing with enough stress and needed to be together.
We called the other hospital and we arranged for immediate acceptance of the two family members, regardless of the extent of their injuries. While the brother-in-law had only minor injuries, Bret, had a significant head injury along with an injury in the abdomen. I needed to get him to the operating room to repair a ruptured bladder. The vascular surgery team and cardiac surgery team took Cody for surgery at the Heart Institute and I took Bret into emergency surgery at the Civic Campus, simultaneously.
A successful night as lives are saved
Bret made a quick recovery. After 10 days in our hospital, he was able to fly home. It was a longer road for Cody. Thankfully, he survived surgery but faced paralysis from the waist down. The 37-year-old U.S. military veteran was in a coma for a week and remained in our care until mid-February, when he was stable enough to get a medical flight back home. He had a tough recovery, but he's learned to walk again. The last time I spoke with him, he told me he's now hiking.
"When you do hear 'thank you' from a patient or a family member, it's humbling. It doesn't make you walk prouder, it's just humbling"
That was a successful day. It all started after midnight. All hands were on deck, including the highly-skilled Drs. Jetty and Rubens. We had never worked together before and those two collaborated on that case and saved the patient's life. Also, there's the exceptional anesthesia care provided by Dr. Adam Dryden – he worked with speed and efficiency to help save the patient. It was a team effort on many levels.
Humbling to hear the words "thank you"
And, when you hear 'thank you' from a patient or a family member, it's humbling. It doesn't make you walk prouder, it's just humbling. There have been cases where I haven't been able to save a life and that will always haunt me.
At the end of the day, when I walk out the hospital doors, the first thing I do is take a deep breath because the air is different outside. I just look up and I say 'thank you' for being able to deliver that specialized care.
Bret Howard says thank you for the compassionate, lifesaving care
"I truly don't believe Cody would be alive today if he hadn't been transferred to The Ottawa Hospital – that saved his life.
"Had we been somewhere other than The Ottawa Hospital, we think the outcome would have been worse, so we're forever grateful."
– Bret Howard
The way the team stepped in to get all of us together was a special thing to do and we won't ever forget that – I actually don't think that's typical. I couldn't have imagined going through all of this at one hospital while my brother fought for his life at The Ottawa Hospital. It meant a great deal to my family that we were all together.
Dr. Matar was incredible. Not only with my surgery but to my family – my wife and my parents. He and his team guided them along and was totally in tune with what was going on with me and my brother.
Thank you to the nurses, to the doctors, to the social workers. I could just tell they were invested in the situation with us and truly wanted to help guide us through it. Had we been somewhere other than The Ottawa Hospital, we think the outcome would have been worse, so we're forever grateful."
Cody, Trevor, and Bret Howard.
Research advancing trauma care
Research at The Ottawa Hospital is helping to improve survival and quality of life for people who experience severe traumatic injuries. Projects underway include:
developing of a simple tool to help detect major bleeding in trauma patients, so that it can be treated earlier.
testing new approaches to manage bleeding and blood clots in people with traumatic head injuries.
developing of new rehabilitation technologies and prosthetics, including a brain computer interface that could help people control a robot arm just by thinking.
developing a tool to help paramedics determine which trauma patients need to be immobilized on backboards, and which can be safely evaluated without immobilization.
It was a routine patrol in Kandahar that altered the course of Bushra Saeed-Khan's life forever. In one brief instant, the detonation of an improvised explosive device (IED) changed everything. She went from a Federal employee on an assignment in Afghanistan, to an amputee trauma survivor grappling with Post-Traumatic Stress Disorder (PTSD). The complexity of Bushra's traumatic injuries brought her to The Ottawa Hospital where a dedicated team of experts were ready to help her get back home.
Facing a war zone
Bushra was just eight weeks into a year-long tour in Afghanistan when she received permission to accompany troops "outside of the wire" – beyond the protection and confines of a military base. When their mission was complete, they headed back. It was then the light armoured vehicle (LAV) Bushra was travelling in ran over an IED buried underground.
Bushra (left), in Kandahar, prior to departing the base on the day of the attack.
She recalls hearing a loud bang, one unlike anything she's ever heard, before being momentarily knocked out. When she came to, there was silence. Confusion and shock paralyzed her entire body. But it didn't matter; she was pinned down inside the vehicle, unable to move. Fear filled her every thought. Was she the only survivor? Could the vehicle go up in flames while she was stuck inside it? Was there anyone around to save her? Each racing thought was as anxiety-inducing as the other, while in a war-torn country, miles away from base, from safety, her family, and her home.
Four soldiers and one civilian, who had become Bushra's friend, died that day, on December 30, 2009. Bushra, one of just five survivors, is lucky to be alive. But she didn't walk away unscathed. To this day, she continues to feel the ripple effects of the incident more than a decade later.
Seeking medical attention
After witnessing the explosion, troops in the second LAV acted quickly, requesting back up to assist the survivors. As they came to Bushra's aid, it was clear her injuries were severe. Her entire body was affected by the blast. The force of the explosion was so fierce it left Bushra's abdomen exposed, and her legs critically wounded – a portion of one completely gone.
Bushra waking in Germany.
Bushra was airlifted by helicopter to a military base for emergency medical care before she was transported to a hospital in Landstuhl, Germany, where she was placed in a medically induced coma. As doctors worked to stabilize her for the long flight to the Trauma Centre at The Ottawa Hospital's Civic Campus, Bushra was introduced to the name Dr. Nancy Dudek, Medical Director of the Amputee Program. Bushra needed to start to think about recovery and Dr. Dudek would soon become Bushra's primary caregiver for over a decade. "I didn't realize at the time just how much of an impact Dr. Dudek would have on my life."
Road to healing and recovery
Once Bushra was in our care, experts began working around the clock to repair the extensive damage that had been done by the IED. "I remember the first time I met Bushra," says Dr. Dudek. "She had just arrived at the hospital and had a lot of injuries. The most critical question I had for her at that time was regarding her leg." Bushra's leg was severely damaged, and it was clear they would have to amputate it. Since her femur bone was also fractured, they needed to decide if her orthopedic surgeon would perform a full amputation of the leg or fix her femur and save as much of her leg as possible. "It's really important, when possible, to include the person who will be receiving the amputation in that decision," says Dr. Dudek. "We want our patients to have a say in what's going to happen to their body." In the end, as a team, they decided to fix Bushra's fractured femur and perform a through-knee amputation.
