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Recent eLetters

Displaying 1-10 letters out of 788 published

  1. Primary care services located with EDs: Effectiveness depends on matching patients to the right clinician

    We read with interest the paper by Ramlakhan et al (10.1136/emermed- 2015-204900) on the effectiveness of primary care services located in EDs. We have just completed a test cycle week of a GP led model for managing lower acuity patients who present to the Clinical Decisions Unit (CDU) at the Glenfield Hospital, Leicester; however, we reached different conclusions. The CDU is a cardiorespiratory unit that receives mixed acuity urgent patients 24 hours a day from a range of sources (999 ambulance, GP referrals and transfers from both the local ED department and Urgent Care Centre located on the same site two miles away), but not self-referrals. The specialist teams are unable to rapidly manage and discharge low acuity patients because the hospital processes and IT systems were not designed for this purpose, resulting in overcrowding and inefficiency. A GP/specialist nurse 'fast track' area was created to rapidly diagnose (with access to chest x-ray and bloods), and discharge safely, all patients triaged by experienced nurses at the 'front door' as potentially fit for same day discharge using the primary care IT system (SystmOne). 67 patients comprising approximately 30-40% of total attendances were seen and 88% were discharged (mean of 116 minutes compared with up to 6 hours at peak periods of activity). No adverse events or seven day readmissions have been reported. Both patient and staff satisfaction was high. The overall proportion of patients who left the department in less than 6 hours (throughput/flow) increased by around 10% easing pressure on specialists who could then focus on the sicker cohort of patients. GPs handle low acuity problems faster because that fits in with their training and skill set (they appraise rapidly and decide). It is a matter of 'right patient in front of the right clinician'. We are planning a further eight week pilot to consider the cost effectiveness of our model, greater integration with the local urgent care system and the best clinician to triage on arrival.

    Conflict of Interest:

    None declared

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  2. Bland-Altman comparison of haemodynamic monitoring methods; not simply a matter of black and white.

    This comparison of non-invasive haemodynamic devices, although valuable, demonstrates some methodological aspects of the Bland-Altman method that should be considered to ensure the accuracy of any proposed conclusions.

    The statistical minimum for comparison of two medical device measurement methods includes reporting mean ?SD values for both methods, correlation, and Bland-Altman bias and precision, mean % differences between methods, and concordance analysis using four quandrant plots if haemodynamic changes were measured in the same subjects during the repeated observations.(1) Of critical importance for application of Bland- Altman statistics is the range of outputs over which the comparison was made. Repeated measures comparing CO values within a narrow "normal range" provide little useful information,(2) as the mean differences between measures will be small and discrimination will be weak. Additionally it is at high and low outputs that accuracy is the most critical and clinically consequential.

    The authors observed USCOM measures were "considerably" lower than NICCOMO measures, which were similar to the values they expected. However the clinical characteristics of the patients are not described, the mean CO and SVR values or SD were not reported, and no quantitative Bland- Altman values nor CO ranges presented. Further upon proposing disagreement between the two methods, no reference was made to normal USCOM reference values.(3) If any differences existed between the USCOM reference normal values and the USCOM Green study normal values, then operator error may have affected the results, and the disagreement is explained, and the conclusion prefaced with an "in our hands" caveat. Conversely, if the USCOM values by Green et al. agreed with the previously published normal USCOM values, and the patient cohorts were substantially clinically matched, then the conclusion is an error in the measurements by NICCOMO, a possibility not raised by the authors.

    Regardless, this comparison of repeated measures in a single series of subjects is only designed to demonstrate agreement between two methods, and not determine which technology is the most reliable, particularly if the endpoint is attainment of arbitrary and undefined expected values. Clinical accuracy is related to a more extensive and rigorous series of comparisons and proofs involving multiple animal and human studies and comparisons across a range of age groups and clinical applications, and across wide ranges of cardiac outputs against multiple technologies.

