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Recent eLetters

Displaying 1-10 letters out of 763 published

  1. Lack of evidence to support use of D-dimer in pregnant women with a suspicion of pulmonary embolism

    The authors state that current evidence supports the use of a negative D-dimer to rule out a suspicion of pulmonary embolism (PE) in pregnancy. They show in Table 2 5 relevant studies to support their conclusion. However, the study of Damodaram was the only study that included patients with a clinical suspicion of venous thromboembolism, thus including pulmonary embolism. All other 4 studies included either healthy pregnant patients or patients with a clinical suspicion of deep vein thrombosis (DVT). Evidence found in healthy patients cannot be extrapolated to pregnant symptomatic patients. Performance of the D-dimer test should be tested in pregnant patients with a clinical suspicion of PE before any recommendation can be made. Since PE is still one of the leading causes of maternal death, ruling out this diagnosis accurately is imperative.

    Furthermore, in non-pregnant patients, use of D-dimer test as a stand -alone test is not supported. The authors state that the Wells score can be a useful tool in calculating pretest probability, as its categories remain relevant. However, this statement is not supported by evidence. The title of this BET may be interpreted as if a D-dimer test can be used as a stand-alone test. In non-pregnant patients with a high suspicion of PE (Wells score >4 points), the presence of PE is found to be 10%, despite a negative D-dimer (Wells, Thromb Haemost 2000). Therefore, the most important conclusion should be that there's a lack of good-quality evidence concerning the management of a clinical suspicion of PE in pregnancy.

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  2. The Psychological Effect of Ebola on ED Staff

    Now 11+ years since SARS, it would be interesting to repeat this study post Ebola... Are staff any better prepared for a highly contagious, fatal disease?

    Conflict of Interest:

    None declared

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  3. Sepsis Six: Are we doing the right thing?

    Dear Editor,

    The "Sepsis Six" resuscitation bundle is now common in UK hospitals, and endorsed by the College of Emergency Medicine, SIGN guidelines, and the Royal College of Physicians.1-3 However, the evidence behind it remains limited and must be re-evaluated as new data emerges - especially since the results of the PRoCESS and ARiSE trials on Early Goal Directed Therapy (EGDT) were published this year.4,5

    The paper supporting Sepsis Six was originally published in 2010 in this Journal, and remains (as far as we are aware) the only published evidence on Sepsis Six.6 We believe this trial is internally flawed, and unable to provide convincing evidence of the benefit of Sepsis Six.

    We have two main criticisms of this sepsis 6 trial - firstly, it is inconsistent. Given that two large randomised controlled trials this year have shown EGDT to have negligible effect on mortality, it is hard to interpret the results of this trial - which showed a relative risk reduction of 91% (mortality dropped from 90.3% without EGDT to 7.5% with it). Also, the subgroup of patients who were shocked shows internal inconsistencies. The worst performing group - with a staggering 97.1% mortality were the shocked patients who received Sepsis 6 - yet if they received EGDT alone, their mortality was 8%. However, the combination of Sepsis 6 and EGDT in shocked patients performed best of all - with a 4.7% mortality!

    It seems inconceivable that in septic shock Sepsis 6 would increase mortality to 97.1% if performed alone, but reduce it to 4.7% if performed in combination with EGDT (which we know from RCT data has a negligible effect).

    The only possible explanation is that of confounding effects - younger, fitter people were receiving EGDT and Sepsis 6- who had a low mortality rate and survived, and less fit people did not receive it This leads to our second criticism - lack of co-variate analysis. Although the authors comment on the difference in age between some of the cohorts, they did not perform a multivariate logistic regression (or similar) that could have included age, MEWS score, source of infection. Given the complexity and difference between the subgroups, it is impossible to compare them without covariate statistical analysis.

    It is very hard to draw causality from observational trials (and the authors do not try here), but given the significant problems with this trial, we do not feel it can be interpreted as supporting evidence for Sepsis 6 either.

