Whether or not a simple wound will get infected depends on the source
of injury, the site of injury, age of the patient and the immune status of
the patient. If the patient is at extremes of age or is immune suppressed
then the chances of infection of the wound is quite higher. Moreover,
simple wound infections in such patients may result in cellulitis,
nectrotising facsitis, abcsess formation and chron...
Whether or not a simple wound will get infected depends on the source
of injury, the site of injury, age of the patient and the immune status of
the patient. If the patient is at extremes of age or is immune suppressed
then the chances of infection of the wound is quite higher. Moreover,
simple wound infections in such patients may result in cellulitis,
nectrotising facsitis, abcsess formation and chronic wound infection; all
which can cause great morbidity and even mortality. Further, simple wounds
on hands, feet and the perinal region are more likey to get infected than
wound on the face and chest.
Studies have shown that most health personnel are carriers of S.
aureus, that are resistant to most commonly used antibiotics and that
transient colonisation of the hands of the health care personnal is common.[1,2] This is has been found to be the main cause of nosocomial
transmission of infections. Proper handwashing with soap and water and
wearing sterile gloves can prevent transmsission of these nosocomial
infections. Therefore, even when it might seem as a waste of resources to
wear sterile gloves when treating simpel wound it might be worthwhile
after all.
Reference
(1) Kac G, Buu-Hoi A, Herisson E, Biancardini P, Debure C. Methicillin
-resistant Staphylococcus aureus. Nosocomial acquisition and carrier state
in a wound care center. Arch Dermatol 2000 Jun;136(6):735-9.
(2) Solberg CO.Spread of Staphylococcus aureus in hospitals: causes
and prevention. Scand J Infect Dis 2000;32(6):587-95.
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortali...
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortality have plateaued. Documented middle grade involvement is unchanged from 1989.
This lack of improvement in the involvement of consultants and middle grades is of concern, and there is great pressure from many sides to increase senior cover on the shop floor. This includes BAEM's 1995 recommendations for increasing the levels of senior staff in A&E departments.[2] Many of these recommendations were repeated in the Workforce Planning Document from BAEM and FAEM[3]: one of the main recommendations of this paper is that shop floor consultant cover should be available 12 hours a day, 7 days a week. This is to achieve the objective of allowing all patients to have an experienced clinician (Specialist Registrar, Non consultant career grade, consultant) either care for them directly, or supervise their care closely. In addition, the recently published NHS Plan made plain the government's intention to have more consultants involved in patient care.[4]
To investigate the current level of availability and involvement of senior and middle grade doctors in patient care in A&E departments, we undertook a survey of the 12 A&E departments in the South West deanery. These departments see between 24,500 and 85,000 new patients each year, and are staffed by between one and five consultants. We looked at the level of medical staff actually available to see new patients throughout two days in April 2001, and obtained information on all patients presenting on those two days, including triage category and level of seniority of doctor involved in their care.
Nine departments responded. No department provided 12-hour consultant cover. Most had at least 12-hour cover from a middle grade doctor, and 3 departments provided 24-hour middle grade cover. Consultant cover was poor: at the maximum, only 5 departments had a consultant on the shop floor at 1200 on Wednesday - other times had lower levels of cover. The level of middle grade and senior cover in these departments was worse at night and at the weekend.
The proportions of patients in each triage category seen by more experienced doctors or with more experienced doctors involved in their care is shown in the table.
Table
Number (%) of patients:
Triage
Total number of patients
Seen initially by experienced doctor
Seen during visit by experienced doctor
With experienced doctor involvement
1
20
2 (10)
13 (65)
13 (65)
2
163
32 (20)
46 (28)
59 (36)
3
502
124 (25)
174 (35)
219 (44)
4&5
1304
337 (26)
381 (29)
418 (32)
Total
1989
495 (25)
614 (31)
709 (36)
("experienced doctor" = consultant, SpR or NCCG)
As expected, there is a trend towards senior and middle grade involvement in the more seriously ill patients (although our sample is too small too prove a statistical relationship). 65% of Triage category 1 patients had senior or middle grade involvement, compared to 32% of category 4&5. Serious problems occasionally occur in patients triaged to category 4 or 5: in our sample, one patient died and one was admitted to HDU despite being triaged priority 4.
