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Recent eLetters

Displaying 1-10 letters out of 748 published

  1. Re:AP pelvis and frog lateral for a limping child

    Many thanks for your letter. With the benefit of hindsight, the radiographs do show signs suggestive of SUFE. However, the original radiographs were reviewed by a senior A&E doctor in a peripheral hospital, and reported by a consultant radiologist as possible Perthes. This was also the working diagnosis of a consultant paediatric orthopaedic surgeon who reviewed the chid in clinic. SUFE was not suspected possibly because of the child's very young age. An MRI was requested due to the abnormal appearance of the femoral epiphysis, but the appointment was missed. Had a frog lateral radiograph been arranged, the diagnosis would have been more obvious.

    Whilst we share your concern on radiation exposure, missing the diagnosis as illustrated in this case is a bigger worry. These radiographs are routinely reviewed by junior frontline doctors that are not necessarily experienced in assessing the paediatric hip. We would normally use MRI to further investigate cases of hip pain, but in this particular case, the purpose of a CT was to delineate the bony architecture with 3D reformats to plan possible surgical intervention for the missed slip.

    A frog lateral view only may well be sufficient to diagnose most hip pathology; however, we would be cautious in recommending this without prospective evidence across a large number of patients, with radiographs assessed by frontline doctors.

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  2. Mobile apps - are we culturally out of signal?

    As an avid user of mobile apps currently working in Emergency Medicine, I enjoyed reading this article (and have since downloaded a couple of apps!). I have found mobile apps are a useful adjunct to my work in the Emergency Department, most commonly for checking drug doses using the British National Formulary app or using a Snellen Chart app in a departmental bay.

    I do think, however, if mobile apps are to be integrated into clinical practice that there needs to be a regulatory and cultural revolution. Authoritative signs dictating 'do not use your mobile phone' litter many hospitals and, in my opinion, have contributed to patients challenging my use of them. Additionally, there is the cultural perception that if you are 'checking your phone' you are probably on a social media site when in actual fact you could well be checking the hospital's antibiotic guidelines for a septic patient.

    From a regulatory point of view, I think at the moment we need to be cautious when using these apps. Very few of these have approval of regulatory bodies such as the Medicines and Healthcare products Regulatory Agency (MHRA) in the case of the UK. If we are using these apps to diagnose and manage patients, we need to view them as much of a medical device as a pulse oximeter.

    Emergency Medicine is incredibly varied and, for that reason, is probably the most ideal specialty to embrace mobile apps. I cannot see a future for the specialty without mobile apps but I think we need to be careful and open about using them.

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  3. Is videolaryngoscope superior to direct laryngoscopes for tracheal intubation during chest compressions?