    Although we do not aim to be unnecessary critical of what may be seen as 'common sense practice', we have three main concerns. Firstly, the claim that sepsis 6 in unlikely to be harmful is not a sufficient basis for it's continued use. 'Common sense' medicine has repeatedly been proven to be harmful on numerous occasions. Secondly, emergency departments and wards are busy and under huge time pressure, and protocols that might tie up staff for an hour or more must be scrutinised. Thirdly, sepsis 6 is likely to lead to the greater use of stat doses of antibiotics in any febrile patient, given the impetus to administer them within the first hour for any unconfirmed sepsis diagnosis. We do not know the long-term impact of this on antibiotic resistance - which is rapidly increasing.

    Sepsis 6 means well, but is unproven, and should be treated as such.

    Fergus Hamilton Bryony Lewis

    1. SIGN. Care of deteriorating patients: Guideline 139. 2014. Available at: http://www.sign.ac.uk/pdf/SIGN139.pdf. Accessed October 14, 2014.

    2. RCP. Acute Care Toolkit 9: Sepsis.; 2014.

    3. College of Emergency Medicine. Clinical Standards for Emergency Departments. 2013. Available at: http://www.collemergencymed.ac.uk/Shop- Floor/Clinical Standards. Accessed October 14, 2014.

    4. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-Directed Resuscitation for Patients with Early Septic Shock. N. Engl. J. Med. 2014:141001063014008. doi:10.1056/NEJMoa1404380.

    5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of protocol-based care for early septic shock. N. Engl. J. Med. 2014;370(18):1683-93. doi:10.1056/NEJMoa1401602.

    6. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg. Med. J. 2011;28(6):507-12. doi:10.1136/emj.2010.095067.

    Conflict of Interest:

    None declared

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  4. Different populations, overall cost increase

    Sir I find the methodology for this paper to contain a significant flaw in that the triage criteria used to determine suitability for the GP unit contain a requirement that the patient will need minimal additional resources for them to be processed. It is hardly surprising therefore that the post intervention analysis sees fewer additional resources subsequently spent on this group with the associated savings.

    In addition, it is contradictory to say that under the cost data the ED cost per patient went up due to "some shift in patient mix after triage" but in the discussion to claim that it was unlikely that the cost differences were explained by differences between the two populations.

    Finally, the rise in patient numbers of around 60% in 5 years represents a phenomenal failure to contain the overall cost of emergency care provision, despite the quoted lower costs per patient for the GP unit. The conclusion that such a model represents "dominance" is therefore quite extraordinary. Sincerely

    Conflict of Interest:

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  5. Towards a valid proxy measure for sepsis associated mortality

    Wright and colleagues1 discuss some interesting issues around blood cultures and sepsis outcome measurement. We agree that evaluating and tracking sepsis associated mortality over time is important. It would facilitate assessment of the impact of changes in practice, both intended effects of sepsis improvement interventions and unintended consequences of other initiatives, e.g. restrictive antibiotic policies, as well as epidemiological changes in populations. An ideal outcome measure would be "simple, objective, clinically meaningful, resistant to ascertainment bias, and, ideally, suitable for automation using data routinely stored in electronic health records"2. Unfortunately, there is no such perfect measure to track sepsis associated mortality.

    Analysis of recorded International Classification of Diseases, Tenth Revision (ICD-10) codes is frequently utilised for tracking trends in healthcare, including mortality3. At first, this seems appealing as ICD- 10 codes should be simple and clinically meaningful and are available from routinely collected data. However, inconsistency in assignment of codes and changes in coding patterns make this susceptible to ascertainment bias thereby compromising the validity and reliability of applying this as a standalone measure2. Where remuneration and penalisation in healthcare is linked to coding, there is also potential for gaming and coding trends to emerge which do not reflect a real change in the population2,3. Additionally, due to the presence of a range of appropriate codes that could be applied to patients with sepsis, analysis of coding is complex4. Both primary and secondary discharge codes require interrogation and organ -specific infection codes, such as community-acquired pneumonia (ICD- 10 code J18.9), do not indicate whether the patient had sepsis, thereby reducing the sensitivity of this as a measure. All-cause mortality is also utilised within the literature. It is simple, objective and routinely collected, however, it lacks sensitivity to detect the impact of improvement interventions in clinical practice.

