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Recent eLetters

Displaying 1-10 letters out of 779 published

  1. 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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  2. HIRT - the pain of prehospital research

    Dear editor I wish to congratulate the authors of the HIRT trial on finally publishing their results. Whilst a negative trial for primary outcomes, to me it highlighted the major challenges in conducting high quality RCTs in prehospital setting. Few countries have been able to perform this level of prehospital research and it can only advance the future planning of prehospital studies trying to examine the very same questions.In one regard, I view this as a positive result in that it showed advanced ground paramedic care in the Sydney region of New South Wales,provided quality care to severe head injured patients that was not significantly improved upon by addition of a prehospital HEMS physician led team.

    The other prehospital RCT of advanced interventions including RSI for severe head injured patients was another Australian study by Bernard et al in Melbourne, Victoria and this did show improved eGOS. It was a paramedic delivered RSI intervention and therefore taken together HIRT and the Melbourne MICA trial would suggest adding prehospital RSI to the NSW paramedic skill set might in fact be the more EBM supported approach for the severe head injured patient.

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  3. Re: A simple tool to predict admission at the time of triage. More ammunition in the fight against blaming patients.

    We congratulate the authors on this excellent piece of work and are particularly pleased to see method of arrival in their tool as a predictor of admission. In a similar piece of work to predict surgical admissions in our institution we found the same effect (1). At a time when it seems to be politically expedient to scapegoat patients for the overcrowding in our departments and lack of available beds on the wards it is helpful to show that those who call 999 are found to be genuinely sicker!

    (1) Who needs an expert? A tool for optimal triage of general surgical patients in the Emergency Department. European Journal of Trauma and Emergency Surgery April 2014, Volume 40, Issue 1 Supplement, S76

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  4. Communicating Pain and Suffering: The PENS Acronym.

    Communicating Pain and Suffering: The PENS Acronym.

    We would like to thank the authors of this study both for reminding us of what is our primary objective as healthcare providers -- to relieve pain and suffering; and for providing the evidence that suggests that we often are failing in this objective. As medical crewmembers in helicopter EMS, we appreciate the need to elicit accurately, and to relay effectively, information about a patient's pain and suffering. We believe that the PENS tool is effective in meeting these objectives.

    The authors remind us that managing a patient's pain and suffering requires that healthcare providers be aware of the constellation of unpleasant sensations experienced by the patient. These sensations may be caused by illness or injury (i.e., their pain). Their pain, a distinct entity, may be associated with both mental and emotional distress, such as fear, anxiety, and uncertainty; and with physical sensations caused by hunger, thirst, nausea, dizziness, fatigue, and the unpleasant features of ambient light, temperature, and noise (i.e., their suffering).

    Managing pain and suffering begins with asking the right questions. PENS, an acronym pronounced as a word, is an abbreviation for the elements of Pain/Discomfort; Emotions/Expectations; Nausea/Nutrition (Elimination); and Sensory-Stimuli/Sleep. The "PENS assessment" begins with asking the patient: "Are you in pain?" It ends with asking: "Is there anything else that I can do for you?"

    We use PENS in transport medicine as a prompt to ask questions that allow us to mitigate pain and suffering in both initial and subsequent patient assessments. We use the "E" for "Expectations" in PENS as a prompt for asking the patient questions such as: "Do you understand what our plans are?" because such questions provide the means for initial creation and ongoing modification of healthcare plans, and are the basis for shared decision-making. We have found that during transitions of care ("handoffs") the information that we elicited from PENS assessments is the type of information that other healthcare providers often find most useful. Finally, we have found the PENS tool to be easy to remember, and simple to apply.

    Mark J. Greenwood, DO, JD, FAAEM, FCLM; Emily J. Bennett, MSN, APRN-BC, EMT-P. Grand Rapids, MI, USA. mkjhgd@aol.com

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  5. Teamwork in paediatric emergency medicine

    I read with interest the study by Bloch and Bloch demonstrating the effectiveness of observation-based simulation training. As they discussed, simulation training not only improves attendees' knowledge and skills but can also improve teamwork and communication[1].

