Indigenous Disproportionate Over-Representation of

Biological, Psychological, and Social Co-Morbidities

+ • physicians may work in various settingsin which Indigenous peoples make up a large proportion of

the population. T reatment approaches in these settings must consider issues unique to Indigenous

peoples, particularly considering that past colonial practices and historical traumas have led to their

over-representation in vulnerable groups. Indigenous peoples in Canada have shown great resilience

against a long history of colonialism,structural oppression, dispossession, and harmful policies.

ELOM28 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

These historical realities perpetuate currentstructural barriers that impact the health of Indigenous

peoples (see Public Health and Preventive Medicine,Colonization and Healthcare,PH7)

• importantly, physicians will encounter Indigenous peoples from a wide variety of personal and

historical experiences.Individualsshould be invited to share their backgrounds and perspectives if

they would like to do so, in an effort to understand the individual’

s unique context and to endeavour

to provide culturally safe care (see Resources in Indigenous Health,ELOM29)

Those Receiving Child Welfare Services (The Cycle of Apprehension and the Millennial

Scoop)

• similar continuation of the legacies of the residentialschoolsystems and the Sixties Scoop, Indigenous

families face higher rates of child apprehension currently.In Canada, 52.2% of children (ages 0-14) in

foster care are Indigenous, while Indigenous children accountfor only 7.7% of all Canadian children

in this age range (2016)

• 38% of Indigenous children live in poverty compared to 13% of non-lndigenous non -racialized

children in Canada (2011)

• in 2016, the Canadian Human Rights Tribunal ruled that the federal government discriminates

against First Nations children on reserves by failing to provide the same level of funding for child

welfare services that existsfor non-lndigenous children, resulting in inequitable services.Despite

the ruling recommending compensation, the Tribunal has issued 10 subsequent orders to ensure

Canada'

s compliance. In 2019, the federal government argued the T ribunal was the wrong forum to

discuss compensation and suggested there was no evidence of harm to individual children before the

Tribunal. The Tribunal rejected both arguments.In September 2019, theTribunal found that Canadas

ongoing discrimination against First Nations children and families was “wilful and reckless"

and that

it had caused serious pain and suffering for victims of the discrimination.Canada was ordered to pay

ights Act to compensate First Niitions

children, youth, and families who have been harmed by the child welfare system. In October 2019,

the federal government launched a court challenge at the Federal Court in an attempt to quash the

compensation order, which wassubsequently denied

• only once the Tribunal reinforced the initial ruling in December 2019 did the federal government

pass an Act respecting First Nations, lnuit, and Metis children, youth, and families, which came into

effect in January 2020. This act allows Indigenous communities to exercise jurisdiction in the welfare

of their own children over Indigenous Services Canada and provincial or territorial governments.

However, the federal government continuesto delay compensation and oppose the order for the

maximum allowable amount of compensation, despite other federal parties calling on the government

to pay

the maximum amount allowable under the Canadian Human Ki

Those in State Custody and the Colonial Legacy Within the Canadian Judicial System

• there is a direct link between family breakdown due to the residential school system,intergenerational

trauma and abuse from colonialism, and subsequent higher rates of child apprehension. Interacting

with the foster care system and the instability of multiple (sometimes abusive) homes is a predictor of

future interaction with the criminal justice system along with poverty and higher unemployment

• 27-30% of adults and 50% of youth taken into custody in 2016-17 were Indigenous,yet Indigenous

peoples make up only 4.1% and 8% of Canada’s adult and youth populations, respectively

• Indigenous youth are also overrepresented in community supervision

• from 2000 to 2010, the number of incarcerated Indigenous women increased by 86.4%, representing

the fastest growing incarcerated population

• Indigenous-based restorative (rather than punitive) justice programs have been proposed to lower

recidivism rates for Indigenous offenders

Those with no Fixed Address and the Colonial Legacy of Fiomelessness

• Toronto’

s Indigenous population is approximately 2-4x larger than estimates reported by Statistics