    In a manikin study simulating cardiopulmonary resuscitation, Tandon et al.1 showed that intubation time was shorter for GlideScope?? videolaryngoscope than direct laryngoscope. This result agrees with the findings of Shin et al2 and Xanthos et al3 in manikin studies simulating cardiopulmonary resuscitation. However, in other similar manikin studies, GlideScope?? videolaryngoscope was not superior to direct laryngoscope with regard to intubation time.4,5 In all these manikin studies,1-5 the authors suggest that further clinical trials are required to evaluate the effectiveness of the studied devices in patients. One of important reasons for this statement is that the manikin cannot precisely reproduce the intubation conditions of real patients. Also, the airway scenarios simulated in manikin studies cannot represent real clinical situations. Despite numerous manikin comparing GlideScope?? videolaryngoscope and direct laryngoscope for tracheal intubation during cardiopulmonary resuscitation, it is really unclear what these contradictory results can tell us for clinical decision-marking. Rai and Popat6 have pointed out that manikin studies often reveal results that are impossible to interpret or even contradictory to subsequent human studies. An example of this is a recent randomized controlled clinical trial by Arima et al7 comparing the Airwayscope and direct laryngoscope for tracheal intubation in prehospital patients primarily with cardiac arrest. In manikin studies simulating cardiopulmonary resuscitation, the Airwayscope has been demonstrated to be superior to direct laryngoscope for tracheal intubation.8,9 However, when tracheal intubation was performed by experienced emergency physicians in the prehospital cardiopulmonary resuscitation patients, the Airwayscope did not show superior efficacy to direct laryngoscope in relation to intubation time, success rate, and difficulty of intubation. Moreover, initial intubation with the Airwayscope failed in 20 cases but was followed by successful intubation with the direct laryngoscope. A major cause of failed first intubation attempt with the Airwayscope was oral vomitus or secretion contamination, which was found in 45 of the total 109 cases (41%) in this clinical study.7 Simple or even sophisticated manikins cannot model vomitus or secretions regurgitated from the esophagus or trachea due to increased intra-thoracic pressure from chest compressions.8 Here, we would like to echo Behringer and Kristensen10 that manikin studies may be warranted in the evaluation of new intubation equipment as a means to teach a technique, maintain safety and oversee conduct of an ensuing clinical study, but they are of negligible value as sole predictors of any given airway device's value in the clinical realm. Thus, to obtain robust evidence regarding exact role of videolaryngoscopes in airway management of cardiopulmonary resuscitation patients, randomized controlled trials comparing each videolaryngoscope against an established alternative (for example, direct laryngoscope) in actual clinical settings are still needed. Shi Yu Wang, Fu Shan Xue, Rui Ping Li Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China. Correspondence to Fu Shan Xue, Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing 100144,China. Email: xuefushan@aliyun.com; fushan.xue@gmail.com References 1. Tandon N, McCarthy M, Forehand B, et al. Comparison of intubation modalities in a simulated cardiac arrest with uninterrupted chest compressions. Emerg Med J 2013; In Press. doi:10.1136/emermed2013-202783. 2. Shin DH, Choi PC, Han SK. Tracheal intubation during chest compressions using Pentax-AWS?, GlideScope?, and Macintosh laryngoscope: a randomized crossover trial using a mannequin. Can J Anesth 2011; 58:733-9. 3. Xanthos T, Stroumpoulis K, Bassiakou E, et al. Glidescope? videolaryngoscope improves intubation success rate in cardiac arrest scenarios without chest compressions interruption: a randomized cross-over manikin study. Resuscitation 2011; 82:464-7. 4. Kim YM, Kang HG, Kim JH, et al. Direct versus video laryngoscopic intubation by novice prehospital intubators with and without chest compressions: A pilot manikin study. Prehosp Emerg Care 2011; 15:98-103. 5. Kim YM, Kim JH, Kang HG, et al. Tracheal intubation using Macintosh and 2 video laryngoscopes with and without chest compressions. Am J Emerg Med 2011; 29:682-6. 6. Rai MR, Popat MT. Evaluation of airway equipment: man or manikin? Anaesthesia 2011; 66:1-3. 7. Arima T, Nagata O, Miura T, et al. Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting. Am J Emerg Med 2014; 32:40-3. 8. Komasawa N, Ueki R, Itani M, et al. Validation of the Pentax-AWS Airwayscope utility as an intubation device during cardiopulmonary resuscitation on the ground. J Anesth 2010; 24:582-6. 9. Komasawa N, Ueki R, Kohama H, et al. Comparison of Pentax-AWS Airwayscope video laryngoscope, Airtraq optic laryngoscope, and Macintosh laryngoscope during cardiopulmonary resuscitation under cervical stabilization: a manikin study. J Anesth 2011; 25:898-903. 10. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011; 66 Suppl 2:57-64.

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  4. AP pelvis and frog lateral for a limping child

    We read the article "AP pelvis and frog lateral for a limping child"(1) with some concern for radiation safety. The AP pelvis radiograph at presentation does not show merely slight irregularity of the articular surface as stated in the article, but a reduction of height of 50% of the left femoral capital epiphysis, increased density projected across the growth plate, loss of clarity and contour of the growth plate and lateralisation of the left hip - all classical signs of slipped epiphysis. In our hospital we performed a study by which we reviewed all cases where an AP and lateral pelvis had been performed over a period of 2 years (2). This showed that the AP view very rarely demonstrated abnormality not seen on the lateral view, whereas the converse is not true. Our protocol since 2008 is frog lateral only for painful hip except where there is a history of trauma. To our knowledge there have been no missed diagnoses as a result of this policy. If any further investigation is required we prefer MRI to CT, which delivers high dose to the gonads in hip examinations.