Following comments from some hospitals that not all the senior involvement might have been documented, we undertook a one-day audit of our own department, looking at whether the involvement of more senior medical staff is actually recorded in patient's notes. On the day studied, 218 patients were seen, of which 61 (28%) were seen initially by a senior or middle grade doctor. Of the 157 seen initially by a SHO, 39 had a senior or middle grade involved in their care at some stage (either seeing the patient, or giving advice on their care). Thus 100 patients (46%) had senior or middle grade involvement. Unfortunately, of the 39 patients for whom SHOs asked advice, this involvement of the more experienced doctor was only documented in seven (18%).
Whilst we acknowledge that our study was too small to draw statistical conclusions from, there is documented experienced staff involved in the care of 36% of patients. In many ways this is better than the impression given in many documents that A&E is still a service provided primarily by SHOs,[5,6] but it is concerning that the proportion of patients seen solely by a SHO (54%) appears to be little improved, despite increasing numbers of consultants and middle grade staff, since the Platt report in 1967, which found that 66% of patients were seen by a SHO only.
We have approached BAEM to raise the possibility of this study being expanded across the country. In the meantime, even if senior and middle grade doctors involved in the care of patients, this involvement may not be getting documented.
References
(1) Lecky FE, Woodford M, Bouamra O, et al. Lack of change in trauma care. Emerg Med J 2002;19:520-3
(2) BAEM. Planning for increased senior staff cover in Accident and Emergency departments. London: BAEM, 1995.
(3) Department of Health. Workforce planning in A&E medicine 2001-2010. BAEM, London 2001. The NHS Plan. London: Department of Health, 2000.
(4) Department of Health The NHS Plan. London: Department of Health, 2000.
(5) Audit Commission By Accident or Design London: Audit Commission, 1996.
(6) National Audit Office NHS Accident and Emergency Departments in England. London: National Audit Office, 1992.
(7) Accident and Emergency Services The Standing Medical Advisory Committee. London: HMSO, 1962.
I agree with the authors’ conclusion that a clinical diagnosis of
epididymitis without urology follow up is potentially hazardous. However,
the importance of testicular microlithiasis(TM) is difficult to
understand.
Retrospective evidence has revealed an association between TM and
testicular tumours to be as great as 40%. However, recent prospective
evidence in one study of 1504 asymptomatic men...
I agree with the authors’ conclusion that a clinical diagnosis of
epididymitis without urology follow up is potentially hazardous. However,
the importance of testicular microlithiasis(TM) is difficult to
understand.
Retrospective evidence has revealed an association between TM and
testicular tumours to be as great as 40%. However, recent prospective
evidence in one study of 1504 asymptomatic men has shown the prevalence
of TM to be between 4% and 14% depending on race affiliation and no cases
were associated with malignancy.[1] In the last decade the reporting of TM
has increased and cases of patients developing interval malignancies
exist. These cases have tended to be in atrophic testes or in patients
with other risk factors for testicular malignancy. This has led to many
patients with TM being commenced on ultrasound surveillance, although the
duration or efficacy of such management is not known. Therefore, some
urologists consider testicular biopsy to detect intratubular germ cell
neoplasia (carcinoma-in-situ) particularly in young men with atrophic
testes or other risk factors. If CIS is present then radiotherapy can be
offered with testicular preservation. If CIS is not found then indefinite
ultrasound surveillance may be avoided although the possibility of a false
negative biopsy exists.
Patients with epididymitis can be effectively treated by emergency
department staff and follow up should be performed by urologists. It is at
this time following consultation and careful examination of the testes
that an ultrasound may be performed but not specifically to detect
testicular microlithiasis.
Reference
(1) Peterson AC. Bauman JM. Light DE. McMann LP. Costabile RA. The
prevalence of testicular microlithiasis in an asymptomatic population of
men 18 to 35 years old. Journal of Urology 2001; 166(6):2061-4.