    We agree with Wright et al that blood cultures should only be drawn where appropriate. As advocated as part of the Sepsis Six5, when patients fulfil two or more Systemic Inflammatory Response Syndrome (SIRS) criteria (see Box 1) and have a suspected or confirmed source of infection blood cultures should be obtained7.

    Box 1: SIRS criteria6

    SIRS present when two or more of the following measured:

    * Temperature <36oC or >38oC

    * Heart Rate >90 beats/min

    * Respiratory Rate >20 breaths/min OR PaCO2 <4.3kPa

    * White blood cell count <4000/?L or >12000/?L

    One concern which we share with Wright et al is that blood cultures are often taken from patients who do not meet SIRS criteria, as found in an audit of patients with cellulitis presenting to an Acute Medical Unit8, but this is not encouraged if the Sepsis Six is implemented correctly. Such snapshot audits are limited to the clinical observations available at the time of data collection and this is likely to result in an underestimation of the prevalence of sepsis at any time during a hospital admission among patients who have a blood culture taken. With the exception of immunocompromised patients or those with suspected endocarditis, blood cultures should only be taken from patients who have two or more SIRS criteria otherwise there is potential to waste resources and cause patient harm7.

    Wright et al reported a rise in blood culture sampling within NHS Forth Valley. This should not necessarily be interpreted as a negative development. The Scottish Trauma Audit Group9 reported that 39% (n=251) of patients fulfilling criteria for severe sepsis in the emergency department had no blood cultures sampled during the first 48 hours following presentation. From this baseline the number of blood cultures being drawn should rise initially if the Sepsis Six is being implemented reliably. Interestingly the beginning of NHS Forth Valley's rise in blood culture sampling appears to pre-date the beginning of the Scottish Patient Safety Programme (SPSP) national Sepsis Collaborative in January 2012. This apparently crude rate may reflect an already increasing awareness of sepsis but may also have been influenced by the increasing number of inpatient discharges in NHS Forth Valley in the period 2010-201310.

    Wright et al suggest that the measurement of mortality among patients with a positive blood culture would be more useful than blood cultures alone. However, the proportion of patients with a positive blood culture is a small subset of the wider sepsis population with one cohort reporting that only 21% of patients with sepsis had a bacteraemia11. Therefore, to restrict the measurement of sepsis associated mortality to this population would significantly underestimate the true incidence of sepsis. Additionally, the presence of a positive blood culture has not been demonstrated to be independently associated with higher mortality once adjusted for age, sex and comorbidity11,12. These considerations limit the clinical meaningfulness of this as a measure, and negate Wright et al's concern about "treating culture-negative sepsis with broad spectrum antibiotics". This concern is not consistent with the objective of the Sepsis Six, which is to ensure that patients with clinical signs of sepsis receive prompt, appropriate and timely antibiotic treatment.

    The proxy outcome measure for the SPSP national Sepsis Collaborative examines the thirty day mortality among adult inpatients in acute hospitals who have had a blood culture sampled. Utilising the existing Scottish Hospital Standardised Mortality Ratio (HSMR) model, the data will be adjusted for changes in clinical activity and acuity of care. However, even crudely adjusted (e.g. for age, sex and occupied bed days or admissions) blood culture mortality is a superior outcome measure compared to the other currently proposed options. We accept that it is not perfect, and are undertaking further work to validate its scope and applicability, including investigating combining blood culture sampling with other routinely available data. Improving the selection of patients for blood culture sampling, as discussed above, would improve the performance of this measure. However, even as it stands, it is simple, relatively objective, clinically meaningful and more resistant to ascertainment bias than most other options, and is suitable for automation using data routinely stored in electronic health records.

