Displaying 207-231 letters out of 763 published
Assessment and risk stratification of patients with acute chest pain
We read with interest Manini et al’s 1 recent paper suggesting ischaemia-modified albumin assays could assist in decreasing the rate of inappropriate discharges from the ED, and that further studies into diagnostic tools for use in chest pain are warranted.
We conducted an audit at Ealing Hospital that also supports the need for developing new diagnostic algorithms for chest pain. Medical histories of 147 patients admitted to the Emergency Department’s Chest Pain Unit for monitoring were studied. All patients gave a history consistent with chest pain of cardiac origin. We studied whether positive troponin-T results correlated with the presence of Framlingham cardiovascular risk factors, or with a past medical history of cardiac or vascular disease (i.e. a history of angina, coronary artery bypass grafting, previous MI, stroke, TIA, heart failure, previous angiography or history of claudication).
In our patient group the percentage of positive troponin results did not increase in line with the number of Framlingham risk factors present, however these patients were highly likely to receive further in-patient investigation. Conversely, while past medical history of cardiac or vascular disease did not appear to have a bearing on the emergency physician’s decision to admit a patient for investigation, those patients with 1-3 conditions appeared to form the majority of patients with positive troponin results (this group made up 55.9% of patients with positive troponin results, but only contributed 36.9% of those with negative troponins).
This data supports a number of other studies on this topic 2,3, and we believe that physicians should consider treating chest pain patients with significant cardiovascular history with a higher index of suspicion that is currently the case. We also believe that further research into the use of past medical history in the assessment and risk stratification of acute chest pain is required.
- Manini AF, Ilgen J, Noble VE et al.. Derivation and validation of a sensitive IMA cutpoint to predict cardiac events in patients with chest pain. Emerg Med J 2009;26:791-796.
- Body R, McDowell G, Carley S et al.. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation 2008;79:41-5.
- Cakir B, Blue K. How to Improve the Management of Chest Pain: Hospitalists and Use of Prediction Rules. South Med J 2007;100:242-7.
This case appears to be describing the Pellegrini-Stieda syndrome/lesion. This is, in fact, a well-known and fairly common finding, generally felt to reflect a post-traumatic ectopic ossification, either acute or chronic. MR is a useful test, as the signal void from the calcification can be seen in relation to the MCL. It may also uncover bone bruising from an associated avulsion fracture (the so-called Stieda fracture). As an academic exercise, MR can also subclassify the lesion into 4 different types, dependent on the exact pattern of ossification (although this has limited, if any, clinical importance).
Reference: Mendes et al. Skeletal Radiology (2006) 35(12):916-22.
Importance of log roll and careful spine evaluation
Dear Editor, I understand that it is very important to log roll and carefully evaluate the whole spine of the patient. By reading this article, I understand the importance of complete spinal evaluation but there are situations in which spinal injuries are missed as a result of incomplete evaluation or not adhering to systematic approach. I want to share one of the clinical cases in the management of which I was involved. A patient presented with hypotension, abdominal distension, bradycardia and unconsciouness in A&E after being involved in a high speed motor vehicle crash. The patient was taken for emergency laparotomy which proved negative. Despite that patient remained hypotensive and cervical spine x-rays were obtained which revealed atlanto-occipital dislocation. The patient died 2 days later but the lesson is to firmly adhere to A,B,C,D and E protocol of ATLS and don’t cut short corners. Unnecessary operations can be avoided and those who are unlikely to survive symptomatic treatment can be decided from the point of presentation.
Primum, non nocere.
I was disturbed to read the article by Body and Foex  advocating the embrace of Utilitarian values in medicine. I hope it was merely a misuse of words. All penguins are birds, but not all birds are penguins. Utilitarianism is a form of consequentialism, but not all ethical thinking that considers the consequences of one’s actions is Utilitarian. The authors of the article correctly make a clear case for efficiency and risk -benefit “consequential” thinking in medicine, and in particular in decision analysis. However, this is not Utilitarianism.
