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St. Mike’s hospital trauma surgeons are using battlefield techniques to treat victims of gun violence

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“One major difference is that today, when someone comes in, we start to give them a blood transfusion very early on,” he said, noting that until just over a decade ago, these patients were immediately given saline IV fluids with blood to follow.

But a 2007 study, of which Rizoli was a contributing author, showed that trauma patients suffering from major hemorrhagic bleeding have much better outcomes if they are immediately given massive blood transfusions.

“They do much better if they get blood from the start,” he said.

Many of these survivors owe their lives to the health professionals such as Rizoli.

St. Mike’s — one of three trauma centres in the city — sees about one shooting victim a week and is able save approximately 80 per cent of them, Rizoli said.

The Star recently spent some time with a Rizoli and the team of trauma surgeons at the hospital to learn how they are trying to keep more of these patients alive.

Rizoli said it stands to reason that shooting victims are faring better today. The increase in gun violence sadly means trauma surgeons are getting much more experience in dealing with these patients.

These days, St. Mike’s averages about one victim of gun violence a week.

“During my training 25 years ago, gunshot wounds were uncommon and many Canadian surgeons had to train in the U.S. to gain experience in treating them. The growth in the number of victims to gun violence and the progression to more lethal weapons had been fortunately balanced by enormous advances in trauma science and practice,” Rizoli said.

Advancements have been made in research, technology, drugs hospital design, workflow, protocols and best practices, he noted.

Much of the learning has come from the battlefield.

“We have learned from wars that patients who have lost a lot of blood cannot clot appropriately,” Rizoli explained.

They suffer from what is known as “trauma-induced coagulopathy,” and if not treated quickly, it can lead to a patient bleeding to death.

“We give them blood, and tons of blood, to start with. Then we try to diagnose, as quickly as possible, exactly what is wrong with their coagulation,” Rizoli said.

They do this by using a piece of equipment, purchased by the hospital about five years ago, which quickly analyzes blood-clotting properties. Called ROTEM, short for rotational thromboelastometry, it guides health professionals in determining what blood products trauma patients require so that their blood clots properly.

St. Mike’s surgeons have recently begun to use another technique developed on the battlefield, this one to stop traumatic bleeding.

The minimally invasive procedure is known as REBOA, or Resuscitative Endovascular Balloon Occlusion of the Aorta. It involves running a catheter up the femoral artery and into the aorta. A balloon at the tip of the catheter is inflated, stopping the flow of blood.

The procedure can be done in the trauma bay. Previously, patients would have been moved to the opening room where their chests would be opened and aortas clamped. That took much longer, was more invasive and carried a higher risk of death.

Before using the new REBOA catheter on patients, St. Mike’s tested it out on a high-tech mannequin. The simulation served to educate those in the trauma program — including nurses, respiratory therapists and surgeons — on how it works.

“It’s like crash-testing a car. You wouldn’t drive a car if it hadn’t been crash-tested first. We do the same thing with new processes. We crash-test them and make sure they work like we anticipate they will,” said Dr. Andrew Petrosoniak.

He and colleague Dr. Chris Hicks are emergency physicians, trauma team leaders and simulation educators at St. Mike’s. Their work on simulation exercises has helped improve the workflow in trauma resuscitation care. It has also informed the design of a new trauma bay at the hospital, scheduled to open in 2019.

One of their exercises involved tracking the movements of three nurses treating a simulated trauma patient. It was videotaped and the movements of each nurse were followed, using an overlay tracing tool, with a different colour for each nurse.

The end result looked like colourful child’s scrawl to the untrained eye. But to Petrosoniak and Hicks, it revealed how the nurses lost time criss-crossing the trauma bay to get different pieces of equipment.

If the equipment needed was closer at hand, nurses would need to criss-cross the room and seconds could be saved. There would be less risk of nurses bumping into each other and dropping instruments.

“So now we understand where they’re moving and we can improve their efficiency,” Petrosoniak said. “The whole point of efficiency is to get the care faster. If you are thinking about gunshot wound patients, time matters significantly.”

Hicks said the information has also been used in the design of the new trauma bay to show how much room is needed around each bed.

The pair have also worked on creating a new “massive transfusion protocol.” They examined steps taken by everyone involved in the transfusing large amounts of blood into trauma patients.

That includes, as an example, porters charged with picking up blood from the blood bank at the other end of the hospital and carrying it over to the trauma bay.

Petrosoniak and Hicks realized seconds could be lost by waiting for an elevator, so now porters must take the stairs. As well porters must announce themselves when entering the trauma bay instead of waiting to be noticed.

Through changes such as this, delivery time for blood has been cut by 12.5 per cent to nine minutes.

“In the past you might have been waiting for blood,” Hicks said, citing research showing that every minute blood is delayed results in a 5 per cent increase in mortality.

Trauma surgeons at St. Mike’s are also working to reduce the need for their services by campaigning to reduce access to guns. Two surgeons with much to say on this happened to be on duty the night of the Danforth shooting in July. Drs. Najma Ahmed and Bernard Lawless say that the Danforth shooting prompted them to increase their activism.

“I think there is greater public awareness that this is a public health crisis. I think there is also greater awareness that guns can be lethal beyond just crimes. They are very often used in adolescent suicide in Canada,” Ahmed said.

This past fall, she helped draft a position statement, calling for limited civilian access to firearms, and then assisted in getting endorsements for it from medical associations, including the Trauma Association of Canada and the Canadian Association of General Surgeons.

She and Lawless have also been lobbying politicians to take steps to crack down on gun violence.

“Dr. Ahmed and I have been contacting decision-makers at all levels,” Lawless said. “It’s going to take political fortitude to make change. When you look at this from a common sense perspective, it’s really not a difficult issue.”