    References

    1. Wright DJ, Beckett DJ, Cooke B. Use of sepsis 6 raises some interesting questions. Emerg Med J Published Online First: 01.09.2014

    2. Rhee C, Gohil S, Klompas M. Regulatory Mandates for Sepsis Care - Reasons for Caution. N Engl J Med 2014; 370: 1673-1676

    3. Vaughan Sarrazin MS, Rosenthal GE. Finding Pure and Simple Truths with Administrative Data. JAMA 2012; 307(13):1433-1435

    4. MacPherson D, Griffiths C, Williams M, Baker A, Klodawski E, Jacobson B, Donaldson L. Sepsis-associated mortality in England: an analysis of multiple cause of death data from 2001-2010. BMJ 2013; 3(8)e002586

    5. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 2011; 28:507-512

    6. Jones GR, Lowes JA. The systematic inflammatory response syndrome as a predictor of bacteremia and outcome from sepsis. Q J Med 1996; 89:7

    7. Coburn B, Morris Am, Tomlinson G, Detsky AS. Does This Adult Patient With Suspected Bacteremia require blood cultures? JAMA 2012; 308:5

    8. Marwick C, Rae N, Irvine N, Davey P. Prospective study of severity assessment and management of acute medical admissions with skin and soft tissue infection. J Antimicrob Chemother 2012; 67:1016-9.

    9. The Scottish Trauma Audit Group. Sepsis Management in Scotland. 2010.

    10. http://www.isdscotland.org/Health-Topics/Hospital-Care/Inpatient- and-Day-Case-Activity/ [last accessed 22.09.14]

    11. Marwick CA, Guthrie B, Pringle JE. Identifying which septic patients have increased mortality risk using severity scores: a cohort study. BMC Anesthesiol 2014; 14:1

    12. Phua J, Ngerng WJ, See KC, Tay CK, Kiong T, Lim HF, Chew MY, Yip HS, Tan A, Khalizah J, Capistrano R, Lee KH, Mukhopadhyay A. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Critical Care 2014; 17:R202

    Conflict of Interest:

    None declared

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  6. Utility of a single early warning score in patients with sepsis in the emergency department

    Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2

    1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA 2Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Correspondence to: Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905; romerobrufau.santiago@mayo.edu

    We have read with much interest the article by Corfield et al. published in a recent issue of Emergency Medicine Journal.1 They describe calculation of the National Early Warning Score (NEWS) in a cohort of septic patients admitted to the Emergency Department (ED). Their results look very promising at first sight, as they report a positive predictive value of 27% and 72% sensitivity for the combined outcome of in-hospital death or admission to the intensive care unit (ICU). With these results, they argue that "Among patients who have sepsis, a single EWS of ?7 in the ED indicates a 27% chance of requiring admission to the ICU within 48h and/or death within 30 days. At this level, an argument can be made for mandating senior ED clinical review for all these patients," and they also argue for review by a critical care outreach team. However, there are important limitations and observations to be made. First, out of the 2,489 patients who fulfilled "sepsis" criteria prior to leaving the ED, 486 (19.5%) were not included in the final cohort for missing data, and the characteristics of these excluded patients are not reported. This exclusion of a large number of patients could bias the cohort, as it can be argued that more severe patients are more likely to have a complete set of observations captured. Second, and more importantly, their inclusion criteria included patients who were hospitalized for more than 48 hours, yet they added in patients who died, regardless of their length of stay. This, in turn, has two important consequences: it means that, to be able to know that a patient has a certain probability, one has to know that the patient will have a length of stay of more than 2 days, which requires data from the future that is obviously not available on admission. But, more importantly, this decision artificially increases the baseline outcome rate in the study's cohort. The final cohort used in the analysis has an overall mortality rate of 15%, and a combined outcome rate of 18%. This means that a patient, just for meeting the study's eligibility criteria, has a 15% risk of dying during the hospitalization. In the light of this finding, the increased risk for a patient that has a NEWS ?7 is only 1.4 above the average patient in their cohort. Even the group of patients with the lowest NEWS (0-4) has an 8% risk of the combined outcome, and a 5% in-hospital mortality risk. It could be argued that this, too, would merit an evaluation by a senior ED clinician, regardless of their NEWS score.

    References 1. Corfield AR, Lees F, Zealley I, et al. Utility of a single early warning score in patients with sepsis in the emergency department. Emerg Med J. Jun 2014;31(6):482-487.

    Conflict of Interest:

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  7. Re:Prehospital care is not for amateurs

    The authors thank Dr Clayton for her comments.

    However, they point out that her critique of their paper is largely inconsistent with what was actually written and can only assume a misunderstanding of the article.