We thank Dr Duby for his interest in our paper and comments.
We think he
misses its fundamental points - the majority of haematology technicians
cannot analyse DPL specimens, and the paucity of experience with the
procedure. Similarly this paper is not a review of the efficacy of
ultrasound.
Dr Duby comments on our asking technicians on how DPL samples are
analysed, even though they f...
We thank Dr Duby for his interest in our paper and comments.
We think he
misses its fundamental points - the majority of haematology technicians
cannot analyse DPL specimens, and the paucity of experience with the
procedure. Similarly this paper is not a review of the efficacy of
ultrasound.
Dr Duby comments on our asking technicians on how DPL samples are
analysed, even though they felt they could not perform it. The
heterogeneity in the responses obtained merely highlights the fact that
these technicians really dont have a clue. His comments regarding
investing in DPL are risible - why invest in DPL, when you have a probably
better alternative - US? What exactly was the alternative to head CT all
those years ago
We accept his criticisms about a response rate of 48%. This does however
reflect 854 responses...His comments about "recently trained
consultants..." assumes that these consultants use DPL for the next 10
years, and are actually involved in trauma care at the sharp end. The
comments in the final two paragraphs are valid.
Maxwell-Armstrong et al[1] have apparently done a significant amount
of work in sampling the current state of knowledge among haematology
technicians on the performance of Diagnostic Peritoneal Lavage (DPL)
analysis. They also report on surgeons’ experience of the procedure. Their
analysis and conclusions, however, seem not to be supported by this data.
Indeed, their paper climaxes with propos...
Maxwell-Armstrong et al[1] have apparently done a significant amount
of work in sampling the current state of knowledge among haematology
technicians on the performance of Diagnostic Peritoneal Lavage (DPL)
analysis. They also report on surgeons’ experience of the procedure. Their
analysis and conclusions, however, seem not to be supported by this data.
Indeed, their paper climaxes with propositions relating to the use of
ultrasound, for the relative superiority of which they have collected as
much evidence as for fortune-telling.
Despite my own high level of interest in the use of ultrasound, I
cannot but disagree with the methods used by the authors in analysing the
use of its “rival” – DPL.
The authors surveyed technician’s experience in the analysis of DPL
specimens and this was found apparently lacking. They then still accepted
these same technicians’ opinions about how this procedure is or should be
performed. They question the fine details of which fluid is used and in
which container it is send when a surgeon would struggle to find a fluid
or container which would be inadequate regardless of what the technician
knew of this. And I would not trust an estimate of an hour to analyse a
sample – it is likely that this was received from those less experienced
technicians who were merely guessing.
To suggest that an investigation be abandoned because it is not as
available as one would like is irresponsible. Only a few years ago, one
would have envied such a level of accessibility to, say, CT scanning for
head injuries or cardiac enzymes for chest pain, as has been identified
herein for DPL. Gratefully, we did not abandon the use of CT then for
these reasons. It would only take a minimal investment to reach an
acceptable level of knowledge and protocols in labs.
As for surgeons’ experience, the data presented was poorly
representative (48% response) and poorly analysed. To claim that there is
little increase in experience with duration in post is misleading. A
closer look at their own data would have reassured the authors. For
example, 51 of 54 consultants with fewer than 2 years’ experience
performed DPL (94%) – an average of 47% per year of work. The figure is
282 of 333 (85%) for those with over 10 years’ experience, which, assuming
10-25 years of practise in this group, is 3.4-8.5% per year worked.
Ignoring pre-consultant exposure for both groups, this shows recently
trained consultants are around 10 times more likely to perform DPL per
year of practise and will thus be more experienced by the time they have
10 years behind them.
No comparative figures were presented on surgeons’ experience in the
performance of ultrasound or on the availability of other trained users
and the costs involved in ultrasound equipment and training. To reach
competence (and hence sensitivity) in the use of ultrasound is certainly
more time-consuming and costly than to perfect the use of DPL.