    Doppler ultrasound has a long history of reliability and clinical utility for flow measurements.(4) The USCOM 1A, a transcutaneous Doppler monitoring technology has been validated against flow probes in animals across a 6 fold range of outputs during application of inotropes and vasopressors,(5) and from 0.12L/min to 18.7L/min in humans.(6,7) It has been validated against invasive standards and non-invasive standards in approximately 100 studies, and found to provide reliable measures across a range of outputs and ages.(8,9,10) It has been demonstrated to reliably measure CI and SVI and detect fluid responsiveness with approximately 90% sensitivity in patients with AF, free breathing and ventilated patients, patients on vasoactive and particularly those with dynamic circulation such as those with sepsis and septic shock where the autonomic nervous system is active.(11) Further the device is recommended in the paediatric sepsis guidelines as a means of monitoring disease progress and titration of therapy,(12) improves outcomes in paediatric septic shock,(13) and has been recommended as a pregnancy monitoring method for early detection of pre-eclampsia.(14)

    Hodgson et al.,(15) compared inter-rater reliability of stroke volume measurements at baseline and following passive leg raising measurements, by emergency physicians and found a 6% error (r=0.96) between measures by different operators and concluded that "following a training period of less than 5 h, USCOM stroke volume measurements demonstrated excellent inter-rater reliability". This confirmed the feasibility of the USCOM technology in the emergency setting, an assessment not completed in the current study despite the title.

    So the USCOM is comprehensively validated, while NICCOMO is a test technology, and its disagreement with USCOM suggests further evaluation in animals and humans, across a wide range of outputs and diseases is required before its utilisation could be countenanced in emergency medicine.

    Comparison of method studies are technically difficult, and involve establishing a reference standard, USCOM, and then comparing paired measures from a proposed test technique, NICCOMO, acquired under identical conditions. Bland-Altman comparison can only determine if the two methods agree or disagree.(2) If the comparison demonstrates disagreement, as the authors propose, then the appropriate scientific conclusion is that, as the reference method has superior validation and clinical proof, the test method doesn't agree with the reference method "in our hands", and is therefore not valid. However additional studies of any new technology may be worthwhile if a suspicion of occult potential clinical utility persists.