Canada, as the National Household Survey relies on mailing addresses, and some Indigenous People

may be skeptical about providing information to the government given historical and ongoing

breaches of trust

• as the statisticssignificantly underestimate the Indigenous population, resource allocation isseverely

compromised.More information is available here:http://www.welllivinghouse.com/wp-content/

uploads/2022/03/OHC-Toronto-2021-Population-Estimates.pdf

• in Toronto, Indigenous peoples make up roughly 15% of the homeless population, yet only 0.5% of the

total population (2010)

• enfranchisement (giving up Indigenous status in order to become a Canadian citizen), on-reserve

housing limitations and shortages, dislocation from community and lands in concert with poor

government funding and support are important links to Indigenous homelessnesstoday

• attempts to serve the needs of Indigenous people in urban areas include the employment of traditional

healers or cultural coordinators in urban health centres as well as the use of traditional medicines (e.g.

sage, cedar,sweetgrass, tobacco)

Missing and Murdered Indigenous Women, Girls and Gender Diverse People

•in Canada, Indigenous women and girls are significantly more likely to be murdered or go missing

than any other demographic of women

• between 2001 and 2015, homicide ratesfor Indigenous women were nearly 6 times higher than for

non-lndigenous women

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ELOM29 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

• interpersonal violence within Indigenous communities is closely tied to the lasting trauma suffered in

the residential school era and has far-reaching health impacts including acute injuries, chronic pain,

sexually transmitted infections, unplanned pregnancies, addiction,self-harm, and suicide

• loss of a mother,sister, or daughter also incurs multi-generational trauma on family and family

structure in Indigenous communities

Indigenous Health Coverage and Jurisdictions

• policy pertaining to the health of Indigenous peoples is considered to be shared amongst variouslevels

of government, the private sector, and First Nations communities themselves

• this current model relies heavily on state-imposed definitions of Indigenous identity and limits the

right to self-determination and self-governance for Indigenous peoples in Canada

• significant historical legislative vagueness, in combination with the multiplicity of authorities

involved, creates much variation across provinces and territories, contributing to inequitable

distribution of care for Indigenous peoples

• bureaucratic delays in approving and providing care, and jurisdictional debates between authorities

over the responsibilities of care, further contribute to a healthcare system which frequently fails to

adequately respond to the needs of Indigenous peoples and communities

• the federal government is responsible for the Non-Insured Health Benefits (N1HB) program, which is

managed by the First Nations and Inuit Health Branch of Indigenous ServicesCanada and is based on

the Indian Health Policy (1979) and the Health Transfer Policy (1989)

the role of the N1HB isto provide eligible First Nations and Inuit individuals with coverage for

specific health benefits and services (most predominantly: eye and dental care, pharmacare,

transport to and from medical appointments, and mental health counselling).There are very

strict criteria to have certain medications and procedures covered

the NIHB relies on state-imposed definitions of Indigenous identity; access to the N1HB extends

only to individuals who are (1) registered under the Indian Act (and consequently referred to

using the paternalistic term “Status Indian"); (2) Inuk, as recognized by the Inuit Land Claim

Organization; or (3) a child under 18 months of age whose parent is registered First Nations or

recognized Inuk

access to care for non-status First Nations and Metis patientsis consequently denied under NIHB

criteria, despite encountering similarsocial determinants of health and barriers to healthcare

experienced by eligible individuals

» clients deemed ineligible for NIHB must then rely on provincial or territorial health insurance,

social programs,or private insurance plansfor healthcare

note that NIHB eligibility does not guarantee access to care, as the criteria for approved services

issubject to frequent changes and impacted by factors including whether the applicant lives onor off-reserve

• the Canadian healthcare system must recognize that Indigenous communities arc best positioned to

identify their own unique health priorities and manage and deliver health care in their communities

although there issome development and implementation of Indigenous-led and Indigenousdirected healthcare services in Canada, the effects of colonialist policies and practices continue to

perpetuate inequities among Indigenous peoples

healthcare providers can work towards dismantling the effects of colonialism in a number of

manners, including allyship and advocacy, engaging in cultural safety training, and better

educating oneself on Indigenous history, the impact of colonialism, and resources available to

meet the unique needs of their patients(see Resources in Indigenous Health)

British Columbia (BC) has established a First Nations Health Authority as a step in addressing