In addition, the ATLS guidelines referred to in the article were compiled
primarily for physicians working in smaller set-ups, not for the “major
units” surveyed. In the latter, most patients will have CT scans unless
unstable enough to need immediate surgery.
Despite the problems presented by ultrasound in the circumstances of
suspected intra-peritoneal haemorrhage – operator
inexperience/unavailability, obese or previously operated patients,
subcutaneous air, etc. – it is still probably worthy of attention. But our
approach must be scientific.
References
(1) Maxwell-Armstrong C, Brooks A, Field M, Hammond J, Abercrombie J.
Diagnostic peritoneal lavage analysis: should trauma guidelines be
revised. Emergency Medicine Journal 2002;19(6): 524-525.
I was interested to read the case report on histamine fish poisoning
by Attaran et al.[1] Having recently reviewed the subject, I am aware that
this journal has highlighted this common condition in 1997 with another
case report,[2] adding to an expanding library of over 150 citations in
popular databases in the past quarter century.
Despite underreporting, the condition still accounte...
I was interested to read the case report on histamine fish poisoning
by Attaran et al.[1] Having recently reviewed the subject, I am aware that
this journal has highlighted this common condition in 1997 with another
case report,[2] adding to an expanding library of over 150 citations in
popular databases in the past quarter century.
Despite underreporting, the condition still accounted in the 1990s
for 32% of reported UK illness associated with fish/shellfish[3] and 50%
in the USA[4] and is credited with about 5% of USA food-borne illness.[5]
As noted in this latest report, even with all the publicity, the condition
is often misdiagnosed. It seems that case reports, which in this case add
no new evidence to the current knowledge base, are not sufficiently
effective in keeping clinicians aware of the condition.
To demonstrate this, consider the report of two anaphylaxis-
associated deaths in asthmatic children, by Rainbow et al, a few pages
away in the same issue of the Emergency Medical Journal.[6] The first case
is of an asthmatic child who died, despite resuscitation attempts, from a
suspected anaphylactic reaction after eating a meal of seafood. The
authors note, however, that no definite trigger for anaphylaxis was
identified on RAST testing for crab, chicken and peanut. The mast cell
tryptase levels measured were within normal limits, not suggestive of an
anaphylactic reaction. And yet, food-borne amine poisoning seems not to
have been considered, despite having been previously reported with both
crab and chicken.[7] Had an assay of the implicated food been conducted,
yielding a positive result, it could have been a potential opportunity to
double the number of reported deaths[4] from the condition.
In 1973, a single mackerel-related outbreak resulted in 2656 known
cases.[7] One hopes that early recognition and notification might nip the
next potential major incident in the bud. Indeed, prevention seems to be
the only current option for improving outcomes. As this condition is worth
repeated mention then perhaps it merits a place as a step in anaphylaxis
management algorithms and their instruction.
References
(1) Attaran RR, Probst F. Histamine fish poisoning: a common but
frequently misdiagnosed condition. Emergency Medicine Journal 2002;
19(5): 474-475
(2) Stell IM. Trouble with tuna: two cases of scombrotoxin poisoning.
Journal of Accident & Emergency Medicine 1997; 14(2): 110-111
(3) Gillespie IA, Adak GK, O'Brien SJ. General outbreaks of infectious
intestinal disease associated with fish and shellfish, England and Wales,
1992-1999. Communicable Disease & Public Health 2001; 4(2): 117-123
(4) Lehane L, Olley J. Histamine fish poisoning revisited.
International Journal of Food Microbiology 2000. 58(1-2): 1-37
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding
emergency oxygen therapy. It also outlines a protocol for the management
of COPD patients that we feel differs only slightly from that proposed by
the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and
ou...
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding
emergency oxygen therapy. It also outlines a protocol for the management
of COPD patients that we feel differs only slightly from that proposed by
the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and
outcomes of 27 COPD patients treated with uncontrolled high-flow
oxygen(HFO) prior to or during emergency admissions to their hospital. PO2
values ranged between 9.6 and 37.7 kPa on HFO and were as low as 4.0 kPa
on room air. Respiratory acidosis was severe with a mean pH of 7.21 and 6
patients were incorrectly diagnosed as asthmatic.