    As reflected in this article, simulation training is typically run on a departmental basis. However, increasingly emergency medicine involves a multidisciplinary team. In the particular case of paediatric resuscitation, in many hospitals the paediatric cardiac arrest team may comprise emergency physicians, paediatricians and anaesthetists, as well of course as emergency and paediatric nursing staff, all of whom may train separately in their own departments. This can lead to incongruities in the approach that is taught, and is a missed opportunity to foster better teamwork and communication between the doctors and allied health professionals playing these different roles during the management of time- critical emergencies.

    Just as there is a drive for conformity in the design and availability of equipment for emergencies, which has been identified as an important factor in increasing the efficacy and efficiency of care for critically ill patients[2], perhaps the need for better conformity of training also needs to be recognised. As this paper demonstrates the effectiveness of observation-based simulation training, this may open a way for multiple departments to train jointly, so that the multidisciplinary team managing paediatric emergencies develop a cohesive approach with stronger interdisciplinary communication and and teamwork.

    References 1 Simulation training based on observation with minimal participation improves paediatric emergency medicine knowledge, skills and confidence. Scott A Bloch, and Amy J Bloch. Emerg. Med. J. 2015 32:195-202 2 Timing and teamwork--An observational pilot study of patients referred to a Rapid Response Team with the aim of identifying factors amenable to re-design of a Rapid Response System. Peebles, Emma et al. Resuscitation, 83(6):782-787

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  6. Serious about change

    I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre- Hospital Training should be included in all Undergraduate Medical Curriculums. They will be pleased to hear that a nationwide Faculty of Pre -Hospital Care Undergraduate Committee has been set-up, aiming to springboard ideas and information about events, funding and training in pre-hospital care, to all healthcare students. Antrum and Ho quite rightly realise that some form of compulsory pre- hospital training in all medical curriculums is only likely to happen if the General Medical Council specifically requests it. However at present, evidence to illustrate to the GMC the real value of such training is lacking. This must change if it is to be a credible competitor for precious curriculum time. The Undergraduate Pre-Hospital Care Committee hopes that through co- ordination of student pre-hospital care events, sharing of information and literary review, as well as a now standardised and followed-up feedback system for pre-hospital training, the evidence-base will grow. I urge anyone involved in student pre-hospital care activities throughout the UK, to get in touch with the Committee and together let's make sure the necessary evidence for such vital training actually exists.

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  7. ANTRUM AND HO (EMJ 2015;32:171-172)

    Dear Editor

    ANTRUM AND HO (EMJ 2015;32:171-172)

    Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.

    There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical graduates have knowledge of twenty first century management of emergencies in the pre-hospital situation. However in this area of medicine, where any medical practitioner can unexpectedly be required to help, it is important to ensure all medical graduates have knowledge of what interventions should not be undertaken as well as these that should be undertaken.

    With a new GMC recognised sub-speciality of Pre-Hospital Emergency Medicine it is timely that the teaching of undergraduate of pre-hospital emergency medicine is standardised within the undergraduate curriculum.

    Yours sincerely

    Dr Colville Laird,
    Chairman of The Faculty of Pre-hospital Care RCSEd
    Email: claird@basics-scotland.org.uk
    Mobile: 07768855798

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  8. Dear Mr. Brody (correct salutation?)

    Your article on ED patients' suffering came to me only this week through Medscape.com. I would like to thank you for your analysis and for bringing this topic to the surface.

    I have been waiting thirty years for this concept to be treated in the scientific literature. When I started practice in 1983 in a busy urban academic Emergency Department in Baltimore, Maryland, and for the next twenty-five years, THIS was the main driver of my practice style. It was very rewarding and I am thrilled to see it championed so.

