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Recent eLetters

Displaying 1-10 letters out of 803 published

  1. high fentanyl doses - is this an error?

    Dear authors,

    In your intersting RCT of propofol versus midazolam sedation, you describe giving a fentanyl dose of 3mcg/kg, in conjunction with a titrated dose of propofol or midazolam.

    This appears a pretty large dose, compared to the procedural sedation literature, where the usual dose is 1 mcg/kg (min-max 0.5-2.0).[1-2]

    From previous research with propofol and midazolam in the Emergency Department, adverse event rate is between 4 and 30%, and around 11% in a 1711 patient cohort.[3] If your fentanyl dose of 3 mcg/kg is indeed correct, I'm curious how you succeeded to have no patients with a respiratory depression.

    kind regards,

    dr. Gael Smits, Emergency Physician

    1. Hohl CM, Sadatsafavi M, Nosyk B, et al. Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review. Acad Emerg Med 2008;15:1-8. doi:10.1111/j.1553-2712.2007.00022.x

    2. Kuypers MI, Mencl F, Verhagen MF, et al. Safety and efficacy of procedural sedation with propofol in a country with a young emergency medicine training program. Eur J Emerg Med 2011;18:162-7. doi:10.1097/MEJ.0b013e32834230fb

    3. Smits GJ, Kuypers MI, Mignot LA, et al. Procedural sedation in the emergency department by Dutch emergency physicians: a prospective multicentre observational study of 1711 adults. 2016;:1-6. doi:10.1136/emermed

    Conflict of Interest:

    None declared

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  2. A timely health warning.

    We thank the authors Challen and Roland for their review (1) which highlights a very important issue faced daily in our Emergency Departments.

    The use of, and more importantly, reliance on the Early Warning Score (EWS) carries risk as up to 1:3 patients admitted to ICU from ED will not score highly on the EWS (2). Clinician opinion may prove a superior assessment tool; this is not adequately explored. Experienced nurse and medical clinicians may be well tuned to using clinical judgement alongside EWS, however more junior staff may be led into a false sense of security by low scores and ignore their own gestalt.

    We conducted a pilot study in our Emergency Department (ED) a few years ago (3) which compared the use of the MEWS (Modified Early Warning Score) with the results of a point of care blood gas analysed as EWS for deviation from normal. What we found was that the blood gas score was independently able to predict imminent organ failure and death (OR 1.35, 95% CI 1.13-1.62, P=0.001, and OR 1.74, 95% CI 1.13-2.69, P=0.01, respectively), proving superior to MEWS which failed to do so in multivariate analysis.

    Identifying critical illness is a core skill for Emergency Medicine. Simple physiological scoring is widely supported despite a lack of data from Emergency Departments. The role of these scores in identifying patients safe for discharge also requires further study. Practical scoring systems, perhaps including a point of care metabolic panel, should be developed and validated for use in the ED.

    1. Challen K, Roland D. Early warning scores: a health warning. Emerg Med J. 2016.

    2. Subbe CP, Slater A, Menon D, Gemmell L. Validation of physiological scoring systems in the accident and emergency department. Emerg Med J2006;23:841-845

    3. Jafar AJ, Junghans C, Kwok CS, Hymers C, Monk KJ, Gold E, et al. Do physiological scoring and a novel point of care metabolic screen predict 48-h outcome in admissions from the emergency department resuscitation area? Eur J Emerg Med. 2016;23(2):130-6.

    Conflict of Interest:

    None declared

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  3. The Golden Rule

    Dr. Basu et al. make an interesting observation: if you kick the dog, eventually he will bite the mailman. How is it we think we can treat the workers without compassion or empathy while expecting them to treat the patients with these same virtues, ones we don't practice?

    This article and an ever-expanding body of literature make it clear: we must treat our staff in the same way we expect them to treat patients.

    Conflict of Interest:

    None declared

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  4. The Critical Role of Medical Scribe Training

    Walker et al. report the first economic analysis of the cost of training medical scribes (1). The concept of the medical scribe has been around for at least 4 decades (2), but with the recent advent of the electronic medical record (EMR), especially in the US, there has been a rapid increase in the use of scribes, particularly in emergency departments (3). The ongoing exponential growth in the use of scribes has been referred to as the "great scribe experiment" (4). Currently 1 in 5 practices with an EMR uses scribes (4). The data so far suggests that scribes increase physician productivity and revenue as well as both patient and physician satisfaction (3,5).