This was the first of several surgeries Bushra underwent at our hospital. "Within the first week of being in the trauma unit I had what felt like over 20 surgeries," says Bushra. "That's when I stopped trying to keep track."
The women of the Rehab Centre
Once Bushra was medically well enough to leave the trauma unit, she was moved to the Rehabilitation Centre. This is where she would remain for over a year as an inpatient, followed by six months as an outpatient. Under the care of some of the best physiotherapists and prosthetists in the field, Bushra had to relearn how to perform the most basic tasks, such as lifting her arms, moving her head and sitting upright in bed, before eventually learning how to walk with a prosthetic leg. "I call them 'the women of the Rehab Centre,'" says Bushra. "They're just so brilliant in their respective fields, but also so kind and caring. It was really nice to see."
Bushra learning to stand again.
At the time, Bushra was still in great discomfort, not just from her surgeries but from flashbacks of the incident, her survivor's guilt, and the thought of living the rest of her life with a disability. Working through those emotions felt like mountains she had to climb and conquer, and some days they were too much to bear. "At one point, I even contemplated suicide. Some days I couldn't even get out of bed. Not just because of the physical reasons, but mentally I couldn't deal with everything I had to fight through that day," says Bushra. It wasn't long before she was introduced to Dr. Josie Marino, a now-retired psychologist at our hospital. Dr. Marino was instrumental in Bushra's care, helping her overcome those mental obstacles. "PTSD never really goes away, it comes back when times get rough, but Josie gave me the tools that I needed to cope," Bushra explains.
"I like giving patients the confidence that they can do more than they think,"
– Marie Andrée.
On those more difficult days, Bushra's physiotherapist, Marie Andrée Paquin, would adapt and cater the exercises to the pain she was experiencing. If Bushra didn't feel well enough to leave her room, Marie Andrée would have her perform exercises in bed. On the days she was feeling stronger, she would push her a little bit further. "I like giving patients the confidence that they can do more than they think," says Marie Andrée.
She even went as far as having Bushra perform exercises that mimicked dance moves so that she could dance at her sister's wedding. "It was really nice that they were so flexible in my care, tailoring it to exactly what I needed," says Bushra.
Discovering hope
Bushra's prosthesis.
After Bushra's amputation, she couldn't help but worry about the future. After all, she had never met someone with a prosthetic leg. "My family and I were very worried about what type of life I would have," says Bushra. Realizing this, Dr. Dudek asked a former patient of hers to visit with Bushra. "I remember so clearly, this woman walking into my trauma unit room. It was shocking for me to see her walking around and playing with her kids," says Bushra. "I am thankful that Dr. Dudek introduced me to this woman. That was a pivotal moment for me." After that meeting, Bushra no longer worried. Rather, she was filled with hope.
This gave Bushra the confidence she needed to try a prosthetic leg. She met with Laura Scholtes, a prosthetist at our hospital, who fitted her with a new artificial limb. It wasn't long before she got the hang of it and once she did, she was introduced to the Computer-Assisted Rehabilitation Environment (CAREN) System.
The CAREN System
Bushra hasn't been the only patient who has experienced injury in Afghanistan. In realizing the need, the Canadian Armed Forces and our community raised funds to bring this virtual reality system to Ottawa — one of only two cities in Canada who have it. The CAREN System has been instrumental for patients in the Rehab Centre.
Bushra on the CAREN System.
"The CAREN System was amazing," says Bushra, when asked about her experience with this unique virtual reality rehabilitation equipment. It combines incredibly large 3D graphics and a platform that moves with the person as they explore a virtual 3D world on a remote-controlled treadmill. "It's very safe and a great way to challenge a patient's balance," explains Marie Andrée.
"The CAREN System was really a catalyst in my recovery as I was able to learn how to walk with a prosthesis and push myself in an environment that I knew was safe," says Bushra. "And it trains you to walk on all kinds of surfaces. There was even a setting for paddle boarding. It was really a lot of fun." Training in the CAREN System boosted her confidence. Today she's riding her bicycle, and excelling in her career as a diplomat, something she didn't expect she would be able to do.
New life after trauma
Bushra holding her daughter.
One of the very first questions on Bushra's mind after her surgery to reconstruct her abdomen was whether or not she would be able to have a baby. The injuries were so extensive that surgeons had to insert a mesh lining to help rebuild the abdominal wall. At the time, her physicians were unsure if her body would be able to adapt to carry a child to full term. Eight years later, Bushra announced she was pregnant, and much like she adapted to a new normal with a disability, her body was able to adapt to a growing baby.
"They are my guardian angels. My heroes. They saved my life." – Bushra Saeed-Khan
As Bushra's belly grew, so did her challenges with her prosthesis. Laura was able to monitor Bushra throughout the duration of her pregnancy to ensure that her prosthesis fit her limb comfortably. But in the last two months of her pregnancy, Bushra was no longer able to walk with ease and temporarily switched to a wheelchair. As she was prepped to undergo a c-section, Dr. Dudek worked alongside Bushra's obstetrician, Dr. Laura M. Gaudet, to ensure that Bushra had the most accessible birthing room possible, one with a doorframe wide enough to fit her wheelchair, and a bed that could be lowered so that she could more easily get in and out.
The day after Bushra gave birth to a beautiful baby girl, Dr. Dudek was there to meet her. "After my initial surgery, my doctors weren't sure if I would be able to have children. And then eight years later there was Dr. Dudek holding my baby," says Bushra. "So, it was a special moment. It really felt like everything was coming full circle."
Today, Bushra is able to play with her two-year-old daughter, just like the patient she met in hospital with the prosthetic leg early on in her recovery. Those feelings of hope have become reality.
More than a decade later
More than a decade after the incident, it would be easy to look at Bushra and be impressed by how far she's come. But she accepts each compliment about her recovery with humility, because she knows she didn't do it alone – she was backed by some of the best healthcare workers in the country. "I'm a product of my circumstances and I was fortunate to have the support structure offered by the Rehab Centre at The Ottawa Hospital," says Bushra. "It felt like a team effort and it's thanks to my caregivers that I was able to gain independence. They are my guardian angels. My heroes. They saved my life."