    The article does not state, nor even imply, that the GMC require students to provide expert or definitive care as she asserted in her response. Indeed the article talks about basic skills and basic prehospital care verbatim, and as such is not culpable for the points outlined in her comments.

    Whilst BLS and first aid may be essential components of prehospital care, the authors disagree that it is 'the best any practitioner (or student) can offer'. As detailed in the article, other aspects of care (and not just treatment) will benefit both the injured and those assisting, not least in ensuring personal safety. Furthermore, whilst BLS may be taught in medical schools, such teaching has been reported as inadequate, and it is the authors' suggestion that its compulsory and regulated integration into the undergraduate curriculum would ensure that it is taught to the correct standard.

    Finally, the authors thank Dr Clayton for pointing out the training that paramedics receive. Nonetheless, they feel they must again emphasise that the article has never once suggested that over-zealous students (and junior doctors) should interfere with and hinder these paramedics, which she wrongly implied in her response. Quite the opposite. As the article states that ambulance response times have been reported as substandard, i.e. are taking longer to reach an emergency than they should, its emphasis is thus that of care prior to the arrival of these paramedics, a time when a student is first on the scene and might improve patient outcome. The authors had hoped that this could be understood from the lines "transferring relevant and detailed information to a 999 operator" i.e. what to say when calling 999, and "on-scene handovers to emergency services" i.e. telling paramedics what has happened as they arrive and take over.

    The authors therefore do not agree with Dr Clayton's suggestion that "everyone else should stand well back" as this implies that no care would be given, the injured may deteriorate and the GMC guidelines are disregarded.

    Conflict of Interest:

    None declared

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  8. High level disinfection reduces HPV contamination of transvaginal sonography probes in the emergency department

    Our previous study reported in your journal in 2012 found that 7.5% of the transvaginal sonography (TVS) probe samples were human papillomavirus (HPV) DNA positive in our Emergency Department, when a barrier was applied along with low level disinfection using a quaternary ammonia based agent. (1)

    M'Zali et al also demonstrated that TVS probes remained substantially contaminated by HPV, C. trachomatis, mycoplasmas, Gram-positive and Gram- negative bacteria with low level disinfection. (2)

    According to the Centres for Disease Control and Prevention (CDC) guidelines, transvaginal probes, as they have direct contact with mucosal membranes, should be processed using a high level disinfection method. (3) However, many suitable agents can potentially damage the transducer and reduce its life span. Since the discovery of substantial HPV contamination in 2011, our department has adopted high level disinfection techniques using the Tristel TRIO wipes system [Tristel Solutions Ltd, U.K.], which is a chlorine dioxide based agent specially designed for endocavity ultrasound probes as well as certain endoscopes.

    After implementation of the new disinfection method for 1 year, we performed another surveillance sampling of the TVS probe. A total of 50 samples were collected daily over 50 consecutive days between March and May 2013. All samples were HPV DNA negative by PCR performed as previously described. (1)

    Our latest results provide encouraging evidence that barrier methods together with high level disinfection can successfully reduce HPV contamination of the TVS probe. The associated increase in cost is worthwhile to ensure a low risk of contamination.

    Reference: 1. Ma ST, Yeung AC, Chan PK, Graham CA. Transvaginal ultrasound probe contamination by the human papillomavirus in the emergency department. Emerg Med J. 2013 Jun;30(6):472-5.

    2. M'Zali F, Bounizra C, Leroy S, Mekki Y, Quentin-Noury C, Kann M. Persistence of microbial contamination on transvaginal ultrasound probes despite low-level disinfection procedure. PLoS One. 2014 Apr 2;9(4):e93368.