    Two approaches to training medical scribes have been described: teaching existing medical personal to perform scribing duties, or bringing on new personnel entirely devoted to scribing. The medical scribe field, as well as Walker et al., are now moving towards the later method, which generally attracts students and recent college graduates looking to obtain medical knowledge and experience before moving on to additional training in the medical field, such as medical or physician assistant school. While the later method has its advantages, it leads to frequent turnover and thus the need for near-continuous training of new scribes, which is why is it critical to evaluate the scribe training process. Walker et al. have made an important contribution in describing the start up cost of a scribe program, but the costs of maintaining an ongoing program are equally, if not more, important.

    In order to bring in medical scribes, hospitals or medical groups generally take one of two approaches. They either contract with existing outside scribe companies (ie. ScribeAmerica, PhysAssist, etc.), or they build an in-house scribe program from the ground up, similar to the process reported by Walker et al. The former approach may be more expedient and even cost effective in the short term, however it is unclear whether it would be as beneficial in the long term and is not an option for every practice or department, particularly those in rural areas. Despite the start-up costs, the later approach is arguably preferable as it allows for more flexibility and customization of the scribes' duties to fit the needs of the practice or department. Further research should be directed towards understanding the costs of maintaining an existing, mature 'homegrown' scribe program as compared to the costs of a contract with an existing major scribe company. This would not only provide direction for practices looking to bring on medical scribes, but also inform their decision on whether to train their own scribes or outsource the training to a major existing company.

    References: 1. Walker KJ, Dunlop W, Liew D, et al. An economic evaluation of the costs of training a medical scribe to work in Emergency Medicine. Emergency Medicine Journal 2016; 0: 1-5 2. Lynch TS. An Emergency Department Scribe System. Journal of the American College of Emergency Physicians 1974; 3: 302-3 3. Gellert GA, Ramirez R, Webster SL. The Rise of the Medical Scribe Industry: Implications for the Advancement of Electronic Health Records. JAMA 2015; 3: 1315-6 4. Schiff GD, Zucker L. Medical Scribes: Salvation for Primary Care or Workaround for Poor EMR Usability? Journal of General Internal Medicine. 2016; 31: 979-81 5. Bastani A, Shaqiri B, Palomba K, et al. An ED scribe program is able to improve throughput time and patient satisfaction. American Journal of Emergency Medicine. 2014; 32: 399-402

    Conflict of Interest:

    None declared

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  5. Accurate diagnostic strategies for PE

    The reported algorithm for diagnosis and exclusion of PE using Wells score < 2 plus negative d-dimer to indicate the patient does not require further imaging is a validated pathway. However, d-dimer specificity is low resulting in large numbers of patients who are low-risk for PE still requiring CTPA or a ventilation-perfusion scan. The aim of recent diagnostic studies, including this study reported by Theunissen JMG et al, is to use alternative diagnostic strategies to reduce the number of patients requiring further imaging. This would reduce harm secondary to contrast enhanced CT scanning (with a 10% false positive rate); anticoagulation (especially for sub-segmental PE for which there remains considerable doubt about the necessity for treatment); and ED and radiology department crowding.

    PERC is an assessment of a threshold of pre-test probability for PE below which testing for and/or treating the disease results in greater potential harm than benefit. This threshold is set at approximately 2%. PERC has only been validated in a population of patients with a low pre- test probability as determined by clinical gestalt. This retrospective cohort study has shown that the use of PERC outside its validated indications even as a sequential investigation with the Wells score results in 2 outcomes - 1 potential and 1 certain

    1.Specificity and sensitivity may be reduced compared to the standard algorithm though the sample size is too small to draw significant conclusions 2.Rates of diagnostic imaging will rise significantly. 79% of patients with a Wells score <2 had a PERC >0 which would have required 203 extra imaging procedures in 377 patients. This would almost certainly increase the immediate adverse event rate defined as secondary outcomes in the paper in addition to the unquantified risk of increased radiation exposure.

    Use of clinical gestalt, PERC score of 0, Wells score <2 and a negative d-dimer in a sequential manner to reduce the pre-test probability to below the threshold for mandatory imaging would seem to be the way forward in ensuring accurate diagnosis without the risks of overtreatment and imaging. We suggest this diagnostic strategy should be urgently evaluated.