Download Pulse Podcast today and listen to Bushra's story.
For an update on Marcie's story, click here to see how far Marcie has come.
It was a bitter cold, winter day on Friday, January 11, 2019. Marcie Stevens was making her way home to Kanata for the weekend from downtown. The Public Safety employee sat on the second level of a double-decker OC Transpo bus when it crashed into the overhang of the Westboro transit station. It was 3:50 p.m.
Ten minutes away from where the crash occurred, the trauma team at The Ottawa Hospital was alerted, and a Code Orange was called. The Emergency Department began clearing space, and a large number of staff converged including surgeons, nurses, anesthetists, emergency physicians, and support staff. A massive team of about 150 people would await the injured passengers. At 4:28 p.m., the first patient arrived at The Ottawa Hospital's Civic Campus, home to the only level 1 trauma centre in eastern Ontario. In total, 13 severely injured patients over a two-hour period were rushed to the trauma centre – one of the injured was Marcie Stevens.
Calm amidst chaos
The married mother of two recalls being conscious and considerably calm throughout the entire ordeal. Though she was pinned on the top level of the bus and critically injured, she was able to call her husband, Christopher, to tell him she couldn't pick up their children. She even thought to call work to let them know she wouldn't be in on Monday and was able to help to calm those around her while emergency crews worked furiously to remove them from the wreckage. Marcie would need that calm composure in the midst of adversity for what awaited her.
"I couldn't have gotten this far without the incredible people and support from The Ottawa Hospital – from the trauma team to the ICU to the Rehab Centre – it's incredible. Compassionate is the best word to describe it." – Marcie Stevens
The trauma team was ready
After arriving at our Emergency Department, Marcie recalls she had lost so much blood and that after her CT scan her blood pressure began to plummet, but the trauma team was ready. "The nurse in the Emergency Department had the O negative blood in her pocket. They immediately started pumping blood back into my system. My blood pressure stabilized, and I was then rolled into the operating room. The only time I passed out was when they put the mask on to put me to sleep."
(From left to right) Dr. Ian Grant, Dr. Peter Glen, Dr. Maher Matar and Dr. Jacinthe Lampron.
Marcie would wake up on Sunday morning, groggy and swollen. That's when she learned from her husband that both of her legs had been amputated. "I knew going into the operation that my left leg was gone, because they told me. But they were going to try to save the right leg, but they couldn't, and on Saturday they had to take it."
While a completely new world awaited Marcie, her positive attitude never wavered. "You adapt and that's what I have been doing. This is the way it goes. I couldn't have gotten this far without the incredible people and support from The Ottawa Hospital – from the trauma team to the ICU to the rehab centre – it's incredible. Compassionate is the best word to describe it."
Waking up to a different life
Soon after the bus crash, Dr. Nancy Dudek, Medical Director, Amputee Program at The Ottawa Hospital Rehabilitation Centre, met Marcie at her bedside for the first time. "I had regular visits with Marcie when she was in the trauma unit to determine when she would be medically ready to come to the Rehab Centre." Our Rehabilitation Centre specializes in the physical rehabilitation of those who have experienced a disabling physical illness or injury. It serves the residents of eastern Ontario.
Dr. Dudek is quick to point out though that Marcie's rehab started soon after she was admitted to the hospital. "We started rehabilitation plans when she was still in the Trauma Unit. She was a very avid participant of early rehab."
Marcie Stevens and her family.
Marcie's road to a new way of living life began with her multi-disciplinary care team helping to get her wounds healed. That would lead to teaching her how to move independently once again.
By the end of February, Marcie moved to The Ottawa Hospital's Rehabilitation Centre. She says the staff were incredible from the moment she arrived. "I was in a room with three other women. They put the two who fell asleep early on one side and me and an older patient – the night owls – on the other."
It was during rehabilitation that Marcie learned how to transfer from the bed to her wheelchair without a lift. She learned how to cook in a kitchen that is not accessible, to prepare for her return home, and she's learning how to drive with hand controls.
Preparing to go home
Dr. Dudek explains there's a great deal to cover in rehab. "We teach wheelchair skills, including what the right wheelchair is for the patient. We also had to work on strengthening, including core strengthening. Then, we talked about what would be the immediate needs to get her home to her family, including her five and 12-year-old boys."
Westboro bus crash double amputee, Marcie Stevens, doing strength testing in the rehabilitation centre at The Ottawa Hospital with Dr. Nancy Dudek.
Marcie went home on Friday, April 12, 2019. Three months after arriving at the hospital. When Marcie reflects on her feelings as she was leaving the rehab centre, she takes a moment and then replies, "It was a giddy day. It's not like I didn't like the Rehab Centre," she quickly qualifies her response smiling at Dr. Dudek, "but it was good to be home with the kids."
Of course, going home didn't mean Marcie's rehabilitation was over, but it was a major advancement in her recovery – a recovery that she faced head on with a resilience that never wavered. Dr. Dudek says it's been inspiring to watch Marcie over the last year. "She is an incredibly positive person. That has been consistent. It's something that was there right from our first meeting and it hasn't really faded. She has a ton of energy and other people really gravitate towards her. She's very popular around here."
"Rehab is great. It is the jewel of the hospital that nobody knows about. They are sort of hidden away here. They have to deal with so many types of injuries and states of mind. Not everyone at the centre is accepting of what happened to them," admits Marcie.
As Marcie recounts all that she's been through in the past year, she still jokes and laughs. When Dr. Dudek is asked if she thinks this incredible attitude helped with Marcie's recovery, the answer comes fast. "One hundred percent. She has made significant changes and implemented new things to her life. It's very impressive to see. We can show people the way, but we can't do it for them."
Today, Marcie and her family are moving forward. A new home is necessary – one that is fully accessible, and Marcie talks about getting back to work someday.
She misses her colleagues, but she knows that day will come with time. "I'm a very positive person and it will take time to get used to the changes in my life, to adjust to having no legs. It's difficult. I'll get there."
