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Highlights from this issue
  1. Darren Walter, Editor

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It's the height of the British summer and holiday time is upon us, a time to recharge the personal solar batteries on a beach and reflect. This month there is plenty of science and some cautionary thoughts. There are some reflections on how we might do better and a flash back to the early days of 4 h performance management.

Worth thinking about

Lee et al present a study on the career longevity of Emergency Physicians in Taiwan in comparison to colleagues from other specialties. They show convincingly that there is a significant attrition rate and hypothesise on the cause. A potential mitigating factor is the development of a portfolio of roles rather than simply being on the front line.

On a more positive note, a summer of sport is in full flow. The Olympics may have moved on, but mass-gathering medicine is specialist field and Al-Shaqsi and colleagues found an interesting trend looking at hospital and staff preparedness for large sporting events.

A bit of science

Collins et al give an epidemiological report on the Irish experience of paediatric traumatic brain injury. Falls form the majority of the cases, but no surprise that beyond this boys are more accident prone than girls. The most interesting bit is that the gender difference begins in infancy!

Gill et al review their experience with patients who had thoraco-lumbar fractures from blunt trauma and find that a small but significant number without distracting injuries would have been missed on clinical examination alone. A low probability finding but a highly significant miss.

Biomarkers are regularly considered for use in our emergency environment but many of them seem to struggle to find a clinical application. Mockel et al introduce a new one for acute shortness of breath that may help guide the level of care required on admission. Looks plausible, but will it gain traction?

Resuscitation basics

There are three papers on improving basic life support. It seems simple, but we can do better. Cha et al ask whether the hand location is right and suggest not, McDonald et al show that we are not able to sustain quality compressions for as long as we think we can and should change person every two minutes. Keeping it going needs a metronome; You et al show that a flashing light can be as effective when there is a lot of ambient noise. These are not cutting edge new ideas, but are well done studies with convincing messages that will help to get the core interventions right.

Near misses

Bilen et al report on the application of decision tools for considering the risk of further episode of self-harm in their Swedish population. Since 20% do repeat within 6 months and 3.8% of these will succeed, focussing mental health resources in the right place is important but not easy.

Expectations of the Emergency Service are ever rising and the intractable problem of those who leave without waiting to be seen or against medical advice is considered by Geirsson et al. Unsurprisingly, the patients tend to be young and male when it is busy, but they tend to come back. There are two distinct groups however, and the ‘against advice’ group do have a higher than anticipated admission rate.

One of the big airway fears in the ED is the ‘can't intubate, can't ventilate’ scenario for the clinically inexperienced. The ‘insurance’ is access to a surgical airway. There are lots of expensive ready-made kits for this procedure but Helm et al reveal a surprise; the standard surgical technique may be more reliable!

Doing better

The Case from HEMS by McQueen et al in this edition focuses on a scene management challenge. The dynamic risk assessment is constantly in flux and safety of the responder and the patient is as important as patient care.

There is not much else for the pre-hospital readers this month, but Faiz et al show how the big wins in improving stroke outcome are to be found in improving public awareness to make the call for help earlier rather than faster ambulance response, but how to do it…

British emergency physicians will remember well the management approach to performance improvement imposed to achieve the notorious ‘4 h target’. Casalino et al show that the French are now being challenged to grapple with similar issues and they provide a revision lesson in how to objectively approach the problem. Some English departments are now struggling to maintain the gains achieved a few years ago and perhaps a review of our understanding and strategy is in order?

Neat trick

Silich et al show that you can find a way to improve even an accepted standard practice. We suture our central lines in place but this is a regular source of needlestick injury. With a refinement in the product, staples can be just as effective. Clever!

Finally, a conundrum, a what do you do with this? Bohm et al describe a case where a pacemaker lead had fractured after relatively minor chest trauma. Cool pictures but when the lead is coiled in the right ventricle, how do you get it?

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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