This is typical of what happens in many other hospitals and is one of
the reasons why guidelines were developed in the North-West. The essence
of these guidelines is to start initially with HFO(to relieve hypoxia) and
then titrate it to maintain an oxygen saturation of 90-92%(to minimise
hypercapnia) . If this had been done in the above patients none would have
arrived at hospital with such high oxygen levels and the degree of
respiratory acidosis would have been much, much less.
Starting with HFO is deemed appropriate in a pre-hospital setting
because of the immediate dangers of hypoxia and the frequent lack of a
definite diagnosis in this setting illustrated well by the incorrect
initial diagnosis of many of the Norwich patients. Patients should only
stay on HFO if they need it .
Although not published in detail in the initial guidelines we did
mention an “alert system” which could be used to protect vulnerable COPD
patients, especially those with previous episodes of respiratory failure.
This has subsequently been added to the guidelines currently used in the
North-West. Here patients with known COPD are given a “COPD Alert” card by
their respiratory physician when seen as out-patients. On the card is
written a target oxygen saturation which corresponds to their PO2 when
stable and a recommended initial FiO2 which patients are to be started on
when they present with an acute exacerbation, based on the results of
previous blood gas measurements. Again the FiO2 is titrated upwards or
downwards to ensure this oxygen saturation is reached and to prevent over
or under-oxygenation. The target oxygen saturation is often between 85 and
90%, the recommended FiO2 is invariably 24 or 28% and Venturi masks are
recommended as soon as practical (usually on arrival in the Emergency
Department). The revised guidelines also advise limiting oxygen-driven
nebuliser treatment to 6 minutes for patients with COPD because many
patients spend their entire ambulance journey and much of the first hour
in the Emergency Department receiving high flow oxygen from a nebuliser
facemask.
The issue of using Venturi masks pre-hospital was also one we
considered. In rural areas when ambulance journeys are prolonged we felt
they should be used. However in urban areas where ambulance journeys are
often less than 10 minutes and patients are often being treated with
bronchodilators through oxygen driven nebulisers we felt that they would
be of limited value and may delay getting patients to hospital. We have
had some feedback from the Joint Royal Colleges Ambulance Liaison
Committee indicating agreement with this.
At present, we have received very positive feedback from different
sources around the UK. The guidelines we have produced are often very
similar to guidelines that have been developed for use in other regions as
is the case, we believe, with Norwich.
We are currently working closely with the above Joint Royal Colleges
Ambulance Liaison Committee, the British Association for Accident and
Emergency Medicine and the British Thoracic Society to try to get
agreement at a national level.
We would be happy to forward copies of the current guidelines and COPD Alert cards to anybody
who may be interested.
Please contact rossmurphy@doctors.org.uk
I was not sure if the September supplement was
plagarised from something written 100 years ago or if
it was for real. If this is truly the attitude of
senior ED staff in the UK then I suggest trainees
emigrate. Australasia has female medical staff, sick
leave, police with better things to do than pamper
medical egos, and eminent specialists who do not
equate true leadership with being called "Doctor"; all
th...
I was not sure if the September supplement was
plagarised from something written 100 years ago or if
it was for real. If this is truly the attitude of
senior ED staff in the UK then I suggest trainees
emigrate. Australasia has female medical staff, sick
leave, police with better things to do than pamper
medical egos, and eminent specialists who do not
equate true leadership with being called "Doctor"; all
things which appear to be lacking in the UK if this
article is to be believed. I hope the supplement does
not reflect the attitudes of the British Association
for Accident and Emergency Medicine.
How refreshing to read the excellent consensus view on pre-hospital
fluid resuscitation. At last it appears that a useful regimen is beginning
to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg
crystalloid bolus, repeated once if required and then followed by a third
bolus...