For now, she will continue with her regular rehab. Eventually she will only need annual visits. For now, her weeks are filled with trips to the gym and the pool, all to get her stronger for the new world she faces. Despite the challenges, she embraces it all with confidence, a smile, and you could say a bit of attitude as she wheels away wearing her black leather jacket, sunglasses, and a streak of pink in her hair.
Update: Two years later
Marcie Stevens with her prostheses.
Today, Marcie is learning to walk again thanks to her new prosthetics. While the pandemic has caused some delays in her progress, she's hopeful the spring will bring more good news. "I am looking at procedures to help me move easier in my prosthesis after significant weight loss," says Marcie. She's lost 60 pounds in an effort to better adapt to using her prosthetic legs.
In the springtime, Marcie is optimistic that she will have a chance to trial powered knees, which will allow her to move better when she sits down and stands up. She'll also have her adapted vehicle, to help her shuttle her boys around town. In two years, Marcie has come a long way. While her recovery continues, our rehab team is with her as she takes each new step forward.
Inside the trauma team and emergency departments response
Injuries and mass casualty incidents can strike at random. But while the timing and location of most incidents are unpredictable, The Ottawa Hospital's response is not—the hospital is ready to provide the very best care to you and your loved ones should you one day find yourself as one of our trauma patients.
The hospital's Emergency Department and Trauma Services involve a multidisciplinary team that work together to provide comprehensive, quality care to injured patients and their families. This team Includes trauma surgeons, anesthetists, physicians, registered nurses, respiratory therapists, social workers, physiotherapists, dieticians, speech-language pathologists, and occupational therapists. Each intricately working together to help our patients reach their full potential recovery after injury.
As the Regional Trauma Centre for eastern Ontario, the only level-one trauma centre in the region, The Ottawa Hospital plays an essential role in the development, evaluation, education, and ongoing quality improvement of adult trauma care.
"Our Code Orange plan means that, no matter what time of day a disaster happens, we're always prepared to respond." – Dr. Andrew Willmore, Medical Director, Emergency Management, The Ottawa Hospital.
Over the past few years, in collaboration with departments from across the hospital, the Emergency Management team, under the leadership of Joanne Read, Vice-President of Planning and Support Services, has revamped the Code Orange plan and has run regular training exercises to test it. "Our goal is to ensure that we can provide the highest level of care for our patients and community during a disaster," said Read. "We want to live up to our vision of providing each patient with the care we would want for our own loved ones."
A Code Orange could be called at the hospital in response to a wide variety of incidents in the community such as a disaster, an active shooter, or a transportation crash like 2019's Westboro bus station crash.
Putting preparedness to the test
On a snowy November morning, the Civic Campus Emergency Department (ED) underwent an emergency response exercise. Those participating in the test were provided with a scenario: A shooting at a conference centre had left dozens injured and paramedics were en route with patients.
Within minutes, the hospital declared a Code Orange, signaling that it was responding to a mass casualty event. Staff leapt into action, as if a real Code Orange had been called, to prepare for patients and find the resources they would need over the coming hours.
While the bulk of the Code Orange exercise was centred on the resuscitation bay, important work happened elsewhere. A team triaged patients near the ED waiting room. Behind the scenes, command posts in the ED and the Operating Rooms (OR) directed resources to where they were needed and used the hospital's real-time occupancy numbers to walk through how they would free up much-needed OR space and inpatient beds in a real scenario.
The Code Orange that morning was just an exercise – one of the largest the hospital has ever done as part of an intentional focus on continued education and training. This type of hands-on education is vital as it allows staff to expand their skills, make adjustments, and ultimately provide better care to patients. In this particular scenario, it meant staff would be even more prepared for the next time a real Code Orange is called. "Our Code Orange plan means that, no matter what time of day a disaster happens, we're always prepared to respond," said Dr. Willmore, Medical Director, Emergency Management, The Ottawa Hospital.
Westboro bus crash
Only a few months following the training exercise a bus crashed into the Westboro bus station.
Late in the afternoon of Friday, Jan. 11, 2019, staff at the Civic Campus ED started hearing word of a serious collision at nearby Westboro bus station. The hospital declared a Code Orange. This time, it wasn't a test. Response teams from all over the hospital began converging on the ED within minutes. Disaster equipment carts were quickly deployed. Pharmacy and transfusion medicine staff took their posts. Eight trauma bays, equipped with a full trauma team, were formulated. Hospital staff were ready when the first trauma patients arrived.
Going through a Code Orange exercise prior to the Westboro bus station crash ensured that our staff were well prepared to manage a disaster of this magnitude. It's for this reason that tests, exercises and mock events have become a routine procedure.
Military level preparedness
Trauma surgeon Dr. Jacinthe Lampron
Trauma surgeon Dr. Jacinthe Lampron was one of the many staff members that took her post on that fateful day – Jan. 11, 2019.
As a reservist with the Canadian Armed Forces, who before working at The Ottawa Hospital, served in Kandahar's military hospital as a trauma surgeon, Dr. Lampron is prepared to face any challenge head on.
She credits her experience in Kandahar's military hospital for equipping her to manage the strenuous circumstances in the trauma unit. "Throughout my tours in Afghanistan working with the military, a mass casualty occurred on an almost weekly basis," explained Dr. Lampron.
Techniques learned on the battlefield are often brought back and integrated into the care patients receive every day. And Dr. Lampron did just that when The Ottawa Hospital called a Code Orange on that cold January day. From her ability to organize eight trauma bays, to managing the treatment of each trauma patient that arrived in the two-hours following the bus crash, Dr. Lampron and the team were ready with military precision.
Marcie Stevens was one of 13 severely injured patients who arrived at The Ottawa Hospital Trauma Centre after the Westboro bus crash. One year later, after losing both legs, Marcie continues her recovery at the Rehabilitation Centre and she's grateful for the compassionate care she's received.
The effects of mass trauma events, such as the crash at Westboro bus station, have a significant impact on not only the patients and their families, but the trauma unit, the ED and the hospital as a whole.