    3. http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf

    Conflict of Interest:

    None declared

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  9. Oxygen Alert Cards: Are they working? Our Local Experience at Yeovil District Hospital

    In Yeovil District Hospital (YDH), o2 alert cards are currently issued by the respiratory nurse specialist. Patients are usually referred by a doctor or the ward nurses for a respiratory nurse review to optimise management of a respiratory disorder and arrange appropriate follow up in the community. If a patient has a documented episode of type II respiratory failure the respiratory nurse will issue an o2 alert card as recommended by BTS. A retrospective audit was carried in Yeovil District Hospital in 2013 to determine if oxygen alert cards are achieving their intended purpose. This included assessing whether alert cards were issued correctly to at-risk patients and to review the compliance of oxygen administration in both ambulances and hospital with BTS guidance. 79 patients were issued o2 alert cards over the 12 month period; 63 notes were available and audited. The results showed that all patients audited had a documented ABG confirming an episode of hypercapnoea; the majority of which had a diagnosis of COPD. Of those 63 patients audited, 19 patients were readmitted with a total of 38 admissions. Therefore the average number of re-admissions per patient was 2 (range: 1-5) During 33 of these episodes the patient was brought to hospital via ambulance. There were only 2 ( reports of alert cards being shown and appropriate venturi masks being issued to the ambulance staff. Furthermore on 76% of episodes, o2 administered in the ambulance was not appropriate and oxygen saturations exceeded the targeted 88-92%. On arrival to hospital there were no recordings of any alert cards being shown to staff and issued with the appropriate venturi mask. On first saturation measurement whilst in hospital only 29% were within the target range and in over 50% these were not acted on appropriately. During the admissions, there were 8 incidents where an ABG was not preformed. However, in the remaining 30 admission episodes in which an ABG was preformed, appropriate action and oxygen titration was carried out in 90% of the episodes. It is clear from this audit that currently, in Yeovil District Hospital, the o2 alert cards issued to patients are not being used. The audit has also demonstrated that oxygen administration in both ambulatory services and hospital setting are not following the current recommendations set by BTS in regards to the administration of oxygen to patients at risk of hypercapnoea. Patients are continuing to be inappropriately administered oxygen and are being put at high risk of the potentially dangerous side- effects of high-flow oxygen. It appears from the study that in the majority of patients it is only after an ABG that oxygen administration levels are appropriately titrated. However, worryingly not all patients have an ABG on admission. There are probably a number of reasons why the o2 alert cards are not currently working. The alert cards are a relatively new scheme in Yeovil District Hospital and therefore education will play a crucial role for improving the use of o2 alert cards. Patient and carers will be targeted as the main source of education and it is hoped that providing them with BTS leaflets on oxygen administration will increase understanding. Obviously education of health professionals will also be important to raise awareness of the scheme and guidelines. Communication between primary and secondary services is another area that could possibly develop; one idea is that the home address and ideal oxygen dose or target saturation ranges of at-risk patients could then be flagged in the ambulance control systems and communicated to ambulance crews when required. A further idea is that the name of the o2 alert cards could be changed to something which implies a more serious danger hopefully this would encourage the use by patients similar to the reporting of drug allergies.

    Conflict of Interest:

    None declared

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  10. Prehospital care is not for amateurs

    The very fact that the author has written this article at all demonstrates to me a profound lack of understanding on his part of the complexities of prehospital care.

    Firstly, the obligation mentioned by the GMC to help victims of accidents is not a requirement to provide expert or definitive care - it is simply a moral duty to provide what help one can given ones own skill set and available resources. As the author rightly points out, opening an airway or stabilising a cervical spine may indeed be life-saving.

    Furthermore, the inability to provide expert or definitive interventions does not reflect inadequacies on the part of medical school curricula, but more the reality that, without equipment (which no-one caries with them except BASICS doctors), the best any practitioner (or student) can offer at the road side is basic life support/ first aid - and this is already taught in medical schools.

    Most importantly of all, there already exists a body of prehospital care experts who spend on average of three years training to provide assistance to accident victims - they are called paramedics, and trust me, they do not appreciate over-enthusiastic medical students/ junior doctors 'helping' them on scene - whether or not their medical school has provided them with prehospital care training.

    Prehospital care is highly specialised, and those that practice within the speciality have extensive experience within the critical care domains and (assuming they have the right equipment available) can sometimes offer the trauma victim an extra survival advantage. Everyone else should stand well back and let the paramedics do what they do better than anyone else.

    Conflict of Interest:

    I am a registrar in retrievals medicine, involving primary and secondary retrievals.

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