How refreshing to read the excellent consensus view on pre-hospital
fluid resuscitation. At last it appears that a useful regimen is beginning
to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg
crystalloid bolus, repeated once if required and then followed by a third
bolus of blood in extreme hypovolaemia still hold true?
2. In young shocked children, should we even permit the quoted two
attempts at cannulation before reaching for the relatively straightforward
and woefully under-utilised intraosseous needle?
3. Are there any indications at all for pre-hospital colloids...or
should all stocks be consigned to the realms of history?
4. In head-injured patients, is there a consensus view on the target
systolic pressure that should be sought in order to preserve cerebral
perfusion?
Hopefully these issues will be clarified in the not too distant
future, such that all pre-hospital emergency providers will be able to
offer uniform, evidence-based management, whilst awaiting that ever-
elusive ideal resuscitation solution!
A gentleman presented to A&E at Lancaster following an RTA, and
was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been
across the centre of the steering wheel at the time of airbag discharge,
which is when the mercedes emblem became branded on his forearm. The mark
remained on the patient's forearm some weeks late...
A gentleman presented to A&E at Lancaster following an RTA, and
was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been
across the centre of the steering wheel at the time of airbag discharge,
which is when the mercedes emblem became branded on his forearm. The mark
remained on the patient's forearm some weeks later, although the patient
took it in good humour.
Photo available on request (patient has given consent for
publication), please contact rmcglone@lineone.net
Dear Ediotr
Whether or not a simple wound will get infected depends on the source of injury, the site of injury, age of the patient and the immune status of the patient. If the patient is at extremes of age or is immune suppressed then the chances of infection of the wound is quite higher. Moreover, simple wound infections in such patients may result in cellulitis, nectrotising facsitis, abcsess formation and chron...
Dear Editor
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortali...
Dear Editor
I agree with the authors’ conclusion that a clinical diagnosis of epididymitis without urology follow up is potentially hazardous. However, the importance of testicular microlithiasis(TM) is difficult to understand.
Retrospective evidence has revealed an association between TM and testicular tumours to be as great as 40%. However, recent prospective evidence in one study of 1504 asymptomatic men...
Dear Editor
We thank Dr Duby for his interest in our paper and comments.
We think he misses its fundamental points - the majority of haematology technicians cannot analyse DPL specimens, and the paucity of experience with the procedure. Similarly this paper is not a review of the efficacy of ultrasound.
Dr Duby comments on our asking technicians on how DPL samples are analysed, even though they f...
Dear Editor
Maxwell-Armstrong et al[1] have apparently done a significant amount of work in sampling the current state of knowledge among haematology technicians on the performance of Diagnostic Peritoneal Lavage (DPL) analysis. They also report on surgeons’ experience of the procedure. Their analysis and conclusions, however, seem not to be supported by this data. Indeed, their paper climaxes with propos...
Dear Editor
I was interested to read the case report on histamine fish poisoning by Attaran et al.[1] Having recently reviewed the subject, I am aware that this journal has highlighted this common condition in 1997 with another case report,[2] adding to an expanding library of over 150 citations in popular databases in the past quarter century.
Despite underreporting, the condition still accounte...
Dear Editor
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding emergency oxygen therapy. It also outlines a protocol for the management of COPD patients that we feel differs only slightly from that proposed by the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and ou...
Dear Editor
I was not sure if the September supplement was plagarised from something written 100 years ago or if it was for real. If this is truly the attitude of senior ED staff in the UK then I suggest trainees emigrate. Australasia has female medical staff, sick leave, police with better things to do than pamper medical egos, and eminent specialists who do not equate true leadership with being called "Doctor"; all th...
Dear Editor
How refreshing to read the excellent consensus view on pre-hospital fluid resuscitation. At last it appears that a useful regimen is beginning to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg crystalloid bolus, repeated once if required and then followed by a third bolus...
DearEditor
A gentleman presented to A&E at Lancaster following an RTA, and was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been across the centre of the steering wheel at the time of airbag discharge, which is when the mercedes emblem became branded on his forearm. The mark remained on the patient's forearm some weeks late...
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