    1.Sultan J, Ali F. Emerg Med J Published online first. 13th January 2014 doi 10.1136/ememed-2013 203366

    2. Is a single radiograph adequate screening for possible slipped upper femoral epiphysis? Gummow A, McGurk SF, WilkinsonAG. Pediatr Radiol (2008) 38 (Suppl 3) S537

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  5. COMMENTS ON: "BET 3: Evaluation of intra-aortic balloon support in cardiogenic shock"

    COMMENTS ON: "BET 3: Evaluation of intra-aortic balloon support in cardiogenic shock"

    Maria Cristina Acconcia(a), MD, Flavia Chiarotti(b), DStat, Francesco Romeo(c), MD, Quintilio Caretta(d*), MD.

    (a)Department of Cardiovascular Disease, University of Rome - La Sapienza, Rome, Italy (b)Department of Cell Biology and Neuroscience, Italian National Institute of Health, Rome, Italy (c)Department of Cardiovascular Disease, University of Rome - Tor Vergata, Rome, Italy (d) Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy

    *Corresponding author at: Quintilio Caretta, MD, Clinical and Experimental Medicine, University of Florence, Largo Brambilla, 3 - 50134 Florence, Italy. Tel: 0039-3487809379; Fax: 0039-06-20904008;E-mail: qcaretta@unifi.it.

    In the meta-analysis "The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularization" by Romeo et al (2013), we assessed the impact of intra-aortic balloon pump (IABP) on in-hospital mortality, safety end points (stroke, severe bleeding) and long-term survival, using risk ratio (RR) and risk difference (RD) estimates(1). We found that IABP support did not significantly affected the risk of death in patients who did not undergo reperfusion, while it reduced significantly in the Thrombolysis (TT) subgroup and significantly increased in the percutaneous coronary intervention (PCI) subgroup the in-hospital mortality.

    Humphrey et al (2013) recently performed a short-cut review to establish whether IABP improves mortality in cardiogenic shock after acute myocardial infarction (2) including our meta-analysis(1) . In Table 3 they stated that the use of the observational studies and the different mortality rates among the three subgroups (83.9% for the no reperfusion subgroup, 66.9% for the TT subgroup, and 38.4% for the PCI subgroup), suggested a weakness of the study. They concluded that "the role of IABP support in patients with cardiogenic shock from myocardial infarction remains unclear, without evidence of clear confirmed benefit compared to conventional therapy, especially when PCI is available". With respect to these remarks we would like to make some comments. First, the statement on the observational studies is formally correct, but in the scientific literature the evidence of IABP support in cardiogenic shock is mainly based on registry data, due to feasibility; indeed, in our meta-analysis the inhospital mortality was analyzed on 14186 patients from 16 studies, 13 observational, including 13526 patients, and 3 randomised controlled trials, contributing with 22, 40, and 598 patients, respectively. Furthermore in our meta-analysis we adopted the more conservative random effect model to take into account heterogeneity among studies. In adjunct Benson and Hartz (2000) performed meta-analyses of randomised clinical trials and observational studies and found that treatment effect estimates from observational studies reported after 1984 were similar to those obtained in randomised controlled trials(3). Also, in their meta-analyses based on randomised clinical trials and observational studies on identical clinical topics, Concato et al (2000) found that the average results of well-designed observational studies (with either a cohort or a case-control design) were markedly similar to those of the randomised controlled trials(4). Finally, an integrated approach is advisable because "Discarding observational evidence when randomised trials are available is missing an opportunity. Conversely, abandoning plans for randomised trials in favour of quick and dirty observational designs is poor science"(5). Second, we think that the authors did not take into appropriate account the role of reperfusion strategies as confounding factor in the meta- analysis. Indeed, from a clinical point of view it is quite different to support patients affected by cardiogenic shock with IABP alone, or with IABP in combination with TT or PCI. This is clearly demonstrated in our meta-analysis by the fact that the three groups of patients who did not receive IABP support (control groups) had significantly different in- hospital mortality rates due to the clinical treatment (83.9%, 66.9%, 38.4%, for no reperfusion, TT and PCI, respectively) (see Figure 4 in Romeo et al, 2013)(1). Thus the actual impact of IABP support could be assessed only if the subgroups were stratified according to clinical treatment. And this must not be interpreted as a gap, but as correct application of the statistical method. Finally, we performed a trial sequential analysis (TSA) using TSA program (The Copenhagen Trial Unit, Center for Clinical Intervention Research CTU, Denmark; version 0.9 beta; available at www.ctu.dk/tsa)(6,7) to settle any further doubt. TSA provides the required information size, a threshold for a statistical significant treatment effect and a threshold for futility. We calculated the relative risk reduction (RRR) both for RR and RD, using the event proportion observed in the control group (i.e. the basal risk) and the actual difference in risks between the experimental and control group observed in our meta-analysis. TSA performed on TT and on PCI subgroups demonstrated that the sample sizes were adequate to verify the hypotheses. The required number of participants was reached in both subgroups of patients (TT: RR, n=1646 and RD, n=1287, RRR=26.6%; PCI: RR, n=2671 and RD, n=2523, RRR=-18.2%). The monitoring boundaries constructed to detect significance were crossed by the z-curves. Thus, our meta- analysis can be considered as conclusive in contrast with the final statement by Humphrey et al (2013)(2).