    References: 1. J. Zhang J, Critchley LAH, Huang L. Five algorithms that calculate cardiac output from the arterial waveform: a comparison with Doppler ultrasound. Brit J Anaesth 2015;1-11: doi: 10.1093/bja/aev254 2. Olofsen E, Dahan A, Borsboom G. Improvements in the application and reporting of advanced Bland-Altman method of comparison. J Clin Monit Comput 2015;29:127-139. 3. Phillips RA, Smith BE, West MJ, Rainer T, Brierley J, Harris T, He S, Burstow DJ, Fraser JF. New noninvasive haemodynamic nomograms to simplify hypertensive management in neonates, children and adults. J Hypertension 2012;30(suppl 1):538 4. Sotamura S. Ultrasonic Doppler method for the inspection of cardiac functions. J Acoust Soc Am 1957;29:1181-1185. 5. Phillips RA, Hood SG, Jacobson BM, West MJ, Wan L, May CN. Pulmonary artery catheter (PAC) accuracy and efficacy compared with flow probe and transcutaneous Doppler (USCOM): An ovine validation. Crit Care Res Prac 2012; doi:10.1155/2012/621496 6. Phillips RA, Paradisis M, Evans NJ, Southwell DL, Burstow DJ, West MJ. Validation of USCOM CO Measurements in Preterm Neonates by Comparison with Echocardiography. 26th ISICEM 2006, Critical Care 2006;10(Suppl1):144. 7. Su BC, Yu HP, Yang MW, Lin CC, Kao MC, Chang CH, Lee WC. Reliability of A New Ultrasonic Cardiac Output Monitor in Recipients of Living Donor Liver Transplantation. Liver Transpl 2008;14:1029-1037 8. Chong SW, Peyton PJ. A meta-analysis of the accuracy and precision of the ultrasonic cardiac output monitor (USCOM). Anaesthesia 2012; doi:10.1111/j.1365-2044.2012.07311.x 9. Beltramo F, Menteer J, Razavi A, Khemani RG, Szmuszkovic J, Newth CJL, Ross PA. Validation of an ultrasound cardiac output monitor as a bedside tool for pediatric patients. Ped Cardiol 2015, DO I 10.1007/s00246-015- 1261-y 10. Wong LS, Yong BH, Young KK, Lau LS, Cheng KL, Man JS, Irwin MG. Comparison of the USCOM Ultrasound Cardiac Output Monitor with Pulmonary Artery Catheter Thermodilution in Patients Undergoing Liver Transplantation. Liver Transpl 2008;14:1038-1043 11. Thiel SW, Kollef MH, Isakow W. Non-invasive stroke volume measurement and passive leg raising predict volume responsiveness in medical ICU patients: an observational cohort study. Critical Care 2009;39:666-688 12. Brierley J, Carcillo J, Choong K, et al. 2007 American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock* Crit Care Med. 2009; 37(2):666-688 13. Deep A, Goonasekera CDA, Wang Y, Brierley J. Evolution of haemodynamics and outcome of fluid refractory septic shock in children. Int Care Med 2013 DOI 10.1007/s00134-013-3003-z. 14. Gagliardo G, Lo Presto D, Tiralongo GM, Pisanai I, Scala RL, Novelli GP, Vasopollo B, Velensise H. Cardiac output and systemic vascular resistance as a target for the intrauterine treatment of fetal growth restriction. J Preg Hypertension 2015 5:133(267-POS). doi:10.1016/j.preghy.2014.10.273 15. Hodgson LE, Venn R, Forni LG, Samuels TL, Wakeling HG. Measuring the cardiac output in acute emergency admissions: use of the non-invasive ultrasonic cardiac output monitor (USCOM) with determination of the learning curve and inter-rater reliability. J Int Care Soc 2015, DOI: 10.1177/1751143715619186

    Conflict of Interest:

    Employee and shareholder of Uscom Limited

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  3. Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper

    Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper

    Lillitos et al are to be congratulated on a most helpful paper clarifying whether disease severity and the need for hospital admission can be predicted using two similar PEWS systems (Brighton PEWS and COAST - the Children's Observation And Severity Tool).

    There has been a proliferation in the uptake and usage of Paediatric Early Warning Scores (PEWS) in recent years, as part of the patient safety agenda. Their original (dare I say, intended) purpose was to detect early deterioration in hospitalised children, prompting timely interventions and predicting the need for possible Paediatric Intensive Care admission whereas increasingly, PEWS are being employed generically in paediatric practice in the UK. Like Cinderella's slipper (following the spirit of this season), Early Warning systems are attractive, colourful and everybody wants to claim them for their own, with Ambulance Call Response/Prioritisations, Hospital Admissions, ED Triage Systems, Telephone Triage and Decision Making algorithms, Minor Injury/Walk-in centres (to name but a few potential suitors) all seeking to shoe-horn their patient's demographics into one of the currently available scoring systems, in some situations avoiding the need for proper face-to-face clinical assessment.

    Of particular importance was the author's subdivision of presenting complaints into both minor and significant "Medical" and "Surgical" conditions which highlights some of the limitations of Early Warning Scores.

    It is reassuring to find that both the Brighton and COAST scores were good at detecting significant respiratory illnesses, (Brighton and COAST ROC scores yielding AUCs of 0.9 and 0.87, respectively). Whilst intended to be universally applicable, both these scores have an inherent respiratory design-bias, measuring multiple respiratory parameters (respiratory rate, moderate-severe respiratory distress, supplemental oxygen (Brighton), hypoxia (saturations ?92% in air (COAST))), both expected and desirable qualities given the prevalence of respiratory illness encountered in acute "paediatric practice" (asthma/wheeze, bronchiolitis, croup, URTI, LRTI etc.)