Indigenousself-determination in healthcare

Resources in Indigenous Health

•please consider watching “The Unforgotten,” a 36-minute film, which consists of five segments: https://

theunforgotten.cma.ca/full-film/

• please consider reviewing this Indigenous Health Guide for Medical Students

https://temertymedicine.utoronto.ca/sites/default/files/lndigenousHealthinOntario-compressed.

pdf

• the following is a list of fact sheets, reports, and toolkits as well as organizational websites providing

resources relating to Indigenous health. All were created by or with Indigenous peoples and

organizations unless otherwise stated. These resources share the aim of highlighting Indigenous

resilience and promoting strength in Indigenous communities.Though not exhaustive, this list serves

as a foundation for the kinds of resources that are available to healthcare providers and/or Indigenous

Peoples seeking care. Of note, physicians have a responsibility to become familiar with local or

regional services that may be able to provide culturally safe trauma-informed care for Indigenous

People

+

ELOM30 Ethical,Legal, and Organizational Medicine Toronto Notes 2023

Table 7. Resources in Indigenous Health

Resource Ref #

Healthcare

National Collaborating Centre lor Indigenous Health (NCCIH) Extensive database o(Indigenous Health research and resources across Canada. Please note that some of these 1

materials may have been collated without Indigenous consultation

Recommendations in culturally appropriate care for healthcare providers in Canada working with Indigenous 2

peoples,reviewed by the Aboriginal Health Issues Committee

Canadian Institutes for Health Research (CIHR)

Wellesley Institute

First Peoples.Second Class Treatment: The Role of Racismin the Health

and Well- being ol Indigenous Peoples in Canada

First Nations Health Authority|FNAH||BC)

Report looking in-depth at the relationship between racism,health, and the well-being of Indigenouspeoples

in Canada

3

BC has its own health authority responsible for theplanning,delivery,and funding of First Nations Health

Programs across the province

Indigenous Health Primer produced by the Royal College of Physiciansand An extensive document that discusses anti-racism interventions, trauma-informed care.Indigenous health

principles,impact of policies on Indigenous peoples,and the diversity of present Indigenous communities

Offers special skills,knowledge, and resources to healthcare workersproviding caie to First Nations

communities.Hasparticular expertise inproviding addiction care

4

5

Surgeons of Canada

Thunderbird Partnership Foundation 6

Child and Family

Fiist Nations Child and Family Services IFNCFS)

National Aboriginal Council of Midwives (NACM)

Interactive map of Canada with allFHCFS service provider locations

Subset of the larger organization. Canadian Association of Midwives, that provides Indigenous midwives for 8

natal care

Social programs,such as women’s shelters and income assistance in Indigenous communities,funded federally 9

by Indigenous Services Canada

7

Indigenous Services Canada

Population-Specific

The national represenfalional body for Inuit people in Canada,with publications on TB elimination strategies and TO

Inuil specific health literacy resources

Inuit Tapiriit Kanatami (ITK)

Patients Facing Additional Layers of Systemic Barriers

People withno fixed address Description of Indigenous homelessness from an Indigenous perspective, emphasizing criteria that arenot

captured in colonialdeflnilions of "homelessness*

Multitude of fact sheets published by the Native Women's Association of Canada covering issues such ashousing,

violence,and health with an intersectional lens

The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls containing

testimonies from survivors and Knowledge Keepers,discussion of influencing factors such as intergenerational

trauma and insecure housing,as well as 231calls lor justice directed at Canadians and Institutions alike

The Centre for Suicide Prevention (branch of the Canadian Mental Health Association) offers many Indigenousspecific resources on suicide prevention,life planning, trauma,and cultural sensitivity

Online course called "River of life,” created for people working with Indigenous youth ages 15 - 24, discusses

strategies to strengthen the protective factors of youth atrisk of suicide

11

Indigenous women,girls,and gender diverse people 12

13

Mental health and suicide 14

15

Trauma informed Indigenousprograms, c.g. Biidaaban Healing lodge in Ontario and Tsow-Tun le turn Society 16.17

in BC

Building Cultural Competency

Indigenous Canada is a Massive Open Online Course (MOOC) from the Faculty of Native Studies that explores 18

Indigenous histories and contemporary issues inCanada.