    References 1. Romeo F, Acconcia MC, Sergi D, et al. The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularization: A comprehensive meta-analysis. Am Heart J 2013:165:679-92. 2. BET 3: Evaluation of intra-aortic balloon support in cardiogenic shock. Emerg Med J 2013;30:1063-4. 3. Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med 2000;342:1878-86. 4. Concato J, Shah N, Horwitz RI. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 2000;342:1887-92. 5. Ioannidis JPA, Haidich A-B, Lau J. Any casualties in the clash of randomised and observational evidence? No--recent comparisons have studied selected questions, but we do need more data. 2001;322:879-80. 6. Thorlund K, Engstr?m J, Wetterslev J, et al. User manual for trial sequential analysis (TSA). Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen, Denmark. 2011. p. 1-115. Available from www.ctu.dk/tsa 7. Wetterslev J, Thorlund K, Brok J, et al. Estimating required information size by quantifying diversity in a random-effects meta- analysis. BMC Medical Research Methodology 2009;9:86.

    Conflict of Interest:

    None declared

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  6. A lesson in PR

    I thoroughly enjoyed reading this honest perspective from an experienced colleague. Like most junior doctors, my career to this point has been littered with examples of unpleasant exchanges. As unpleasant as they are, at my level being put in ones place seems to have some value. As an example I remember when the on call general surgical registrar informed me that she was "not the only one in the hospital with effing fingers." I was embarrassed, but in the year since this incident I have never attempted to refer a patient with potential small bowel obstruction without first completing my examination. The unforgiving tone of this remark will likely stay with me for the rest of my career. Perhaps a gentler delivery would not have had the same impact.

    Conflict of Interest:

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  7. Reliability and validity of a new French- language triage algorithm: the ELISA scale. Methodological error

    I was interested to read the papers by Jobe J and colleagues published in Feb 2014 issue of Emerg Med J.1 The authors aimed to investigate the validity and efficiency of a specific French-language triage system named Echelle Liegeoise d'Index de Severite a l'Admission (ELISA). 1 As the authors pointed out validity was estimated by studying the correlations between the triage ranking assigned by the nurse and actual resource consumption and patient outcome.1 Why did the authors not used well known test for validity analysis such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio positive and likelihood ratio negative as well as odds ratio (true results\false results - preferably more than 50)? 2-9 Regarding reliability or agreement, it is good to know that ICC should be used for quantitative variables and weighted kappa (not simple Cohen's ? coefficient because kappa has its own limitations too) for qualitative ones. 2-9 It is crucial to know that there is no value of kappa that can be regarded universally as indication good agreement. Two important weaknesses of k value to assess agreement of a qualitative variable are as follow: It depends upon the prevalence in each category and also depends upon the number of categories. Moreover, statistics cannot provide a simple substitute for clinical judgment. 2-9 As the authors pointed out in their conclusion, ELISA is a valid triage tool with high interrater and intra rater agreement. Such a conclusion is a misinterpretation due to inappropriate use of statistical test to assess validity and reliability and should really be avoided by researchers.

    As a take home message, for reliability and validity analysis, appropriate tests should be applied.