    Conflict of Interest:

    None declared

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  6. Re:Letter to the Editor

    Dear Editor,

    We agree with our colleagues at Erasmus Medical Centre that physician actions motivated by pure self-interest are antithetical to a physicians' responsibility to their patient. Fortunately, we have never encountered such a Machiavellian physician in our practices. It was perhaps na?ve on our part to assume all readers would approach our research with the foundational belief that physicians are both empathetic and primarily motivated to demonstrate empathy effectively for the patient's benefit. The empathetic statements used in our research are communication tools physicians may use to communicate better with their patients. Importantly, while our colleagues equate sympathy with empathy, they are not the same. Empathy is defined as a cognitive attribute (as opposed to affective) that involves an understanding of the inner experiences and perspectives of the patient combined with a capability to communicate this understanding to the patient. In short, since empathy is a cognitive attribute, we do not believe it can be faked. Our call for learning additional tools to better communicate is an important one. The choice to use thoughts of litigation as a measure of effectively demonstrating empathy was deliberately made to allow prima facie conclusions. Litigation is linked to flawed communication and a valuable relationship to measure. We believe it highly unlikely readers would argue study participants who had more thoughts of litigation consider their study physicians more empathetic than those with fewer thoughts of litigation. In addition to decreased thoughts of litigation, subjects were more likely to regard the physicians' discharge instructions as understandable, regard the physician as an expert, believe the physician cared about them, and want the physician as their doctor. We reject any suggestion that a communication tool that benefits both patient and physician should be immediately suspect. Empathetic physicians should consistently analyze their communication skillset and adopt methods shown to be beneficial.

    Conflict of Interest:

    None declared

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  7. Letter to the Editor

    Dear Editor, With amazement we have read the article of our colleagues from Loma Linda University Medical Center, recently published in your journal. This article is a call to use short empathic statements in our daily medical practice (on the Emergency Department), as this will reduce the thoughts of patients regarding litigation. Although we encourage the use of empathy in daily practice, we fiercely object to the call of this article, as we consider this kind of behavior to be utterly immoral. According to the philosopher Immanuel Kant it is not the end or purpose that gives an act moral worth, but it is the motive. If empathy is used as a way to reduce the risk of being sued instead of showing sympathy, this action lacks moral worth. We are concerned that if patients realize that our empathic behavior has the main purpose of preventing lawsuits, it could undermine the trust and respect of patients in medical care. Finally we were flabbergasted by the recommendation that "clinicians must judge for themselves whether the 0.29-point improvement we found on our 5-point thoughts of litigation scale (..) might justify demonstrating empathy to their patient encounters." It is a sad medical world if we have to justify showing empathy with numbers regarding litigation.

    Conflict of Interest:

    None declared

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  8. Response to Obstacle Course runs: Review of Qcquired injries and illnessas at a series of Canadian events (RACE)

    As authors of a previous report about serious injuries that occurred during an extreme sports obstacle course in the U.S. (1), we read with interest the article by Alana Hawley, etal describing injury and illness outcomes in a series of Canadian obstacle course events. (2) In this Canadian study a small percentage of participants presented to onsite medial services; the majority of complaints were minor and musculoskeletal in nature. Only 2% of those treated were transferred to hospital through EMS which is consistent with other types of mass gathering events. This is in sharp contrast to our report in which over 100 EMS (advanced life support calls) were activated on a single race. Social media drives continued interest in these outcomes, and as authors, we were surprised by the robust response of interest by a variety of media outlets in our 2014 manuscript. Particularly as these events become more popular internationally, we just ask participants and readers to exercise caution before they are left with the impression that these events are safe. Other than the identified limitations that the Dr Hawley and her study team expresses, it should be noted that they studied ONLY Mud Hero obstacle courses. According to the Mud Hero frequently asked questions, (3) the obstacles in these races have both hard and easy options and they do not expose their participants to barbed wire, ice baths, or electric shocks. The electrical shock injuries were the most severe type (myocarditis, cerebrovascular accident) that we reported in our study. Ideally those in the medical profession preparing for an event in their area would determine the type of obstacles that will be used in the race, and organize the appropriate EMS support. Likewise, participants preparing for obstacle races should recognize the potential for increased personal risk in those that have more dangerous obstacles (such as electrical shocks). (1) Greenberg MR, Kim PH, Duprey RT, etal. Unique obstacle race injuries at an extreme sports event: a case series. Ann Emerg Med. 2014;63:361-6. (2) Hawley A, Mercuri M, Hogg K, Hanel E. Obstacle Course Runs: Review of Acquired injuries and illnesses at a Series of Canadian events (RACE) Emerg Med J (online ahead of print) 9/15/2016 (3) Mud Hero Frequently Asked Questions. http://www.mudhero.com/en/faqs/ Accessed 09/20/2016

    Conflict of Interest:

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  9. In response to the e-letter "An interesting study of the wrong cohort"

    Many thanks for your interest in our study.