    Importantly, both local and regional experience and reviews of adverse incidents, morbidity and mortality have anecdotally found PEWS scores to be less reliable in the early detection of neurological conditions, surgical conditions and blunt and penetrating trauma (where compensatory mechanisms delay physiological abnormalities until disease progression has advanced) and again the authors should be thanked for quantifying these reported observations (they describe AUC's of i) 0.48AVERAGED for significant neurology, 0.56 for general surgical conditions, 0.65 for significant trauma and 0.7 for head injury; Table 3). (I suspect that in major trauma, simple descriptors such as "fall from height", "ejected through windscreen" might well outperform medical COAST/PEWS systems).

    The study also validates what has been termed the "currency of COAST" - that a high COAST score (a score ?3) must be taken seriously. (Due to the score's poor specificity, the converse is not true - a low score does not exclude significant illness/the need for admission). By choosing to use the PEWS/COAST score at Triage, the authors were reliant solely on abnormal physiological findings at one isolated point in time (influenced by external factors such as crying and fever etc.) whereas tracking scores over a period of observation or on an admissions/inpatient wards may have revealed the trends of deterioration described in the early papers that supported the introduction of PEWS systems (1). Even so, like other clinical descriptors (e.g. haemorrhagic rash, shock, unresponsive, fitting) the chosen individual trigger parameters would be expected to prompt an appropriate nursing/medical response e.g. this child's heart rate is abnormally high, their respiratory rate is depressed, their conscious level diminished etc. (Previous authors have discussed the possible merits of using aggregate weighted scores rather than single clinical parameters but neither approach has been found to be superior to the other (2); aggregate scores are certainly more complex, less user- friendly and suggest a knowledge and appreciation of disease processes that - if universal- is at best, currently poorly understood i.e. what happens to "normal" heart rates in an unwell/injured 5-year old as their condition progresses).

    One of the study's shortcomings was to "wrongly" assign each child with a universal score of "1" for parental concern, "on the basis that parents/carers, by bringing their child to the ED, were by default concerned". Parents do sometimes make uninformed choices when presenting to ED; 60% of parents whose children had ATS (Australasian Triage System) category 4 and 5 scores described the severity of their child's illness as the primary (or secondary) reason for ED attendance (3). The intension behind the "Doctor/Nurse/Family concern" trigger was to appreciate the importance of gut feelings - something subjective, often unquantifiable and unmeasurable - to prompt an appropriate clinical response. (Van den Bruel, A et al's paper helpfully supports this approach (4)). [Within the confines of a retrospective study, the authors can legitimately claim that they unfortunately had no alternative]. As an advocate of PEWS scores (I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010), I do question how often these scoring systems have identified a child that would not otherwise have been identified and am concerned that, in the headlong rush to employ a PEWS system in any and every clinical setting, their value has been overstated at the expense of comprehensive nursing observations and medical assessments. They do most certainly i) have an important role to play in ensuring deteriorating trends are appreciated, communicated and acted upon by nursing and medical teams and ii) can be useful when used as a safety netting tool but, paraphrasing social media, might I suggest that we.... "Don't confuse my early warning score for years of clinical training and experience!"

    Dr Julian Sandell, Consultant in Paediatric Emergency Medicine, Poole Hospital NHS Foundation Trust, and author of the Children's Observation And Severity Tool (COAST), 2010

    www.institute.nhs.uk/safer_care/paediatric_safer_care/pews_charts.html

    REFERENCES: (1) Detecting and managing deterioration in children. Monaghan A. Paediatric Nursing. 2005 Feb;17(1):32-35 (2) "Systematic review of paediatric alert criteria for identifying hospitalised children at risk of critical deterioration". Chapman SM et al. Intensive Care Med. 2010 Apr;36(4):600-11. Epub 2009 Nov 26. (3)Why parents present to ED for non-urgent care. Williams A et al. ADC 2009;94:817-820 (4)Clinicians' gut feeling about serious infections in children: observational study. Van den Bruel, A et al. BMJ 2012;345:e6144

    Conflict of Interest:

    I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010

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  4. Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment?