Calling gun violence a “disease,” Ahmed said it makes perfect sense for physicians to be involved in trying to eradicate it.

“It has its own risk factors and own epidemiology, its preventable strategy,” she said.

Lawless said the profession has a long history in working on injury prevention: “Trauma surgeons have long played a role in injury prevention, whether it’s around seatbelt use, drinking and driving, and even working with engineers on how cars and roads are designed.”

Rizoli said diseases can be eradicated and points to smallpox as an example.

“No one should be injured by a disease that is completely preventable. No one in Canada should he a victim of gun violence. There could come a time when this could end.”

Theresa Boyle is a Toronto-based reporter covering health. Follow her on Twitter: @theresaboyle

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‘Business as usual’ for Dorel Industries after terminating go-private deal

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MONTREAL — Dorel Industries Inc. says it will continue to pursue its business strategy going forward after terminating an agreement to go private after discussions with shareholders.

« Moving ahead. Business as usual, » a spokesman for the company said in an email on Monday.

A group led by Cerberus Capital Management had previously agreed to buy outstanding shares of Dorel for $16 apiece, except for shares owned by the family that controls the company’s multiple-voting shares.

But Dorel chief executive Martin Schwartz said the Montreal-based maker of car seats, strollers, bicycles and home furniture pulled the plug on a deal on the eve of Tuesday’s special meeting after reviewing votes from shareholders.

“Independent shareholders have clearly expressed their confidence in Dorel’s future and the greater potential for Dorel as a public entity, » he said in a news release.

Dorel’s board of directors, with Martin Schwartz, Alan Schwartz, Jeffrey Schwartz and Jeff Segel recused, unanimously approved the deal’s termination upon the recommendation of a special committee.

The transaction required approval by two-thirds of the votes cast, and more than 50 per cent of the votes cast by non-family shareholders.

Schwartz said enhancing shareholder value remains a top priority while it stays focused on growing its brands, which include Schwinn and Mongoose bikes, Safety 1st-brand car seats and DHP Furniture.

Dorel said the move to end the go-private deal was mutual, despite the funds’ increased purchase price offer earlier this year.

It said there is no break fee applicable in this case.

Montreal-based investment firm Letko, Brosseau & Associates Inc. and San Diego’s Brandes Investment Partners LP, which together control more than 19 per cent of Dorel’s outstanding class B subordinate shares voiced their opposition to the amended offer, which was increased from the initial Nov. 2 offer of $14.50 per share.

« We believe that several minority shareholders shared our opinion, » said Letko vice-president Stephane Lebrun, during a phone interview.

« We are confident of the long-term potential of the company and we have confidence in the managers in place.”

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Anglais

Pandemic funds helping Montreal businesses build for a better tomorrow

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Many entrepreneurs have had to tap into government loans during the pandemic, at first just to survive, but now some are using the money to better prepare their businesses for the post-COVID future.

One of those businesses is Del Friscos, a popular family restaurant in Dollard-des-Ormeaux that, like many Montreal-area restaurants, has had to adapt from a sit-down establishment to one that takes orders online for takeout or delivery.

“It was hard going from totally in-house seating,” said Del Friscos co-owner Terry Konstas. “We didn’t have an in-house delivery system, which we quickly added. There were so many of our employees that were laid off that wanted to work so we adapted to a delivery system and added platforms like Uber and DoorDash.”

Helping them through the transition were emergency grants and low-interest loans from the federal and provincial governments, some of which are directly administered by PME MTL, a non-profit business-development organization established to assist the island’s small and medium-sized businesses.

Konstas said he had never even heard of PME MTL until a customer told him about them and when he got in touch, he discovered there were many government programs available to help his business get through the downturn and build for the future. “They’ve been very helpful right from day one,” said Konstas.

“We used some of the funds to catch up on our suppliers and our rents, the part that wasn’t covered from the federal side, and we used some of it for our new virtual concepts,” he said, referring to a virtual kitchen model which the restaurant has since adopted.

The virtual kitchen lets them create completely different menu items from the casual American Italian dishes that Del Friscos is known for and market them under different restaurant brand names. Under the Prasinó Soup & Salad banner, they sell healthy Greek options and their Stallone’s Sub Shop brand offers hearty sandwiches, yet the food from both is created in the same Del Friscos kitchen.

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Downtown Montreal office, retail vacancies continue to rise

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Some of downtown Montreal’s key economic indicators are heading in the wrong direction.

Office and retail vacancies in the city’s central core continued to climb in the fourth quarter of 2020, according to a quarterly report released Thursday by the Urban Development Institute of Quebec and the Montréal Centre-Ville merchants association. The report, whose first edition was published in October, aims to paint a socio-economic picture of the downtown area.

The survey also found office space available for sublet had increased during the fourth quarter, which may foreshadow even more vacancies when leases expire. On the residential front, condo sales fell as new listings soared — a sign that the downtown area may be losing some of its appeal to homeowners.

“It’s impossible not to be preoccupied by the rapid increase in office vacancies,” Jean-Marc Fournier, the former Quebec politician who now heads the UDI, said Thursday in an interview.

Still, with COVID-19 vaccinations set to accelerate in the coming months, “the economic picture is bound to improve,” he said. “People will start returning downtown. It’s much too early to say the office market is going to disappear.”

Public health measures implemented since the start of the pandemic almost a year ago — such as caps on office capacity — have deprived downtown Montreal of more than 500,000 workers and students. A mere 4,163 university and CEGEP students attended in-person classes in the second quarter, the most recent period for which figures are available. Border closures and travel restrictions have also brought tourism to a standstill, hurting hotels and thousands of local businesses.

Seventy per cent of downtown workers carried out their professional activities at home more than three days a week during the fourth quarter, the report said, citing an online survey of 1,000 Montreal-area residents conducted last month.

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