Cancer Cate Ontario.Indigenous Relationship and Cultural Safely Courses 13 courses available lo provide knowledge about the history and culture of First Nations, Inuil and Metis people 19

and communities

University of Alberta’s Indigenous Canada online course

Resources:

1. National Collaborating Centre for Indigenous Health [Internet],Prince George (BC): National CollaboratingCentre lor Indigenous Health;(.2005- 2020. IndigenousHealth links Database;(cited 2020

Apr 19J.Available from: https://www.nccih.ca/511/Research_lnstitutes_and_ Organi2atlons.nccah.

2. Smylie J.A guide for health professionals working with Aboriginal peoples:Cross cultural understanding.J SOGC 2001:1-15.

3. Allan B.Smylie J.First Peoples.Second Class Treatment: The Role of Racism in the Health and Well

-being of Indigenous Peoples in Canada [Internet].Toronto (ON): the Wellesley Institute:2015|cited

2020 Apr 19|. Available from: https://www.wulleslcyinstltute.com/wp- content/uploads/2015 02/Summary-First-Peoplcs-Second-Class-Treatrncnt

-Firial.pdf.

4. First Nations Health Authority [Internet].Vancouver (BC): First Nations Health Authority:c2020 [cited 2020 Apr 19].Available from:https://www.fnha.ca/.

5. The Indigenous Health Writing Group of theRoyal College.Indigenous Health Primer [Internet].Ottawa (ON):Royal College of Physicians and Surgeons of Canada:2019 [cited 2020 Jun 3].Available

from:http://www.royalcollege.ca/rcsite/documents/health-policy/indigenous-health-primer-e.pdf.

G. Thunderbird Partnership Foundation [lntcrnut|.Bothwull(ON): Thunderbird PartnershipFoundation: c2020 [cited 2020 Jun 2.. Available from:https://thunderbirdpf.org/.

7. Government of Canada.Child andFamily Services [Internet].[Ottawa (ON)]:Government of Canada:[updated 2020 Jun 22].First Nations Child andFamily Services Interactive Map:c2012 [updated

2015 May 14:cited 2020 Apr 19].Available from:https://geo.aadnc-aand:.c;c /.d FNCFS-SEFPN/.

8. National Aboriginal Council of Midwives (Internet). [Montreal(OC)]:National Aboriginal Councilol Midwives; c 2020. Publications;2012-2020 [cited 2020 Apr 19]. Available from:https://

Indigenousmldwifery.ca/publicatlons/.

9. Government of Canada.Indigenous Services Canada [Internet].[Ottawa (ON)J:Government of Canada:[updated 2020 Jun 22],Social Programs:[updated 2020 Apr 4:cited 2020 Apr 19J.Available

from:https://www.sac-isc.gc.ca/eng/1100100035072/1521125345192.

10. Inuit Tapiriit Kanatami [Internet).Ottawa (ON): Inuit Tapiriit Kanatami; c2020. Publications; 2001-2020[died 2020 Apr 19). Available from: https://www.itk.C4 category/publications/.

11. Homeless Hub.[Internet). Toronto (ON):Canadian Observatory on Homelessness:c2019. Definition of IndigenousHomelessness In Canada; 2017 [cited2020 Apr 19J.

Available from:https://www.homelesshub.ca/lndigenousHomelessness/.

12. Native Women’s Association of Canada (Internet).Ottawa (ON): Native Women's Association of Canada.Publications & Resources;2003-2020 [cited 2020 Apr 19J.Available from:https://www.nwac.

ca/browse/.

13.National Inquiry IntoMissing and Murdered Indigenous Women and Girls.Reclaiming Power and Place:The Final Report of the NationalInquiry Into Missing and MurderedIndigenous Women and

Girls.Volume1a/1b.[Internet],[placeunknown]:National Inquiry Into Missing and MurderedIndigenous V/omen and Girls; 2019 Dec 6[cited 2020 Apr 19].Available from:https://w ww.mmiwg-tfada.

co/flnal

-report/.

14.Centre for SuicidePrevention [Internet].Calgary (AB):Centre for SuicidePrevention.Resources:[cited 2020 Apr 19].Available from:https://www.suicldeinfo.ca/resources/.

15.River of Life.River of Life Program [Internet],[place unknown]:River of Life: c2020[updated 2020;cited 2020 Apr 19L Available from:https://riveroflifeprogram.ca/.