    We wish to thank Wilmer et al for their recent article "Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment", which we read with interest. As researchers in the field of triage we feel it raises a number of interesting questions. We believe that there are considerable similarities between triaging for enhanced trauma team despatch (eg LAA) and effective triage for direct transfer to a Major Trauma Centre (MTC). It could be reasonably suggested that those requiring treatment at a MTC would benefit from a LAA response and indeed be the target population.

    We would welcome some further clarification which we feel would strengthen this work and assist with further research in the field.

    Although MOI has historically been used as a dispatch criterion due to "a high rate of serious injury", the authors conclude that it is the least accurate method of tasking. We wonder if it is possible to clarify the injury patterns amongst patients identified via MOI, particularly injury severity and life-saving interventions performed by LAA.Are the authors able to identify whether any of the six MOI criteria are more accurately predictive than others? We are not aware of any such study in the literature and this could greatly benefit the MOI criteria for MTC triage.

    We note that the authors' findings of 31% overtriage and 19% undertriage are amongst the closest described to the US field triage guidelines tolerance for over and under triage (up to 35% and 5% respectively)1. . Clearly a decision must always be made as to the trade- off between minimising either over or under triage. The authors describe a number of risks of over triage and this is indeed correct, a linear relationship between over triage and critical mortality has indeed been shown2. This is often over looked, with the harmful effects of under triage being the most obvious. With that in mind, we would be interested to see more information on those patients who were under triaged in this study, particularly their MOI. Can the automatic despatch criteria be further refined by looking at these under triaged patients?

    We welcome the authors' response and their views on using this work as a foundation to optimise MTC triage decisions.

    1American College of Surgeons. Resources for the optimal care of the injured patient: 2014. Chicago, IL: American College of Surgeons; 2014. 2Frykberg ER. Medical Management of Disasters and Mass Casualties From Terrorist Bombings: How Can We Cope? J Trauma 2002; 53(2):201-12

    Conflict of Interest:

    A PICO research suggestion on MTC triage has been submitted by the author (JV) for the James Lind/RCEM Research priorities

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  5. Preparing medical students for the front line: experiences from a curricular innovation in Ireland

    Dear Editor,

    We read with interest the article by Seligman and colleagues (1) which evaluated a novel first responder scheme for medical students as a collaborative venture between a medical school and the local ambulance service. Previous authors have advocated the early introduction of Emergency Medical Technician teaching in an undergraduate medical curriculum in the United States.(2) We would like to report our experiences in delivering an innovative special study module (SSM) in pre- hospital emergency care (PHEC), which has consistently been one of the most popular elective modules offered to the preclinical medical students at our institution.

    The PHEC SSM was designed by senior medical educators in partnership with paramedics and advanced paramedics at our local hospital. Our university has conferred honorary clinical fellowships on the paramedic supervisors involved. Second year students complete the SSM over a 10-week period in small groups of 12 students as part of their core medical professionalism module. Participants actively shadow ambulance crews on emergency calls and assist in patient assessment, monitoring and hand-over in the emergency department, under the supervision of experienced paramedics. Students have the opportunity to consolidate their theoretical knowledge and practise procedural skills such as blood pressure measurement, capillary blood glucometry, electrocardiography and oxygen administration in an authentic clinical environment. They also become familiar with standardised emergency management, first aid, and patient safety protocols. Students maintain a reflective log of their emergency calls and are debriefed in the case of traumatic incidents. Assessment involves a combination of supervisor-led student evaluation, and submission of a written assignment based on a contemporary emergency medicine topic. Students also deliver a group presentation in which they are required to critically analyse the efficiency of the ambulance service and compare it to international best practice.