    Most Sincerely,

    Steven L. Joffe, M.D.

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  9. Alternative to the use of an LMA bite guard

    An alternative to the use of a bite guard in conjunction with the LMA would be to employ the intubating laryngeal mask airway (iLMA), since the single-use version of the iLMA has a rigid plastic airway tube which resists occlusion by biting, as does the silicone-coated stainless steel tube with the reusable version. Additional benefits would be that the iLMA can facilitate seamless progression to blind tracheal intubation without any interruption in oxygenation or ventilation, and the fact that there is no separate bite guard to become dislodged and obstruct the patient's airway.

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  10. Precision of paediatric weight estimates

    Editor,

    Skrobo and Kelleher rightly stress the importance of accurate, rapid weight estimation in children when the situation precludes actual measurement of their weight.[1] They also rightly emphasise the need for estimation tools to be validated locally.

    The CORKSCREW study convincingly demonstrates that the mean bias of weight estimates using the Luscombe formula (3xage+7) is much smaller than that for the old APLS formula (2xage+8). Interestingly, this was true for 1-5 year olds too, which suggests that it might be better to use the Luscombe formula in all children, rather than just in 6-12 year olds as recommended in the latest APLS manual.

    However, the authors have not provided any results for the precision of these methods, although they suggest that estimates should be within 15% of actual weight. The ISO standard for accuracy of measurement methods defines both trueness and precision.[2] Trueness is the closeness of agreement between the arithmetic mean of a large number of test results and the true or accepted reference value. This is what the CORKSCREW study has presented. Precision refers to the closeness of agreement between test results. It is quite easy for a method to have very good trueness (for example, using the median weight for a given age, as found on standard age -weight curves), but have such an imprecision that it is clinically useless. One commonly used method to describe trueness and precision is described by Bland Altman.[3] The bias reflects trueness, and the limits of agreement (LOA) reflect precision. For a given weight estimate, LOA indicate the range of actual weights within which 95% of subjects will fall.

    Of the published methods of paediatric weight estimation, age-based methods have the worst precision, deteriorating with increasing age.[4] We would be particularly wary of using age-based weight estimation in teenagers, as the range of weights for a given age is far too broad to allow meaningful estimates in individuals. In comparison, the Broselow tape is a very precise method in children, but not useful in over 10s.[5] Newer methods of estimation based on mid-arm circumference (MAC) appear to be at least as precise as the Broselow tape in older children and adolescents.[6,7]

    Of course, tape-based methods require the presence of the child, and age-based methods might still have a role to play during preparation for a child's arrival in the resuscitation room. A MAC tape could be readily available pre-hospital as well as in the emergency department, and useful when the condition of the patient precludes objective measurement of their weight.

    Sincerely, Giles N Cattermole Colin A Graham Timothy H Rainer

    References: [1] Skrobo D, Kelleher G. CORKSCREW 2013 CORK study of children's realistic estimation of weight. Emerg Med J 2015;32:32-5 [2] ISO 5725-1:1994. https://www.iso.org/obp/ui/#iso:std:iso:5725:-1:ed- 1:v1:en [3] Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986 Feb 8;1(8476):307-10. [4] Cattermole GN, Leung MPY, So HK, Mak PSK, Graham CA, Rainer TH. Age- based formulae to estimate children's weight in the emergency department. Emerg Med J 2011;28:390-6. [5] Cattermole GN, Leung PYM,Graham CA, Rainer TH. Too tall for the tape: the weight of schoolchildren who do not fit the Broselow tape. Emerg Med J 2014;31:541-544. [6] Cattermole GN, Leung PYM, Mak PSK, Graham CA, Rainer TH. Mid-arm circumference can be used to estimate children's weights. Resuscitation 2010;81:1105-10. [7] Abdel-Rahman SM, Ridge AL. An improved pediatric weight estimation strategy. Open Med Devices J 2012;4:87-97.

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