An event of such magnitude touches many lives. For our patients, their arrival in the ED that afternoon was just the beginning of their road to recovery. Severely injured patients, like Marcie Stevens who lost both legs in the crash, underwent multiple surgeries in the weeks following the incident, followed by lengthy rehabilitation. Their emotional healing lasting much longer.
Hundreds of staff continue to be affected, as we take our vision to treat all our patients like loved ones seriously and develop a strong connection with each of them during their hours of need.
"The lasting effect of this event on our hospital, the staff and each patient was significant," said Dr. Lampron.
One-year Anniversary
One year later, there is much to remember. Members of our community continue to persevere and heal.
"No matter how much you train for these events, it's never the same as the real thing and there are always lessons to be learned," explained Dr. Lampron. "We've never been more prepared then we are today to provide exceptional care to our patients."
June 20, 2017, was a day like any other on the construction site, until the 14-inch diamond blade on Adrian Molloy's power saw jammed in the concrete he was cutting and kicked back into his arm, slicing through to the bone. Though he was not particularly close The Ottawa Hospital's Trauma Centre at the time, a new 60-minute bypass initiative brought him straight there to an assembled team of trauma experts who were ready for him.
The 40-year-old contractor had been using power saws on the job for 20 years. He was down in a hole cutting concrete when the saw kicked back. He was covered in dust so couldn't see his arm, but knew he'd hit himself. He grabbed his right arm above the elbow, and his fingers landed on bone. Adrian knew it was a serious injury, and managed to get out of the hole and head to the road for help. His arm was bleeding badly.
"It happened so quickly, I didn't even know I was injured," Adrian said.
Contractor Adrian Molloy underwent two four-and-a-half-hour surgeries to repair his partially severed arm.
Quick thinking
At the road, two Hydro One workers were sitting in their truck getting ready to leave. When they saw Adrian, the passenger called 911. The driver jumped out, and quickly took off his belt and tightened it around Adrian's arm in a tourniquet. He was calm, and kept Adrian talking until the ambulance arrived.
In the ambulance, Adrian heard the paramedics talking with the dispatch.
"I knew they were looking to bypass Kemptville, but didn't know what was going on," said Adrian. "I knew my best hope was The Ottawa Hospital, so was happy they said we were heading to the Trauma Centre at the Civic. I was going somewhere where they could handle my injury."
60-minute bypass initiative
What Adrian didn't realize was that he was one of the first patients to be part of a quality improvement initiative that the Ottawa Regional Trauma Program was testing in an effort to get patients to trauma care and provide more successful outcomes.
"Adrian was a direct recipient of our 60-minute bypass initiative," said Mathieu LeBreton, Trauma Coordinator of the Ottawa Regional Trauma Program at The Ottawa Hospital. "Provincially, paramedics have rules that can permit them to bypass local hospitals to get to a lead trauma hospital if they are within 30 minutes of getting to a trauma centre. With the approval of all regional community hospitals, we expanded it to 60 minutes. Much of the literature suggests the sooner a patient receives definitive trauma care, the better."
Where Adrian was injured was about a 45-minute ambulance drive to the Trauma Centre. Previously, he would've had to go to the nearest community hospital. LeBreton said trauma patients who need resuscitation from life-threatening injury need very resource-intensive care. They require more medical staff, access to operating rooms, imaging capabilities, more blood, and other resources that community hospitals do not have in their emergency departments. There is a team of health-care professionals at the Civic Campus specifically trained to deal with trauma situations.
Trauma team assembles
When paramedics notify the Civic Campus Emergency Department that they are bringing in a patient with multiple or life-threatening injuries, a Code 1 Trauma is called over the hospital's intercom. This alerts the trauma team, which includes trauma surgeons, emergency physicians, nurses, anaesthesiologists, respiratory therapists, and trauma coordinator Mathieu LeBreton, to prepare for the patient's arrival. A Code 1 Trauma also notifies the blood lab, radiology department, and operating room staff that blood-work, X-Rays, CT scans, and surgery may be needed.
"Sometimes a trauma code comes in without advance notice, and then we're reacting to it in the moment," said Kelly Barnett, Clinical Manager of the Trauma Unit. "Everyone has a job, and it's a code that runs smoothly to diagnose, triage, and save the patient."
"I'd never been to a hospital injured like this before," said Adrian. As he lay in the ambulance, his mind raced with concerns. "I asked, 'Do they know I'm coming? Are they ready for me?'"
Rushed to surgery
The answer was yes. The trauma team was ready and waiting for him when the ambulance arrived. When he was rushed through the emergency room doors, Adrian said he couldn't believe, "You can get so many people in one room for one patient." He was in the operating room within 47 minutes from the time he entered the emergency department.
"I knew my best hope was The Ottawa Hospital, so was happy they said we were heading to the Trauma Centre at the Civic. I was going somewhere where they could handle my injury."
The power saw had cut 75 percent of his right bicep, two arteries and a nerve. In the operating room, surgeons reattached his arm. The four-and-a-half-hour surgery repaired arteries and his severed nerve. He underwent a second four-hour surgery to repair the damaged bicep with a donor muscle in November 2017.
The Ottawa Hospital's Civic Campus is the adult lead trauma hospital for eastern Ontario. This takes in an area of 1.3 million people that includes Ottawa, stretches west to Pembroke and east to Hawkesbury. People with life-threatening injuries from Gatineau and western Quebec, as well as patients from Baffin Island and eastern Nunavut are brought to the Trauma Centre. Twenty percent of the population it serves lives in a rural area.
The Centre treated 856 trauma cases last year. One hundred and ninety-two of those patients benefited from the extended time guidelines from accident scene to trauma centre, with the average transfer time being 42 minutes.
Trauma care for 1.3 million people
The eight-bed trauma unit is dedicated to patients who have multiple injuries. This could include head or brain trauma, limb loss, vascular, spinal cord, internal organs, multiple broken bones, broken spine, or neck injuries.
"Patients come into trauma from emerge [emergency department], and once they are stabilized, they then move through the hospital, as soon as possible, in order to get them back home, into rehab, or somewhere they can convalesce," said Kelly.