    The PHEC SSM provides a formative early introduction to immediate care and emergency medicine and it focuses students' attention on the realities of clinical practice outside of a hospital setting. SSMs such as this are a useful vehicle for fostering greater inter-professional learning opportunities and improving communication between members of a multidisciplinary clinical team, as well as promoting a deeper appreciation for team-working and the ethical dilemmas of patient care. Some medical students will also benefit from being motivated towards a future career in emergency medicine. This educational intervention has greatly facilitated collaboration between the ambulance service, emergency department and the medical school, and we propose that it may serve as a model of good practice for other higher educational institutions. Consideration should be given to ultimately integrating this clinical placement into the core undergraduate medical curriculum.

    Ben Murphy, Craig Joyce, Barry Hannagen, Michael Smith, Gerard Flaherty

    School of Medicine, National University of Ireland, Galway, Ireland

    Correspondence to Dr. Gerard Flaherty, School of Medicine, National University of Ireland, Galway, Ireland; gerard.flaherty@nuigalway.ie

    REFERENCES

    1 Seligman WH, Ganatra S, England D, et al. Initial experience in setting up a medical student first responder scheme in South Central England. Emerg Med J 2015;0:1-4. Doi:10.1136/emermed-2015-204638.

    2 Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as EMTs: skill building, confidence and professional formation. Med Educ Online 2014;19:24829. Doi: 10.3402/meo.v19.24829.

    Conflict of Interest:

    None declared

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  6. Encouraging task-orientated coping mechanisms

    Dear Editor,

    This article by Howlett et al. makes for interesting reading as a junior doctor at the start of Emergency Medicine training.

    This study suggests that in order for trainees (and Consultants) to maintain successful, long, enjoyable and fruitful careers, and avoid 'burnout', we should develop 'task-orientated coping' mechanisms. Currently one may argue that this is encouraged via personal reflection in the e-portfolio, may I suggest that a more collective approach is called for.

    The Emergency Medicine training programme dictates that one must learn to reflect regularly and use this reflection to direct self-learning and 'learn from our experiences'. The e-portfolio is relatively rigid in how one must reflect: 'What you did', 'What would you do differently and why', 'what have you learnt', and does not necessarily encourage timely discussion with a senior colleague.

    Trainees should be encouraged to discuss learning points from an experience with their Clinical/Educational Supervisor or another senior colleague. In the busy Emergency Department environment this cannot happen as frequently as it may be required and one way to combat this may be achieved through changing staff members' attitudes to the importance of reflection.

    Whilst our main focus is patient care, we must acknowledge that in order to continue to provide excellent care for our patients, we need to care for ourselves and ensure that we do address issues that arise in a timely matter. All doctors will make mistakes over their career with differing impacts on patient outcome. Open discussions regarding mistakes made by clinicians at different levels will encourage all doctors to reflect and discuss issues they have been involved with and improve learning from these experiences.

    Furthermore perhaps 'task-orientated coping' mechanisms should be included in the Undergraduate medical curriculum to encourage this practice from the outset for newly qualified doctors.

    Conflict of Interest:

    None declared

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  7. RE: Bowness J, Kilgour PM, Whiten S, et al. Emerg Med J 2015;32: 620-625.

    We read this article with interest, given the high prevalence of penetrating chest trauma in South Africa and the fact that we and others (1,2) have published on the challenges faced in high-volume systems with errant tube placement. While we also advocate the "safe-triangle" approach, we aim to place the tube rather in the 4th ICS to avoid the risk of trans-diaphragmatic injury. We are also adamant that the "finger-sweep" be performed to gently displace any organ (lung or herniated viscus) away from the chest tube during placement and to ensure placement within the thoracic cavity. Directing all tubes apico-posteriorly is also advocated strongly.

