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Do lights and sirens matter?
Not as much as I thought in the paper by Isenberg et al. They have looked at the need and filtering of 911 calls to reduce the number of responses that require a full lights and sirens response. Their three step protocol reduces the needs by one third, which may not only be good for crew safety, but may also make the world a more peaceful place (see page 592).
Do we need BLS instructors?
This month we have a really interesting study from Denmark by Nielsen et al. They have compared BLS performance among laypersons who were trained face to face versus those trained by DVD and their own, take home and try, manikin. They have found no difference between group, regardless of how the learners accessed the information which does ask questions about the small industry that exists around teaching BLS. It also questions all of us involved in education and life support related courses…how much influence do we really have on long term learning outcomes? (see page 587).
Routine follow-up CT scans
For those of us looking after head injuries as in-patients you will be familiar with the dilemmas and perhaps varying advice about the need for repeat CT scans in patients with traumatic brain injury. Practice seemingly varies around the world so it is interesting to read the systematic review from New Mexico that questions the need for routine follow-up scans. The answer seems to be to watch, wait and act on clinical findings rather than just scanning everyone. This seems sensible advice and reflects my experience of UK practice, but as we seem to be trending towards US practice in other areas perhaps it is wise to know the evidence now before advice changes here as well (see page 528).
More on radiological exposure
Is it me, or are we doing more CT, MR, X-rays these days? It certainly feels like it and I am starting to get worried about some of the radiation doses we are pumping into our local populations. Headache is an area that when I started in EM it was virtually impossible to get on the day imaging, but now it is commonplace, but what effect is this having on our pick up rates for pathology? In the US Gilbert et al have looked at trends in imaging for headache over a 10-year period and have shown an increase in imaging use, but a decline in positive CT findings for raised ICP. What factors have influenced this in the USA, and what might we do about it? They make some suggestions for reducing the number of scans requested, though some well derived and validated decision support seems to be what we may need in the future (see page 576).
We're all stressed, or are we?
It will be no great surprise to many readers that the paper by Yates et al finds that the ED is stressful, but how do we explain the finding that physicians are more stressed than other members of the department, and why do we differ from orthopaedic colleagues? Interesting stuff at a time when the specialty seems to be facing a staffing crisis. Are we pushed too hard in the workplace? How do we cope and what coping strategy works best? Read on and find out (see page 533).
Does anyone still use Flumazenil in the ED?
To answer the question, then yes! I was surprised to see that Flumazenil use to reverse benzodiazepine overdose takes place as I don't think I've seen it in years. Veiraiah et al have identified 80 cases from poison service records to show that it has been used, and that it's use is successful in most cases. This counteracts the teaching I have had in the past and perhaps we might revisit this drug for the treatment of some patients (see page 565).
Ask the patient if they need to come in
What would happen if we admitted and discharged patients on the basis of whether they thought they were sick? Crazy question, well perhaps not entirely as self perception of illness may add something to initial assessment and triage. This is what our colleagues in Japan have attempted by adding patient self assessment as a predictor of need for hospital admission or other care. You'll have to read the paper by Miyamichi and colleagues to find out the conclusions, and it may be a topic that's quite parochial but I think this shows that patients are perhaps not as accurate as they think they are (see page 570).
More things to do in the prehospital environment
The EMJ has covered a wide range of procedures that can be performed in the prehospital environment over the years and this month we must add EEGs to the list. Our colleagues in Germany led by Rainer Nitzschke demonstrate that it is practical to obtain EEGs in emergency ambulances. So, perhaps we will be assessing prehospital EEGs sometime soon. If so I'm going to need some training! (see page 536).
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