Kelly said a patient's length of stay in the trauma unit can be as short as 24 hours or as long as several months, depending on the severity of the injury and the ability to recover and heal. The health professionals in the Centre plan the patient's follow up care or work closely with physiotherapy, and rehabilitation services to assess their need for rehabilitation.
"I know we often compare ourselves to similar standards from regional trauma perspectives: other hospitals we benchmark against in standardizing trauma care. We look to hospitals like St. Mikes [St. Michael's Hospital] in Toronto to see their practices, and share ideas and common goals that we are trying to achieve," said Kelly.
The Ottawa Hospital is part of the Trauma Association of Canada where members from across the country share vibrant practices about ways to improve patient care.
Hamilton and Kingston also have trauma centres, though The Ottawa Hospital is bigger because of the larger area patients come from.
The Ottawa Hospital has one of the largest trauma centres in the province, with Sunnybrook and St. Michael's as the two largest. However, both Toronto hospitals cater to a dense urban population. The Ottawa Hospital covers a larger geographical area, so the timing to get patients to the trauma centre from a distance and the reason why the 60-minute bypass initiative is critical.
"What we found is there have been no negative outcomes yet. People like Adrian have benefitted directly from this," Mathieu said.
A year later, Adrian is back on the construction site with full use of his right arm and hand.
"I lost the motion for using a screwdriver. I use it as an excuse to get out of work I don't like. I use it to my advantage now," laughed Adrian. "I'm doing everything I was doing before."
Adrian Molloy stands with his wife Shelly outside their home.
Life can change in an instant. Thankfully, Ashley Ruelland lived to tell the story of her 'instant' after a head-on car crash brought her to The Ottawa Hospital's Trauma Centre with extensive, life-threatening injuries followed by months of intensive rehab.
In early March 2015, then 27-year-old Ashley was living in an apartment with her two cats. She was busy working as a construction manager, part time as an office administrator, and she had started a catering business. She had never really been sick, and had no idea where the Civic Campus of The Ottawa Hospital was located.
That changed on Friday, March 13. Ashley was driving the bride-to-be and another friend to a bachelorette party in Mont Tremblant. It was a clear day and the three were brimming with excitement.
A head-on crash
About an hour from their destination, on highway 323, a car crossed over the centre line, head on into their lane. That was Ashley's instant. The noise from the impact was horrific, with the earth-shattering sound of grinding metal and fragmenting glass.
Ashley, her mother Cheryl Ruelland-Jackson, Therapeutic Paws of Canada therapy cat Pecan, and her brother Robbie Ruelland.
Miraculously, one of the first people on the scene was a resident from The Ottawa Hospital. She quickly assessed how serious Ashley's injuries were. It took first responders over an hour to extricate Ashley from the car. She was rushed to the Hull Hospital, but because of the severity of her injuries, she was transferred to the region's only trauma centre at The Ottawa Hospital Civic Campus.
While her friends had relatively minor injuries, Ashley had a grocery list of broken bones: from her right big toe to her ribs and just about everything in between. Most significant were an open compound femur fracture, an open left elbow fracture, right humerus fracture, crushed and broken left and right foot and ankle fractures, an open book pelvis fracture, and multiple broken lumbar vertebrae.
"This lady's life changed forever that day," said Dr. Guy Hébert, Head of the Department of Emergency Medicine, when he looked at the hundreds of files related to Ashley's surgeries and treatment.
She remained in an induced coma in the intensive care unit for two months. She endured numerous reconstructive surgeries, 100 hours of orthopaedic and internal surgery, and over 100 blood transfusions and infections.
Beginning the long road to recovery
A year and a half after her "instant", Ashley was able to walk again with the help of a walker.
Four months after the crash, Ashley began physiotherapy in her hospital bed and could finally eat solid food.
She had lost all of her hair and had severe nerve damage, chronic illness myopathy and neuropathy.
"I was scared to think of the life that was waiting for me outside those hospital walls." — Ashley Ruelland
"I couldn't feed myself, brush my own teeth or move much at all. The first couple of weeks seemed like torture. The nurses would set little goals, like sitting up in my wheelchair for 20 minutes a day. The physiotherapist and occupational therapist didn't know if I'd ever walk again. I was scared to think of the life that was waiting for me outside those hospital walls," said Ashley.
But then her first real sign of recovery came a few weeks later when she was able to feed herself.
In August, Ashley moved to the rehabilitation centre at the General Campus where she began an intensive regime of physical, occupational and psychological therapy programs. Just before Christmas, nine months after the accident, Ashley left the hospital. Although she was in a wheelchair and hadn't made many functional gains, Ashley felt stronger and healthier.
The young woman continued as an outpatient with rehab, and had her last surgery in February 2016, which allowed her to transfer from her bed to chair, independently.
"In May 2016, I stood independently for the first time," she said. "And after many more weeks of painful standing and walking in the hospital's therapy pool, I started to walk with the aid of a harness within the parallel bars. By the end of the summer, I was able to move with a walker."
Over two years later, Ashley is walking again. In fact, not only is she walking but she's travelling, recently returning from Ireland. She's also in school and looking to buy a home.
A Better
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Karen Toop was hit by a snowplow while crossing the street in January 2012. She was critically injured when she arrived at our Trauma Centre. A multi-disciplinary team was ready to care for the injuries that some only see once in their career.
Donors, Gift In Will, Patient Care, Rehab, Trauma
A meningioma tumour leaves mother facing blindness
With vision in her left eye deteriorating quickly, Michele Juma travelled from her home in Sault Ste. Marie to The Ottawa Hospital where she received specialized care after learning she had a meningioma tumour – and time was not on her side to save her vision.
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Bryde Fresque needed a skilled team to come up with a diagnosis of pheochromocytoma – a rare tumour that left his future uncertain.
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Bushra Saeed-Khan's tour in Afghanistan was cut short after an IED nearly took her life. The Ottawa Hospital was ready to help her heal.
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Breast cancer patients benefit from Ottawa-based study
Ottawa study is changing the standard of care for breast cancer patients world-wide.
Hope despite aggressive skin cancer diagnosis
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text:
Q: How do I increase the result presented by my "for loop"? for (int j=1; j<=120; j++){