    What has been clearly shown in previous studies is that senior clinicians have much lower complication rates and that technical "errors of execution", especially the continued use of trochars (3), are to blame for many complications. The range of complication rates are listed between 10 and 30% across most of the studies. Indeed, it may be time for a "check -list approach" for trauma chest tubes! (4)

    Better training, under the watchful supervision of senior experienced clinicians, could probably reduce the complication and misplacement rates where often junior staff place these tubes initially1,2,3. In addition, a return to the counting of the intercostal spaces and the use of the 4th ICS rather than the 5th ICS may further reduce these misplacements.

    Regards, Dr TC Hardcastle, MMed(Chir), PhD, FCS(SA), Trauma Surgeon Deputy Director: Trauma Services, and Trauma ICU, IALCH, and Head: Trauma Training Unit, UKZN, Durban ZA Dr MS Morris, MBBS, FCEM(UK), Emergency Medicine Specialist (ret) Honorary Senior Lecturer, Emergency Medicine, Groote Schuur, UCT, Cape Town, ZA

    References 1) Maritz D, Wallis L, Hardcastle T. Complications of tube thoracostomy for chest trauma. S Afr Med J, 2009;99:114-117. 2) Kong V, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa. Ann R Coll Surg Engl, 2014;96:609-613 3) Kong V, Clarke DL. The spectrum of visceral injuries secondary to misplaced intercostal chest drains: experience from a high volume trauma service in South Africa. Injury, 2014;45:1435-1439 4) Civil IDS. Tube thoracostomy in trauma: Is it time for a checklist for chest tubes? Injury, 2013; 44:1143-1144

    Conflict of Interest:

    None declared

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  8. A pinch of salt or a drop of saline?

    We were surprised by the EMJ decision to publish the study by Scotter et al (1) A number of previous studies including those studied by Scotter and colleagues have concluded that bilateral, fixed, dilated pupils in the context of severe head injury are not universally predictive of poor outcome. Performing a meta-analysis of five, retrospective, cohort studies, one of which was conducted before 1988 does not change this message. The results provided in the abstract are potentially misleading; the overall mortality for patients with extradural haematomas should not be reported as 29.7%, but rather that 25 of 82 patients died. Similarly, for patients with subdural haematomas, the mortality was not 66.4% but that 38 of 57 patients died. A favourable outcome was seen for 13 patients with extradural haemorrhages and bilateral fixed pupils and 3 of those with subdural haematomas.

    The authors are correct regarding the limitations of their study - there is considerable potential for selection bias in the published reports, the age ranges of the study patients are unclear, the delays to surgery are largely unreported and none reported the presence or absence of co-morbidities. Whether a pupil of 4mm should be considered fixed and dilated is also open to question. None of the studies addressed whether there was any direct injury to the face that might have produced traumatic mydriasis. There is also no mention in either Scotter's paper or those reviewed, about the value of aggressive pre-hospital care including intubation, ventilation and administration of hypertonic fluids. A young patient with an extradural haematoma who is rapidly resuscitated, arrives in a neurosurgical centre within minutes of the pupils becoming fixed and dilated might have reasonable expectations of survival. Equally, a patient with a subdural haematoma who has fixed and dilated pupils on arrival of the paramedics, who is transported to a district general hospital for intubation and who is on anticoagulation has no need to be referred for consideration of neurosurgery but rather should be allowed to die with comfort and dignity.

    We would also take issue with the statement that patients should be able to undergo surgery within an hour of arrival following the introduction of major trauma networks in the U.K. Outside of London, many patients with major trauma are initially managed in district general hospitals. In Wessex, nearly 50% of patients with an injury severity score of >15 (major trauma) were admitted to trauma units (Trauma Audit Research Network, personal communication). For many patients with severe head injuries, the initial admitting hospital remains distant from the regional neurosurgical service. Only by altering the referral pathways have we any hope of reducing the time to surgery for these patients (2, 3).

    The motives for Scotter's paper are laudable but the messages should be taken with a drop of (hypertonic) saline solution.

