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  1. Simon Carley, Associate Editor

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It's NICE to dream of a better neurosurgical service

The NICE guidelines on the management of head injury are challenged this month by Barrett et al who have conducted their own systematic review on the benefits of transferring an increased number of patients to neurosurgical centres. Their review highlights the unmet need of head-injured patients but also seriously questions the evidence base on which the NICE guidelines are based. This issue will have major implications for emergency departments that are not co-located with a regional neurosurgical unit. How ‘evidence based’ are the NICE guidelines? Barrett et al raise some serious concerns (see page 173).

A rapid Troponin is better for patients and the hospital

It's good to see a diagnostic test that seems to be of obvious benefit (near patient testing of Troponin levels) subjected to a formal evaluation. As Loten et al explain, there are often barriers to the adoption and utility of near-patient tests and their decision to formally test this in a randomised controlled trial is to be commended. I won't spoil their conclusion by stating it now but it certainly had an effect on their 8-hour ED target time. This paper is worth a read by anyone considering point of care testing as there is a good discussion on the human and cultural factors that might affect the adoption of these new tests (see page 194).

Domestic violence in the ED

Boyle et al provide a timely reminder of the importance of recognising domestic violence in our ED patients. For victims this is an incredibly damaging experience and emergency physicians have a role to play in the identification, management and support of patients. This ambitious study seeks to find factors that might help clinicians identify patients at high risk. As the authors state we do not know yet whether interventions will be successful in preventing future assaults, but this is a worthy and important step on the road to reducing the impact of these crimes (see page 203).

S100B may have a new role in spinal fractures

A small but potentially interesting study from Korea this month suggests that serum levels of S100B might help identify patients with spinal injuries. While the numbers are small, it is interesting that certain patients with normal plain films but with raised S100B levels were subsequently shown to have fractures on MR or CT scanning. All emergency physicians know that plain films can miss fractures, but also that routine whole spine CT results in a significant radiation dose. Might we see larger studies in this area over the coming years? (see page 209).

Consultants and GPs agree, and disagree, about NHS referrals

I find that many emergency physicians moan about NHS direct referrals, stating that they are ‘inappropriate’, but paradoxically also stating that it is too hard to make a judgement over the phone. All telephone assessments are compromised by not being able to see the patient, so how do we decide what is appropriate to send to the ED and what is not? Cook et al used panels of GPs and ED consultants to make judgements on what was appropriate and found that both groups felt the number of ED referrals could be reduced. However, more patients were deemed appropriate by consultants than GPs. The disagreement is interesting, but can we know who is actually ‘correct’? (see page 213)

The neurosurgical experience of earthquakes

The recent disaster in Haiti has again reminded us of the human cost of natural disasters. This paper from China describes the experience of their health system in managing the large number of brain-injured patients who presented as a result of the Wenchuan earthquake in 2008. This account describes the difficulties inherent to any disaster with large numbers of casualties compounded by damage to healthcare infrastructure. The description of the decision to leave a seriously ill patient to die in order that resources could be used to save a greater number of people is a disturbing reality of the challenges that these doctors faced (see page 216).

Airway management in prehospital care

The use of advanced skills in the prehospital care has been controversial for as long as I have been in medicine. The questions of who should be doing what, to whom and when rage between regions and specialities with seemingly entrenched views on all sides. This paper from the JRCALC working group report published this month is therefore a welcome analysis of the role of airway management in prehospital care. On reading it, I am reminded of the old adage that ‘the only people you can intubate without drugs are the newly dead and the very nearly dead’. The JRCALC's findings are controversial and will not be welcome to many readers (see page 226). The commentary by Malcolm Woollard on behalf of our paramedic colleagues is well worth a read (see page 167). Clearly this is the start of an impassioned debate which we all hope will be a heated agreement rather than argument.

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