16. The Biidaaban Healing Lodge [Internet.Heron Bay (ON): The Biidaaban Healing Lodge;n.d.(cited 2020 Apr 19]. Available from:http://www.biidaaban.com/.

17. Tsow-Tun le lum Society:Substance Abuse and Trauma Treatment Centre [Internet].Inntxville (BC): Tsow-Tun lelum Society ;n.d.[cited 2020 Apr 19]. Available (torn:htlp://www.tsowtunlelum.org/.

18. Indigenous Canada.University of Alberta [cited 2021June 6] Available from:https://www.ualberta.ca/admlsslons-ptograms/online-courses/lndigenous-canada/lndex.html

19. Indigenous Relationship andCultural Safety Courses.Cancer Care Ontario.Available from:

https://www.cancercareontario.ca/en/resources-first-nations-inuit-metis/tirst-nations-inuit-metis-courses

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EL0M31 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

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Government of Canada,First NationsChild and Family Services [Internet],[Ottawa (ON)]: Government olCanada;[updated 2020 Jun 22).Reducing the Number of Indigenous Children in

Care;[updated 2020 Feb 20;cited 2020 Apr14],Available from:https://www.sac-isc.gc.ca/eng/1541187352297/1541187392851.

Government of Canada,Indigenous and Northern Affairs Canada [Internet],(Ottavra (ON)]:Government of Canada;[updated 2020 Jun 22],

Government of Canada,Indigenous Services Canada [Internet],[Ottavra (ON)]:Government ol Canada;[updated 2020 Jun 22].Non-insuied health benefits for First Nations andInuit;

[updated 2020 Jan 24; cited 2020 Apr 16],Available from: https://www.sac-isc.gc.ca/eng/1572537161086/1572537234517.

Government of Canada [Internet],[Ottawa (ON)]:Government of Canada;[updated 2020 Jun 22],Treaties and agreements;[updated 2018 Sept 11;cited 2020 Apr 18]. Available from:

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www.sac-isc.gc.ca/eng/1583703111205/1583703134432.

Government of Canada,Minister of Justice;2020 Jan1[updated 2020 Mar 19;cited 2020 Apr14],Available from:https://laws.justice.gc.ca/PDF/F-11.73.pdf.

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e60-e76.

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2018 [cited 2020 Apr14].Available from:https://vrvrw.homelesshub.ca/resource/12-dimensions-indigenous-homelessness.

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Lavoie, JG.Policy silences:Why Canada needs a NationalFirst Nations,Inuit and Metis health policy.Int J Circumpol Heal.(2013). 2013 Dec 27;72(1):22690.

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theglobeandmail.com/news/national/vrhat-really-happened-to-the-inuit-sled-dogs/article983351/.

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638-x/2009001/artide/10825-eng.htm.

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-

day info-sheet.pdf.

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[cited 2020 Apr 19].Available from:

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r

^ L J

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E1.0M33 Ethical,Legal,and Organizational Medicine Toronto Notes 2023

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with Aboriginal peoples:Cross cultural understanding.J SOGC 2001:1-15.

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58958.

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AL GRAWANY

Anesthesia

Evan Tang and Kathak Vachhani, chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, EBM editor

Dr. Ahtsham Niazi,staff editor

Acronyms

Overview of Anesthesia

Preoperative Assessment

History and Physical

Preoperative Investigations

American Society of Anesthesiology Classification

Preoperative Optimization

Medications

Hypertension

Coronary Artery Disease

Respiratory Diseases

Aspiration

Fasting Guidelines

Hematological Disorders

Endocrine Disorders

Obesity and Obstructive Sleep Apnea

Monitoring

Airway Management

Airway Anatomy

Methods of Supporting Airways

Tracheal Intubation

Difficult Airway

Oxygen Therapy

Ventilation

Intraoperative Management

Temperature

Heart Rate

Blood Pressure

Fluid Balance and Resuscitation

IV Fluids

Blood Products

Inductioa

Routine Induction vs.Rapid Sequence Induction

Induction Agents

Muscle Relaxants and Reversing Agents

Maintenance

Extubation

Complications of Extubation

Regional Anesthesia

Epidural and Spinal Anesthesia

Peripheral Nerve Blocks

Local Anesthesia

Local Anesthetic Agents

Systemic Toxicity

Local Infiltrationand Hematoma Blocks

Topical Anesthetics

Postoperative Care

Common Postoperative Anesthetic Complications

Pain Management

Acute Pain

Neuropathic Pain

Chronic Pain

Obstetrical Anesthesia

Paediatric Anesthesia

Uncommon Complications.

