Displaying 1-10 letters out of 757 published
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:
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.
Conflict of Interest:
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:
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.
Emergency medicine: the job we're all waiting for?
Much has been written about the current difficulties of recruiting and retaining doctors in key specialities: most recently psychiatry (1) and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of doctors choosing to enter speciality training immediately upon finishing their FY2 year: in 2013 only 64% of FY2's chose to enter speciality training (3). Instead, many FY2's opt to work abroad, or to take trust grade positions.
Currently, going "off-program" allows junior doctors the flexibility to develop their own skills and interests, in a way that rigidly structured training programs don't. It gives them a chance to take ownership of their own training, and to see their personal and professional development as their own responsibility, rather than an exercise in "hoop-jumping". They have a chance to work abroad, pursue additional qualifications or research, and to choose where they live and how many hours they work. They can choose to work in specialities that they didn't get to experience during the foundation program.
As a "sessional" speciality which requires a broad portfolio of skills, and doesn't require continuity of care, emergency medicine could capitalise on juniors doctors' apparent desire to have greater flexibility and freedom in their training: trainees could be offered "half-time" contracts, which would leave them 6 months a year free to pursue other interests, degrees, or specialities.
Similarly, a more permissive approach to offering sabbaticals, and a greater variety of less-than-full-time-training rotas would offer FY2's the best of both worlds: the flexibility associated with trust-grade work, and the support and development opportunities afforded by training jobs. Emergency departments would benefit from having committed doctors on full- time contracts, who would be guaranteed to return the following year to continue training.
Svirko et al identified that one of the key factors repelling trainees from emergency medicine is the perceived lack of a "work-life- balance" (2): emergency departments can improve this by offering a wider variety of training contracts, to suit the different lifestyles and interests of the diverse group of doctors who are drawn to the emergency department.
(1) Mukherjee, Psychiatric Bulletin (2013) 37: 210-214 (2) Svirko, Lambert et al Emerg. Med. J. 2014 31:556-561 (3) Foundation Programme Annual Report http://www.foundationprogramme.nhs.uk/pages/home/keydocs
Conflict of Interest:
Clinical Examination in place of end-tidal CO2
Hunter and colleagues gives a good method to distinguish COPD and heart failure in a dyspnoeic patient. May i politely suggest an easier, clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent, bulging veins has COPD as the predominant cause for the breathlessness compared to the patient with heart failure who has collapsed, thready veins. The therapy can be directed accordingly and early benefits achieved using this clinical marker of distinction. Of course, this venous distension could reflect higher CO2 levels in the COPD patients. As a junior doctor, i found it much easier to cannulate these patients in emergency department compared to the congestive heart failure patients where cannulation was much more difficult.
So, the quick clue for the acute on chronic breathless patient is bulging veins = worsening COPD, thready veins = worsening heart failure
Conflict of Interest:
Re: Clinical navigation for beginners: the clinical utility and safety of the Paramedic PathfinderWe applaud Newton et al in their efforts developing the Paramedic Pathfinder tools. We feel that supporting paramedics in decision making regarding non-conveyance and use of alternative referral pathways is vital in meeting the challenges facing modern pre-hospital care, and appreciate their efforts in empowering pre-hospital staff to safely make decisions regarding such patients. However we remained unconvinced that protocolising the decision making process alone will improve the ability of pre-hospital clinicians to make the best use available resources to provide optimal clinical outcomes.
Protocolising referral decisions is not a new concept. Snooks et al investigated a protocolised approach to patients being diverted to a minor injury unit over the emergency department, and discovered no increase in the number of patients referred to an alternative point of care. Conversley, Mason et al and Gray and Walker identified that paramedics when given extended training in assessment, treatment and diagnostic skills were able to safely reduce attendance at the emergency department, while Clesham et al showed that ambulance staff are able to correctly identify most patients that could be diverted away from the emergency department, without the need for a strict protocolised approach, if sufficient governance is in place to support them in making these decisions.