Pop=10180000;            //Pop = Population //
Increase=Pop*0.0118;
Pop=Increase+Pop;

cout<< Increase <<endl;
cout<< Pop <<endl;

}

I am really new here, sorry if I made a mistake. I am suppose to find out the amount of population (10.18mil) for 120 months with the increase of 1.18% every month.
I managed to find the first month but my for loop repeats the same result every line for the next 120 lines.

A: Your problem is that you're setting the initial value of the population every iteration of the loop. You should be doing that once before the loop starts.
You can also simplify the calculation since a 1.18% increase can be achieved by just multiplying by 1.0118. That gives you something like:
int Pop = 10180000;
for (int i = 1; i <= 120; i++)
    Pop = Pop * 1.0118;
cout << Pop << endl;

Of course, if you were writing real code, you may want to factor out the functionality so that it could be re-used easily:
int increaseValue(
    int          value,
    double       ratePerPeriod,
    unsigned int periodCount
) {
    for (unsigned int i = 0; i < periodCount; i++)
        value *= (ratePerPeriod / 100.0 + 1.0);
    return value;
}

:

cout << increaseValue(10180000, 1.18, 120) << endl;

A: In your code, you re-initialize Pop as 10180000 at the start of each iteration. You should move it above the loop so that its value does not get reset at each iteration.
Pop=10180000;            //Pop = Population //
for (int j = 1; j <= 120; j++) {
  Increase=Pop*0.0118;
  Pop=Increase+Pop;

  cout<< Increase <<endl;
  cout<< Pop <<endl;
}

redpajama_set_name: RedPajamaStackExchange


text:
ASPCA Assists Animals Endangered by Kilauea Volcano Eruptions
At the request of the Hawaii Island Humane Society (HIHS), the ASPCA's disaster response team is on the ground in Pahoa, Hawaii, assessing areas impacted by the Kilauea volcano eruptions, assisting in managing the Disaster Pet Hotline for residents requesting assistance for their pets, and providing lifesaving field rescue for displaced animals. Search-and-rescue efforts are being led by HIHS and the ASPCA. Some conditions are so dangerous that animals had to be airlifted by helicopter to safety.
"These search-and-rescue efforts are absolutely critical to safely remove animals trapped in areas completely cut off by active lava fields and steep banks," said Dick Green, Senior Director of ASPCA Disaster Response. "The ongoing and relentless destruction caused by the Kilauea volcano eruptions has put hundreds of animal lives at risk, and the ASPCA is pleased to be in a position where we can partner and assist the Hawaii Island Humane Society to save as many displaced animals as possible."
"Hawaii Island Humane Society has deployed up to eight animal control officers each day when allowed access to search for animals and pets. We've gone door to door in the subdivisions in our search for animals at risk and continue to leave food and water for those animals not yet found and rescued. To date, Hawaii Island Humane Society rescued approximately 165+ animals with nearly all returned to owners and the remainder in foster homes. We're grateful for the help that ASPCA is providing in these efforts," said HIHS Executive Director Donna Whitaker.
Your urgent gift today can help keep us prepared for response to animals in crisis. Please give now to help support our lifesaving programs—including critical rescue operations like this.
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redpajama_set_name: RedPajamaCommonCrawl


Step onto Your Own Wisdom Path: Must We Shout Creation's Glory?
In my perception, Spirit's, God's Creation is the energy of Love. This, to me, is the energy of all that is manifested. I perceive Love as wise and appropriate. In conjunction with this, I perceive that expressing and being Love is the goal and gift of Spirit, the Cosmos. Since I am part of Creation expressed as a physical being, I feel that I must consciously express and be Love now. I feel that I must shout it's glory to remind myself and others of Love's grandeur and presence. In this way, I am respecting and trusting the Creator, respecting and trusting myself. Why is this significant?
This is significant because, as a divine being of Light and frequency expressed in human format, I desire, I feel the need to show Spirit, God, appreciation, gratitude and thankfulness for its Creation that I am. This expression of my thankfulness to me is the essence of enlightenment. It says that I know that I am Spirit in form and thank you Spirit for your Creativity. I am aware of it and I enjoy it.
I have found that as I express my gratitude to the Creator, the Creator bonds more indelibly with me in expanding both my awareness and my capabilities to be more abundant, prosperous, wise, healthy, peaceful, Loving, happy, kind and safe.
Again, it is a state of enlightenment and it does take intentional practice to arrive at. I encourage all who read this to look at this state of being Creation/Love I am talking about, not in the tired old religious ways, the dogmatic ways, the ways of any organized religion but in the ways of being Spirit, being God also.


Canada's Human Rights Commission requested last month the appointment of a tribunal to hear the complaints of eight female professors against Industry Canada.
The complaints, filed in May 2003, allege the Canada Research Chairs Program discriminates against women, aboriginal people, people with disability, visible minorities and other equity-seeking groups contrary to section 5 of the Canadian Human Rights Act. It is believed this is the first section 5 complaint involving allegations of systemic discrimination referred to a human rights tribunal.
The complaints specifically allege that the structure of the CRC program discriminates against equity-seeking groups because, among other things, it allows universities to disregard the equity obligations contained in faculty collective agreements and provincial legislation.
Mediation sessions held in the fall of 2003 resulted in a continuing stalemate between the complainants and Industry Canada. The investigator's report, which recommended referral of the complaints to a tribunal, was finally released in August this year.
The parties will be consulted by the tribunal within the next few weeks to set dates for hearings at which both sides can present their arguments and call witnesses.
In the gender-based analysis and in the fifth year evaluation of the program completed last year on behalf of the CRC secretariat, independent consultants advised there was evidence of gender discrimination in the program. But neither the secretariat nor the consultants made any effort to ascertain the existence or scope of discrimination against other equity-seeking groups.
Background: Bulletin reports June 2001, April 2003 & May 2003.


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Three-time champions Mumbai Indians have six more games remaining and Bond said they still can turnaround the script.
Defending champions Mumbai Indians are languishing at the second-last position in the IPL 2018 points table.
With just two wins from eight matches, Mumbai Indians are currently languishing at the second last position in the eight-team IPL.
"We have six games left and we have to win them all. That is what we have to do. I still believe when you look at our squad, we have key players who can win us six games in a row. We have done it in the past (in 2015) and I believe we can do it again," Bond said after Mumbai lost by 14 runs against Royal Challengers Bangalore in Bengaluru on Tuesday.
"We just have to take one game at a time and hopefully we can do that."
Bond said Mumbai players take a lot of pride in their performances so motivation is never a concern.
"Motivation is there for the players. The guys take a lot of pride in their performances," he said.
Bond said Mumbai bowlers did well for most part of the day, except for three overs of RCB innings which cost them 60-odd runs.
"We gave 15 runs above than what we would have liked. We bowled well for 17 overs. We bowled three terrible overs which cost us probably 60-65 runs. I think 155 or anything under 160 would have been good for us," he said.
JP Duminy conceded 22 runs in the fourth over, Hardik Pandya gave away 20 in 10th while Mitchell McClenaghan was hammered for 24 runs in the final over which eventually hurt Mumbai badly.
Bond also defended skipper Rohit Sharma's decision to come down the order instead of opening the innings.
"If you look at the success of the team and the times we have won titles, he (Rohit) has always batted at No. 4. He has batted at No. 4 and won games for us. There is always a debate about where Rohit should bat. But history suggests No. 4 is the best place for Rohit," he said.
Meanwhile, RCB pacer Tim Southee praised Virat Kohli's captaincy and Mohammad Siraj's brilliance with the ball in the penultimate, which left Mumbai to score 23 runs of the last over.
"It got a little bit close towards the end. But I think Virat backed the guys to go out there and back their strongest skill set and we saw that with the way Siraj closed out his last over and made my job a little bit easier with a few more to defend," he said.