    References:

    1. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undego surgery: a systematic review and meta-analysis. Emerg Med J 2015; 32: 654-659

    2. Trebilcock H. The impact of increasing the running time to the major trauma centre (MTC) to 60 minutes in the south west. Emerg Med J 2015; 32: e17-e18 doi:10.1136/emermed-2015-204980.18

    3. Dickinson P, Eynon CA. Improving the timeliness of time-critical transfers: removing 'referral and acceptance' from the transfer pathway. Journal of the Intensive Care Society 2014; 15: 104-108

    Conflict of Interest:

    None declared

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  9. Cutting Titanium Rings off in an Emergency. (Advice for A&E Staff)

    Just to clarify, they can be cut off using the same tool for cutting off precious metal rings found in most high street jewellers. Probably the only stipulation is that the blade is in new/really good condition and lubrication is used e.g. Aquagel,(although a lubrication oil on the blade such as WD40 would be better for prolonging the blade life)

    It can heat up quite rapidly as well so keeping it cool with irrigation is advisable. Ampoules or tap water dripped on whilst cutting can aid here.

    For ease, it is advisable to cut the ring twice from both sides so that the ring falls off making it a 'one man job'. Failing that, if the ring is cut only once, a method will be needed to force the ring open enough to be removed from the finger which could involve more staff, tools and brute force.

    As shown in the article, a method of forcing the ring open when it has only been cut once would be to feed a couple of straightened paperclips through each side of the cut and grip with pliers. It may be only necessary to spring the ring open a short distance to remove it.

    A single unused blade will cut off one or two titanium rings with ease. New blades are available from specialist jewellery tool companies.

    Conflict of Interest:

    None declared

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  10. Mortality is key

    Dear Editor, I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes. However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variables, it is not particularly surprising that they are closely related. The major problem is that both scoring systems do not have a particularly strong relationship to mortality. Previous research on EWS in sepsis have shown AUC figures of around 0.6-0.7, much less than the figures presented here (1-3). A recent paper by Kaukonen et al (4) (published after this paper was submitted), has shown that the SIRS criteria are also not particularly ideal for defining 'cut off points' in patients with sepsis. The authors suggest that using an EWS of >=3 has a NPV of 99.5% for 'severe sepsis', and a specificity of 77%. However, in Corfield et al's paper on sepsis mortality, the same cut off has an NPV of only 92.3% and a specificity of 11%(1)! Subsequent data from that paper show that the mortality of patients with NEWS between 0-4 are almost identical (EWS =0, mortality 18.8%, EWS = 1, mortality 18.8%, EWS =2, mortality 19.3%, EWS=3, mortality = 20%, EWS =4, mortality = 21.3%). Without presenting figures for mortality in this dataset, it is hard to know the relevance of using the cut off they suggest. Sepsis is clearly a condition which has a significant mortality attached, but this does not appear to be well related to either SSC definitions or EWS figures, apart from in extremes. Did the authors collect any mortality or outcome data in this cohort? Thanks, Fergus Hamilton 1 )Corfield, A. R., Lees, F., Zealley, I., Houston, G., Dickie, S., Ward, K., & McGuffie, C. (2014). Utility of a single early warning score in patients with sepsis in the emergency department. Emergency Medicine Journal : EMJ, 31(6), 482-7. doi:10.1136/emermed-2012-202186 2) ??ld?r, E., Bulut, M., Akal?n, H., Kocaba?, E., Ocako?lu, G., & Ayd?n, ?. A. (2013). Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department. Internal and Emergency Medicine, 8(3), 255-60. doi:10.1007/s11739-012-0890-x 3) Geier, F., Popp, S., Greve, Y., Achterberg, A., Gl?ckner, E., Ziegler, R., ... Christ, M. (2013). Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wiener Klinische Wochenschrift, 125(17-18), 508-15. doi:10.1007/s00508-013-0407-2 4)Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D. J., & Bellomo, R. (2015). Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. New England Journal of Medicine, 372(17), 150317020036009. doi:10.1056/NEJMoa1415236

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