    References: 1- Job? J, Ghuysen A, G?rard P, Hartstein G, D'Orio D, Reliability and validity of a new French-language triage algorithm: the ELISA scale. Emerg Med J, 2014 Feb;31(2):115-20. doi: 10.1136/emermed-2012-201927. Epub 2013 Jan 23 2- Jeckel. J.F, Katz. D.L, Elmore, J.G, Wild, D.M.G, Epidemiology, Biostatistics and Preventive Medicine, 3rd edition. 2007, SAUNDERS, Elsevier, Philadelphia, PA, United State 3- Kenneth J. Rothman, Sander Greenland, Timothy L. Lash. Modern Epidemiology, 4th edition. 2010. Lippincott Williams & Wilkins, Baltimore, United States 4- Sabour S, Dastjerdi EV. Reliability of four different computerized cephalometric analysis programs: a methodological error.Eur J Orthod. 2013 Dec;35(6):848. doi: 10.1093/ejo/cjs074. Epub 2013 Oct 16. 5- Sabour S. Single slice vs. volumetric MR assessment of visceral adipose tissue: reliability and validity among the overweight and obese. Obesity (Silver Spring). 2013 Jan;21(1):6-7. doi: 10.1002/oby.20093. 6- Sabour S, Dastjerdi EV. Reliability of assessment of nasal flow rate for nostril selection during nasotracheal intubation: common mistakes in reliability analysis. J Clin Anesth. 2013 Mar;25(2):162. doi: 10.1016/j.jclinane.2012.10.006. Epub 2013 Jan 16. 7- Sabour S, Ghassemi F. Accuracy, validity, and reliability of the infrared optical head tracker (IOHT), Invest Ophthalmol Vis Sci. 2012 Jul 13;53(8):4776. doi: 10.1167/iovs.12-10324. 8- Sabour S, Ghassemi F. Reliability and validity of conjunctival ultraviolet autofluorescence measurement. Br J Ophthalmol. 2012 Sep;96(9):1271; author reply 1271. doi: 10.1136/bjophthalmol-2012- 302087. Epub 2012 Jun 13. 9- Sabour S, Ghassemi F. The reproducibility of measurements of differential renal function in paediatric 99mTc-MAG3 renography: is this correct? Nucl Med Commun. 2012 Dec;33(12):1311; author reply 1311-2. doi:10.1097/MNM.0b013e328359453a

    Conflict of Interest:

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  8. PALM consensus statement: estimation of population incidence using an island model.

    We read with interest the PALM consensus statement (1). This is an airway rescue technique for comatose hypoxaemic patients in the pre- hospital environment. The PALM procedure could also apply to the general practitioner (GP) run community hospital environment since the facilities of a metropolitan hospital, specifically rapid sequence induction of anaesthesia (RSI), are not available.

    The islands of the west coast of Scotland are served by such hospitals. The catchment population of these hospitals is clearly defined and almost all patients will present to, or be initially transported to, these hospitals. Since these hospitals do not have facilities for ongoing management of intubated patients, critically ill or injured patients are retrieved for ongoing care in metropolitan hospitals. These three circumstances provides for a unique opportunity to estimate the RSI incidence per head of population. It should then be possible to examine these cases to assess if a PALM procedure by the island GP would have been indicated as an initial procedure.

    We examined our service database from 1st Jun 2008-1st December 2013 inclusively for ventilated patients retrieved from the islands of Arran, Barra, Benbecula (and the Uists), Bute, Cumbrae, Coll, Colonsay, Islay, Jura, Mull and Tiree. These islands are served by a GP hospital or surgery. We could not assess deaths under medical care in the pre-hospital setting thus there may be a survivor bias but we suspect this is small. The total population of these islands is 25 204. Over a 4.5 year period, 68 ventilated patients were retrieved. Therefore we estimate that the "all cause" RSI rate is 0.60 per 1000 of population per year.

    We examined our service patient report forms for these 68 patients. 41 were comatose (an initial GCS of <9 either at referral to us or at our initial assessment) and 17 were hypoxaemic (an initial SpO2 <90%). 13 patients were both comatose and hypoxaemic. Of these 13 patients, 4 had airway management without drugs. Of the remaining 9 patients (a potential PALM rate of 0.08 per 1000 per year), 5 had a primary neurological diagnosis and 4 a primary respiratory diagnosis. Of the 13 patients there was mention of an airway problem in 1.

    We agree that PALM is likely to be a rare procedure. Our results, within the clear limitations of our approach, may help inform that opinion. We agree that the faculty should develop a robust registry to inform discussion about this interesting development. We question if the likely frequency of PALM for any one doctor is sufficient to maintain currency unless very clear mechanisms are mandated.

    References: Moss R, Porter K, Greaves I. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J 2013; 30: 1073-1075.