We commend the safe approach taken by the authors in retrospectively applying the tool to patients seen by North West Ambulance Service staff. However we are concerned that this may not be generalisable to ambulance staff in other areas of the country. Recent performance data demonstrated that as of April 2014 NWAS were the poorest performing Trust in the country for emergency department conveyance and calls closed via telephone triage. We would like to see the Pathfinder tools retrospectively applied to patients seen by pre-hospital clinicians in other areas of the country before stating that they categorically reduce hospital admissions, as the effect of the tools may be weakened - or even detrimental - when applied to Trusts performing stronger against these metrics. Additionally, where the patient had not been conveyed or referred to another agency, there was no follow up in the study to determine if this was a safe and appropriate thing to do. It would seem vital to ensure that the patients that the tool recommends for non-conveyance were not discharged in error.
In attempting to be easily applied by all front-line staff, the tools also fail to account for the grade of clinician making the clinical decision. As already stated, improved training allows paramedics to avoid ED admissions more often[3-5], so it would be important to establish if this triage tool performs equally well for each grade of clinician. One would presume that the sensitivity and specificity of a clinician making the same decision without the tool should increase as their clinical grade becomes more senior, but this increased experience and knowledge risks being over-ridden by the use of a rigid protocol unless some flexibility is built in. Additionally, the tool makes use of the Pre-Hospital Early Warning Score (PHEWS) to filter out patients at risk. As with similar track-and-trigger protocols, this fails to consider patients with baseline "abnormal" physiology, nor does it allow for normal paediatric physiology, despite Paramedic Pathfinder being recommended for use in anyone over the age of five. Strictly applying PHEWS further reduces the clinician's autonomy in deciding what they feel is best for their patient.
Although we welcome the efforts of Newton et al in developing a tool to assist paramedics in making such clinical decisions, we are concerned that the Paramedic Pathfinder tool risks reducing highly trained and experienced pre-hospital professionals to a flowchart, with no scope to take account of a patient's holistic needs or wishes. When providing increased training and skills to front-line staff has been shown to just as effectively reduce ED attendance safely, this paper provides no compelling evidence that increased reliance on rigid and inflexible protocols instead will achieve a better outcome for patients. We feel that Paramedic Pathfinder will become a useful tool in providing clinicians with a safety net when making decisions regarding use of alternative referral pathways, especially when used by less qualified pre-hospital practitioners, but this can only be achieved in concert with improved training and increased clinical autonomy for pre-hospital practitioners, and the tool needs to be validated in a national setting before widespread implementation can be supported.
James Goulding, Paramedic, Yorkshire Ambulance Service NHS Trust.
Dr Nick Plummer, Academic foundation doctor, Lancashire Teaching Hospitals NHS Foundation Trust.
 Newton, M., Tunn, E., Moses, I., et al. 2013. Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder. Emerg Med J Published Online First: 7 October 2013.
 Snooks, H., Foster, T., et al. 2004. Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews. Emerg Med J , 21(1), 105-111
 Mason, S., Knowles, E., et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. Brit Med J, 335(7626), 919.
 Gray, J. T. and Walker, A. (2008). Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire. Emerg Med J , 25(3), 168-171.
 Clesham K, Mason S, Gray J et al. 2008. Can emergency medical service staff predict the disposition of patients they are transporting? Emerg Med J 25(10): 691-4
 AACE (2014) Measuring Patient Outcomes: Clinical Quality Indicators [online at: http://aace.org.uk/national-performance/ accessed 19/06/2014]
Conflict of Interest:
Access to a helipad and the impact to the hospital
We read with interest the article written by Freshwater et. al. (1) 'Extending access to specialist services: the impact of an onsite helipad and analysis of the first 100 flights' and were very impressed with the findings and at the outset we would like to congratulate the authors on this innovative analysis. This paper demonstrates the great impact retrievals and transfers can have on the referred hospital, however we provide some constructive criticism on the article below.
Although this article is a first in investigating the success of a new helipad at the University Hospital Southampton (UHS), we feel that the authors have overlooked more updated and recent data on the number of missions flown annually in the UK. The Association of Air Ambulances' website, under the document '2013 Framework for A High Performing Air Ambulance(2)', states that 19 charity air ambulances flew approximately 25500 missions in 2012. This is considerably more than the 19,000 stated within the article. Following this, additional numbers of charities have been established, thus we feel that the total figures until the time this article was published will be far greater. This updated information would have only strengthened the findings of this study.