When it comes to comics, Ryan Reynolds knows a thing or two. The "Van Wilder" star has famously played beloved characters from both Marvel and DC franchises: Deadpool and Green Lantern, respectively. However, there was a stark difference between his roles, in that he was critically acclaimed for one and not the other. Where "Deadpool" cinched 90% positive reviews on reviews aggregate RottenTomatoes, "Green Lantern" languished with a mere 26%. Speaking with Entertainment Weekly, Reynolds explained what "Deadpool" did right -- and what, exactly, "Green Lantern" got wrong.
When it released back in 2011, "Green Lantern" managed to make $220 million worldwide -- just over its reported budget of $200 million. On the other hand, "Deadpool" grossed $363 million on a reported budget of $58 million. In fact, "Deadpool" -- which released earlier this year -- has been nominated for two Golden Globe awards: Best Picture, Comedy or Musical and Best Performance by an Actor in a Motion Picture, Musical or Comedy. This is rare for a genre film and stands testament to the quality of the film in the eyes of the general public. "Green Lantern" received no sequel film and has not yet appeared in Warner Bros.' DC Extended Universe.
Reynolds will next appear in "Deadpool 2," which is currently in development at Fox. Though the film does not yet have an official release date, it is expected to arrive in theaters sometime in 2018 with "John Wick" co-director David Leitch behind the camera.


I never thought I would hear another Godspeed You! Black Emperor album. It has been 10 years since the last one but it was worth waiting for. Explosions in the Sky have been keeping the seat warm (and they are great), but this much more post-rockier (is that even a word?). Gone are the 21 minutes instrumentals of the previous album, and in their place are 20 minute instrumentals.
Actually the albums opener, the 20 minute instrumental Mladic, is as good as anything they have done, wonderfully intense and sounding like Hawkwind's rebellious kids. I listened to it today while wandering around Sainsbuys and it was a very odd experience and made me a more discerning shopper. I am positive I would have bought more in the shop had I listened to the pipped Christmas Muzac. While listening to We Drift Like Worried Fire, a second box of Dinner Party Purple and Gold Christmas crackers just didn't make sense any more.
This entry was posted in 2010s, Uncategorized and tagged Godspeed You! Black Emperor. Bookmark the permalink.


EAST HANOVER, NJ – At the SMTA International 2018 technical conference, Portland State University, Zymet, Inc., and MK Electron Co, Ltd., will present their investigation on the board level reliability of low temperature solder (LTS) assemblies and the efficacy of a reworkable edgebond adhesive to enhance reliability. LTS assembly results in less warpage and, hence, fewer assembly defects. It also offers a path to board level assembly of modules, without subjecting them to their first-level reflow conditions. One disadvantage of low temperature solders is poorer board level reliability, particularly for harsher environments.
The -40°C to +125°C thermal cycle performance of BGA's assembled with LTS is compared with those assembled with conventional SAC solder. Non-edgebonded LTS assemblies (Figure 1a) are compared with those bonded with a reworkable edgebond adhesive (Figures 1b & 1c). The expected lower performance of LTS, relative to SAC solder, is confirmed. The reworkable edgebond adhesive, when applied to LTS-assembled BGA's, is found to improve performance to levels well beyond that of SAC-assembled non-edgebonded BGA's. With appropriate adhesive selection and configuration, LTS-assembled BGA's can meet more difficult board level reliability requirements, even those of a harsh environment application.
The paper, "Low Melting Temperature Interconnect Thermal Cycle Performance Enhancement Using Elemental Tuning and Edgebond Application", will be presented at Session APT7: Reliability of Low Temperature Solder (LTS) Interconnects, October 18, 2018. For more information about edgebond adhesives, visit Zymet at Booth #828, SMTAi 2018, Rosemont Convention Center, Rosemont, IL, October 14 -18, 2018. Or, email the company at info@zymet.com. Zymet is a global supplier of adhesives and encapsulants, focused on the development and manufacture of enabling materials for the electronics industry.


How sick will we become?
Who will call our bluff?
Here, even bees still swarm.
Angela lives in the beautiful state of California where she is a Massage Therapist. She journals and also choreographs dance. She accepted Christ over a decade ago and continues her pursuit after the heart of God through the performing arts of poetry, dance and health.
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text:
Anesth Analg. 1996 Feb;82(2):377-81.
Oscillometric blood pressure measurements by different devices are not interchangeable.
Kaufmann MA1, Pargger H, Drop LJ.
Department of Anesthesia, Massachusetts General Hospital, Boston 02114, USA.
Blood pressure (BP) is frequently measured in patients by noninvasive blood pressure (NIBP) monitors. Values obtained by oscillometric devices of different brands may appear in one patient's record as if they were interchangeable; their concordance, however, has not been established. In 25 patients with major depression who were treated with electroconvulsive therapy (ECT) BP was measured on either arm by devices manufactured by SpaceLabs (SpL, 12 patients, 182 data points) and Marquette (Marq, 13 patients, 193 data points), respectively, and comparisons were made with simultaneous measurements on the opposite arm by Dinamap 1846SX (DIN), during the awake state and at 1-min intervals up to 5-7 min after ECT. Because ECT is associated with an intense, but short-lasting hyperdynamic state, comparisons of BP values could be made over a wide range of pressures. Bland-Altman plots were constructed to show the distribution of pressure differences at all pressures. Agreements between two instruments were judged according to guide lines by the American Association for Advancement of Medical Instrumentation (AAMI). The standard deviation of the difference (SDD) between two DIN devices was 7 mm Hg for systolic (SBP) and 6.3 mm Hg for diastolic blood pressure (DBP), whereas mean differences were 0.9 and 0.2 mm Hg, respectively (P = not significant [NS]), thus showing reproducibility. Corresponding SDD values SpL versus DIN were 9.1 for SBP and 8.3 mm Hg for DBP, while the mean differences were 1.6 (P = 0.026) and 7.3 (P = 0.0001) mm Hg, respectively. Corresponding SDD values for Marq versus DIN were 11.8 and 9.7 mm Hg with mean differences of 0.8 (P = NS) and 0.3 (P = NS) mm Hg. Whereas SBP differences DIN versus DIN exceeded 10 mm Hg in only 10% of observations, they exceeded that threshold in 31% and 32% of observations for SpL versus DIN and Marq versus DIN, respectively. In view of the variability that exceeds the AAMI guidelines and the one out of three occurrence of individual SBP differences exceeding 10 mm Hg for comparisons of SpL or Marq versus DIN, measurements by these three oscillometric devices are not interchangeable.
Oscillometric blood pressure measurement: time for a rethink? [Anesth Analg. 1996]
10.1097/00000539-199602000-00029
Blood Pressure Determination/instrumentation*
Electroconvulsive Therapy
Oscillometry


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