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Recent eLetters

Displaying 1-10 letters out of 781 published

  1. 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:

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  2. 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:

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  3. 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

    Conflict of Interest:

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  4. 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.

    Conflict of Interest:

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  5. 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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  6. 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

    Conflict of Interest:

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  7. 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

    Conflict of Interest:

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  8. 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.

    Conflict of Interest:

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  9. 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

    Conflict of Interest:

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  10. 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.

    Conflict of Interest:

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