On a similar note, regarding 'blue-light' times vs normal speed drive times, a more recent article by McKeekin et. al. (3) states that whilst the software used is appropriate to estimate 'blue-light' times from normal speed drive times (as stated by the authors in the article), more importantly there needs to be adjustments made in the software to account for population density, traffic and other factors involved. This again is more recent evidence than that quoted by the authors in this paper (4) (5).
Due to the nature of this type of study, the results are quite subjective because it is human decision whether to send the patient via air to the hospital. That human is not always the same and changes per shift, and therefore there may be some times where patients were sent to UHS or alternative sites when others would not have made that decision. This can alter the results, and therefore for future studies, it is important to address this issue to ensure results are as accurate as possible. We appreciate that the sample size was small because the service was new, however we would suggest that in future, the data would be more accurate if a larger sample size is analysed over a greater period, by comparing with other trauma centres which have helipads. Also it is important to compare results internationally to better understand the findings in a national and international context. Finally, a discussion into the implications on the staff, resources and wards of the hospital since the introduction of the helipad would be equally important.
Once again, we commend the authors on a brilliant piece of work, and look forward to reading further articles exploring into this topic further.
1. Freshwater ES, Dickinson P, Crouch R, Deakin CD, Eynon CA. Extending access to specialist services: the impact of an onsite helipad and analysis of the first 100 flights. Emergency Medicine Journal. 2014;31:121-5.
2. Association of Air Ambulances. Framework for A High Performing Air Ambulance. 2013:9. Available from: http://www.associationofairambulances.co.uk/resources/events/AOAA- Framework%202013-OCT13-%20Final%20Document.pdf [Accessed on 13.04.2014]
3. McMeekin P, Gray J, Ford GA, Duckett J, Price CI. A comparison of actual versus predicted emergency ambulance journey times using generic Geographic Information System software. 2013;0:1-5.
4. Lerner EB, Billittier AS. Delay in ED arrival resulting from a remote helipad at a trauma center. Air Med J. 2000;19(4):134-6.
5. Hunt RC, Brown LH, Cabinum ES, Whitley TW, Prasad NH, Owens CF, Jr., et al. Is ambulance transport time with lights and siren faster than that without? Ann Emerg Med. 1995;25(4):507-11.
Conflict of Interest:
Don't ignore the ASA grade.
We welcome our Edinburgh colleagues' further contribution1 to the emergency medicine literature regarding procedural sedation for relocating hip prostheses. Their work raises a number of points worthy of debate.
The number of patients in their study is unlikely to accurately determine a relationship between ASA grade and complication rates. This is particularly so for (meaningful) sentinel adverse events and outcomes since we have demonstrated that these are rare2, occurring in only about 1% of patients sedated with propofol. The notion that ASA grade has no influence on complication rate defies logic. Since the Edinburgh paper was submitted, a consensus working party adverse event reporting tool has been published3 allowing meaningful comparison of data between studies. Dawson and colleagues' work would be more helpful if re-analysed using these parameters, rather than (undefined) apnoea (as opposed to apnoea >60s) and desaturation <90% at any time (as opposed to <75% at any time or <90% for >60s).
The successful relocation rate of 78% is poor and likely reflects the limited use of propofol in their study - 87 of 204 patients (30%). Our work has previously demonstrated success rates of about 95% with this agent (their references five and six). It is our opinion that a deep level of sedation is required to enable relocation of a joint on which such large muscle groups act. Propofol reliably allows this, as indeed does larger doses of midazolam; it is the short duration of action of the former that is its key advantage. We applaud their cautious approach to the sedation of this elderly patient group. An updated version of our protocol which they quote is available (www.enlightenme.org/); notable features include the use of nasal capnography and an emphasis on a smaller (0.5mg/kg) bolus and top- up for this age group.
1. Dawson N, Dewar A, Gray A, et al. Association between ASA grade and complication rate in patients receiving procedural sedation for relocation of dislocated hip prostheses in a UK emergency department. Emerg Med J 2014;31:207-209 2. Newstead B, Bradburn S, Appelboam A, et al. Propofol for adult procedural sedation in a UK emergency department: Safety profile in 1008 cases. BJA 2013;111(4):651-5 3. Mason K, Green S, Placevoli, et al. Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedations Task Force. BJA 2012;108(1):13-20
Conflict of Interest:
We have published in this clinical arena in this and another journal.
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.
Conflict of Interest:
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