    Conflict of Interest:

    None declared

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  9. Thunderstorm Asthma and London Ambulance Data

    London Ambulance Service compiles an illness category for each Category A (life threatening) incident. Triaged Cat A illness data for 4505 days (3,677,454 incidents) between the 1st April 2001 and the end of July 2013 has been examined for a study on the impact of extreme weather and climate on LAS operations [1,2]. As part of this study a number of very significant asthma peaks have been identified - which may also be related to thunderstorm activity in London. The average daily number of asthma incidents across London is close to 24 (about 3% of Cat A calls). On the following dates, associated with thunderstorm activity recorded at Hampstead in London [3], the following number of asthma incidents were recorded:

    06/08/2002 100 cases (22% of Cat A incidents) 17/06/2003 63 cases (14% of Cat A incidents) 24/06/2005 136 cases (30% of Cat A incidents) 25/06/2005 149 cases (33% of Cat A incidents) 13/06/2006 89 cases (20% of Cat A incidents) 16/06/2009 112 cases (25% of Cat A incidents) 23/07/2013 34 cases ( 8% of Cat A incidents)

    Further analysis of the thunderstorm locations and timings are currently being examined and it will be interesting to see if these peaks are linked to other factors such as pollen/fungal spore levels.

    [1]Thornes JE (2013) The Impact of Extreme Weather and Climate Change on Ambulance Incidents and Response Times in London: Pilot Report for the London Ambulance Service. [2] Thornes JE (2013) Predicting Demand through Climate Data, Ambulance Today, 4 (10), 39-42 [3]http://www.weather-uk.com/hampstead/data.htm

    Conflict of Interest:

    None declared

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  10. PALM: A fringe benefit for a wider group of patients

    It is a pity that the Royal College of Anaesthetists felt unable to support the recent Faculty of Prehospital Care consensus statement on pharmacologically-assisted laryngeal mask insertion (PALM) [1]. PALM was only ever intended to be used as an emergency rescue technique in patients with a lowered level of consciousness (GCS <8-9 or AVPU P or U) AND an SpO2 reading of 92%-or-less. This despite best efforts to reverse hypoxaemia using basic airway techniques (opening the airway, suctioning, insertion on an OPA/NPAs/both, application of hi-flow O2 therapy using a NRBM or BVM, decompression of a tension pneumothorax, etc.) [2].

    When basic methods intended to improve oxygenation fail and the patient will not tolerate insertion of a supraglottic airway device (SAD), the only two choices open to practitioners below Level 3 status is to undertake an emergency cricothyrotomy, or to wait until the patient becomes so obtunded by virtue of increasing hypoxaemia and hypercarbia that they ultimately submit to SAD insertion. The former is not an option for most UK paramedics who are not adequately trained or equipped to perform a surgical cricothyrotomy (many are not even issued with scalpels), and I maintain that the latter is not in the patient's best interest.

    It is suggested in the consensus statement that PALM will only rarely be necessary in the prehospital environment. While this may be so, insertion of a SAD is a standard strategy on the airway ladder for failed RSIs within UK hospitals. Under these circumstances, anaesthetists are effectively undertaking a PALM procedure to rescue the airway. No anaesthetist working in the hospital environment would perform a surgical cricothyrotomy for a 'cannot-intubate/cannot-ventilate' (CICV) situation before first considering a SAD insertion, so it is difficult to understand why they are unable to support PALM in the prehospital environment too.

    It has been suggested that there should be an official register to record all PALM cases undertaken in prehospital care. I would like to suggest that all failed intubations within UK hospitals where a SAD has been used to rescue the airway are also shown in a linked parallel register. Only then will we know how frequently a PALM-type technique is used in this country to rescue a critical airway situation, and what are the outcomes in such cases. It would be interesting to know if the Royal College of Anaesthetists would be prepared to cooperate on this matter.

    [1] Moss R, Porter K, Greaves I (on behalf of the consensus group, Faculty of Pre-Hospital Care). Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J 2013;30:1073-1075 doi:10.1136/emermed-2013-203215

    [2] Mason AM. Prehospital use of the intubating laryngeal mask airway in patients with severe polytrauma: a case series. Case Reports in Medicine 2009; doi:10.1155/2009/938531

    Conflict of Interest:

    Since 1999, AMM has helped to develop and refine the PALM technique and also delivered the keynote presentation at the PALM Consensus Meeting held at BHI (Bromsgrove) on 13/04/12.

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