Malignant Hyperthermia

Abnormal Pseudocholinesterase

,A2 Appendices

Difficult Tracheal Intubation in Unconscious Patient

A2

Difficult Tracheal Intubation

A2 Advanced Cardiac Life Support Guidelines

Landmark Anesthesiology Trials

References

A30

A34

.A35

A4

A7

A7

.A12

A16

,A20

A20

A20

A21

A 22

A24

A25

P T

L J

A27

A28

A29 +

At Anesthesia Toronto Notes 2023

A2 Anesthesia Toronto Notes 2023

Acronyms

2.3 8PG 2.3-Bisphosphoglycerate

ABG arterial blood gas

ACC American College of Cardiology CVP

ACh acetylcholine

AChE acetylcholinesterase

ACV assist-control ventilation

AFib atrial fibrillation

AHA American Heart Association OKA

ALS amyotrophiclateral sclerosis OM

aPTT activated partial thromboplastin ETC02

time

ARDS acute respiratory distress

syndrome

ASA American Society of

Anesthesiologists

atmosphere

BBB blood brain barrier

BMV bag-mask ventilation

blood pressure

CCS Canadian Cardiovascular

Society

CHF congestive heart failure

creatine kinase

central nervous system

cardiac output

CPAP continuouspositive airway

pressure

CSF cerebrospinalfluid

CV cardiovascular

CVS cardiovascular system

central venous pressure

CVD cardiovascular disease

CXR chest X-ray

DIC disseminated intravascular LA

coagulation

diabetic ketoacidosis

diabetes mellitus

end-tidal CO2

ETT endotracheal tube

Fi02 fraction of oxygen in inspired air MAP

FFP fresh frozen plasma

FRC functional residual capacity MS

GA general anesthesia

GE gastroesophageal

GERD gastroesophageal reflux disease NPO

NYHA

international normalized ratio PCA

intraocular pressure

immune thrombocytopenic PEEP

purpura

intravenous

local anesthetic

long-acting g-agonist

lower esophageal sphincter

laryngeal mask airway

level of consciousness

minimum alveolar concentration RA

mean arterialpressure

malignant hyperthermia

multiple sclerosis

musculoskeletal

neuromuscular junction

nil per os

New York Heart Association SV

oral corticosteroids

orogastric

operating room

obstructive sleep apnea

pulmonary artery

arterial partial pressure of

carbon dioxide

arterial partial pressure of

oxygen

patient-controlled

INR patient-controlled analgesia

pressure-controlled ventilation

positive end-expiratory pressure

parasympathetic nervous

system

post-anesthetic care unit

postoperative nausea and

vomiting

positive pressure ventilation

peripheral vascular disease

regional anesthesia

rapid sequence induction

short-acting p-agonist

succinylcholine

syndrome of inappropriate

antidiuretic hormone

sympathetic nervous system

stroke volume

systemic vascular resistance

transient ischemicattack

total body water

total intravenous anesthetic

transurethral resection of

prostate

upper respiratory tract infection

ventilation'perfusion

ventricular tachycardia

venous thromboembolism

I0P PCV

ITP

IV

PACU

LABA PONV

LES

LMA PPV

LOC PVD

MAC

RSI

MH SABA

SCh

MSt SIADH

atm NMJ

SNS

Gl gastrointestinal

genitourinary

initial hemoglobin

final hemoglobin

hematocrit

BP GU OCS SVR

Hb(i) OG TIA

Hb(f| OR TBW

Hct OSA TIVA

CK HES hydroxyethyl starch PA TURP

hyperosmolar hyperglycemic

state

heart rate

intracranial pressure

inhaled corticosteroids

CNS HHS PaC02

CO URTI

HR Pa02 VO

ICP VT

ICS PC VIE

Overview of Anesthesia