    We agree that as a retrospective study that compares head injured patients presenting within and after 24 hours of injury that have undergone CT imaging our study does have limitations. However, there are currently few data to guide clinicians in this area. We found only 2 other retrospective cohort studies and an abstract that assessed such patients in a recently published systematic review {1}. Our study is the first to directly compare patients presenting late after injury with those who don't, to our knowledge, and includes novel findings.

    We agree that it is not possible to estimate the overall prevalence of significant traumatic brain injury in head injury patients presenting after 24 hours of injury from our study. However, our study shows that in patients that undergo CT imaging the prevalence of significant injury is similar in patients presenting within and after 24 hours of injury. The yield from the CT scans performed suggests a similar relation between risk of pathological finding and clinician behaviour, but agree the denominator for those attending late would be needed to confirm this. Our key finding is that absence of NICE guideline indications may not reliably exclude significant injuries in patients presenting after 24 hours of injury.

    We agree with Richard Body (Associate Editor) when he opines that the findings of our study probably call for further research. A prospective study that evaluates all head injured patients presenting late and identifies the risk factors that predict significant injury would inform clinician gestalt. This, in turn, would likely reduce the risk of missing significant injuries in what appears to an important sub-group.

    1. Marincowitz C, Smith CM, Townend W. The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review. Systematic reviews 2015;4(1):165.

    Conflict of Interest:

    We both contributed to the original article.

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  10. An interesting study of the wrong cohort

    I thank the authors for highlighting an ongoing concern I have with NICE head injury guidance - namely that the guidance is based on studies of acute head injuries presenting soon after injury and doesn't take delayed presentations into account. However my concern would be the reverse of their own as I feel if we adhered to NICE guidance in patients presenting after 24 hours we would be performing large numbers of unnecessary investigations for very low yield.

    I cannot help but feel that the entire premise of this paper and conclusions reached are incorrect simply because they look at the wrong cohort.

    The paper examines those patients who underwent a CT of their head and compares between the delayed presentation and early presentation (greater and less than 24 hours respectively) and those that had a NICE indication and those that didn't.

    This is easy data to collect retrospectively and analyse but not the most appropriate.

    What is far more valuable is to know what happened to ALL the patients presenting post head injury - not just those who were selected for a CT. This is far more challenging data to collect due to coding issues, quality of note keeping and the vastly higher number of patients involved.

    Conclusions such as clinicians being aware that 'application of NICE guidance to those presenting >24hrs misses a high proportion of injuries, clinicians appear aware of this and so are more likely to request a CT even though no NICE indication is present' appear invalid. We do not know what proportion of patients with a head injury presented before and after 24 hours we only know those that had a CT performed. The clinicians themselves had already selected a group based upon a combination of NICE guidance and gestalt.

    We can best evaluate the sensitivity and specificity of the NICE guidelines for patients presenting after 24 hours by looking at the unselected head injured patients presenting to the ED. If we evaluate those who a clinician had seen and ordered a CT head on then all we can really comment on is the positive and negative predictive value of the guidelines in the ED clinician selected patient (which one would hope to be an inherently higher disease prevalence group).

    Whilst I agree that there is somewhat of a lacuna in the guidance when it comes to delayed presentations of head injuries, clinical gestalt is key rather than the use of NICE guidance. The data presented does not in my view show a distinct risk profile for those presenting after 24 hours with a head injury (as stated in the conclusions), but instead demonstrates that the negative predictive value of the 2007 NICE Head Injury guidelines in patients at Hull Royal Infirmary who had a CT after presenting >24 hours after head injury to be lower than in those presenting <24 hours after head injury. (7.7% compared with 9.9%).

    Conflict of Interest:

    None declared

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Poll

Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?

Results

0.5% - 43% response rate
3% - 41% response rate
10% - 16% response rate

Related original article: PCT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study