Primary Survey
WALK IN CENTRES
Many of you will have experienced the co-location of NHS walk in centres with emergency departments and opinions are often strongly expressed on their value and effectiveness. Salisbury et al compared activity at walk in centres attached to emergency departments, and at matched emergency departments without walk in centres. Interestingly, they did not see any difference in terms of patient attendance rates, waiting times, costs or outcomes. They suggest that this may be a result of a disconnection between the centrally-determined aims for walk in centres alongside emergency departments and the way in which this policy has been implemented locally. It is unclear why this may be, but I am sure many of you recognise the concept of taking government led directives and then perhaps “moving the goalposts” towards something with a more direct local relevance. See page 265
SUSPENSION TRAUMA
“Rescue death” is a worrying concept. The idea that the process of rescue itself may lead to the death of the casualty should give us all concern. This month Lee and Porter review the evidence for the condition and suggest that emergency clinicians in prehospital and hospital settings should be made aware of this potential condition. It might also explain why your next suspension trauma patient might arrive with sat up rather than laying down. See page 237
EMERGENCY CARE PRACTITIONERS
ECPs are something of a red rag to some readers of the journal, and controversy has raged about their role and effectiveness. In this issue Mason et al have looked beyond mere opinion and examined what ECPs actually do. They have found that ECPs do less investigations than other providers, and that patients are more satisfied. This is all sounds positive, though some readers will lament the lack of a measure regarding whether the care was actually correct. This well conducted study of process and satisfaction will take the arguments further, but I suspect will not convince all of the worth of ECPs. See page 239
TWOS AND GREENS???
For many consultants on call from home a green warning light is an essential means of getting to the hospital at busy times of the day. Pring et al conducted a questionnaire showing that many consultants would break the law whilst using one. In this self reported survey 30/166 (18%) of consultants had been stopped by the Police whilst attending an emergency and four had been prosecuted. Anyone who is thinking about using a green light should read this carefully. See page 244
DRAT THE RAT
Super rats presumably require super rat poison. One such superwarfarin almost killed a farmer in an agricultural accident reported by Binks and Davies. These superwarfarins are certainly toxic to the rats, but the farmer and clinicians must have been surprised at the haematological effects that occurred solely after skin contamination, with no oral ingestion. It would also seem that the long half life of these agents may present challenges for post exposure monitoring. See page 307
IS THERE A ROSY FUTURE FOR THE MANAGEMENT OF THE COLLAPSED PATIENT?
I am sure that everyone who has spent any time in an emergency department will occasionally have been puzzled about who needs admission after a collapse. The myriad of potential causes, some benign, some life threatening, means that getting it wrong can have serious consequences for the patient and your legal department. The ROSE study suggests that a clinical decision rule (CDR) may be able to predict who is at risk, and perhaps as importantly for the emergency department, who can be safely allowed home. Unfortunately, none of the scores assessed showed the balance of sensitivity and specificity that the practicing emergency physician needs. The study is a pilot but the results will no doubt inform future work towards an effective CDR for emergency department use, we look forward to seeing that some time soon. See page 270
INTIMATE PARTNER VIOLENCE AND HIV RISK FACTORS.
A study from the US, which makes difficult reading, again alerts us to the importance of intimate partner violence in women presenting to the emergency department. In this interesting study they suggest that intimate partner violence has associations with behaviours that are likely to lead to HIV transmission. Although the study was conducted in New York, the high rates of violence (49.6%) and rape (15%) are indeed shocking and we should not be complacent in thinking this is just an American problem. Could it be an issue in your department? See page 255