Utilitarianism is an ethical theory in which the “right” action is that which maximises the aggregate “good” outcome across a population. The “good” can variously be defined as pleasure, or preference satisfaction, or as in this article, health benefit. There are practical problems with the theory which are common to any consequential thinking: the difficulties of making predictions and calculating relative risk-benefits for people with different perceptions of what is good for them. However, the big problem with utilitarianism itself is that it justifies any action, so long as there is an aggregate net increase in what is considered good. Plagiarism, falsified research data, dishonest job applications, unfair discrimination - could all in some situations be justified. And so could bribery, theft, or murder. Of course, doctors would never be involved in inhuman human experiments, forced sterilisations, “eugenic” murder, or torture for the “greater good”… but they would, and they were, and it didn’t stop with Nazi Germany or Tuskegee. And why should it, if you accept Utilitarianism? Why not kill an unwilling patient in order to harvest his healthy organs to save five others who would otherwise die?
If we seek to do net good in medicine, the command to “do no harm” is a helpful warning against the evil of imposing a centrally defined, collective “good”, on vulnerable individuals. As such, it is good that Hippocrates is said to have made it a priority. Bentham might have considered rights to be “nonsense upon stilts”, but it is because consequence-based ethical thinking is so inherently dangerous, that we need human rights, and aphorisms such as “first, do no harm”.
No-one outside the extreme wing of the health-and –safety lobby would suggest that “do no harm” means that one must never perform an action that might be painful. Foex and Body are setting up a “straw man” by using examples such as venous cannulation to argue against the importance of non -maleficence. Patients consent to undergo discomfort or risk in order to achieve a later benefit: this expresses their right to choose for themselves (autonomy), and is a balance of good and harm (beneficence and non-maleficence). If the patient cannot consent, then we have to weigh up very carefully what is in the patient’s best interests (risk-benefit) – not primarily the interests of the State.
Utilitarianism can impose deliberate involuntary harm on an individual for others’ benefit. By reminding ourselves of the importance of autonomy and doing no harm, we would remember that the good we seek is that of the patient we are treating, that the harm that may ensue is accidental, and the risks agreed by the one facing them.
Consequence-based reasoning and good medicine are of course “inescapably intertwined”. But for goodness’ sake, do not call this “Utilitarianism”.
Sincerely, Giles N Cattermole.
Body R, Foex B. On the philosophy of diagnosis: is doing more good than harm better than “primum non nocere”? Emerg Med J 2009;26:238-40.
 Bentham J. Anarchical fallacies. In Bowring J (editor): The Works of Jeremy Bentham (Vol 2). Edinburgh, Wm Tait. 1843, p501. Viewed 26 May 2009. http://books.google.co.uk.
Propofol is not safe for sedation for hip relocation
University Department of Anaesthetics Level 2, University Block Glasgow Royal Infirmary 10 Alexandra Parade Glasgow G31 2ER
19 February 2009
We read with interest the clinically based study, on the use of propofol to sedate patients for relocation of hip prostheses in the emergency department. The authors rightly point out that there are problems with the safety and efficacy of using midazolam, and conclude that the described technique is both effective and safe. In another paper by the same authors they demonstrate this technique of “sedation” has a better success than midazolam, reduces the delay in these patients going to theatre, and therefore the patients discomfort (although there is no mention of pain scores of these patients). However we disagree strongly with the conclusions that adverse effects were acceptably uncommon, and argue that the authors have not demonstrated the safety of this technique.
First, we would like to comment on the sedation protocol. Disappointingly there is no attempt to describe the depth of sedation provided. The report of the Academy of Royal Colleges on Safe Sedation Practice states clearly that “verbal contact with the patient is maintained throughout the period of sedation”. To us, 1mg.kg-1 of propofol in this age group is a dose close to that required for induction of anaesthesia , and without documentation of the maintenance of verbal contact it cannot be termed sedation. By your own admission, many of the patients in this study were, in fact, anaesthetised. The Academy of Royal Colleges document (to which the Faculty of Accident and Emergency Medicine were party) again is quite clear that “provision of sedation deeper than this (verbal contact)… is bordering on anaesthesia. As such, this depth of sedation must be supervised by those with the same level of training and skills necessary to provide general anaesthesia”. Given that many of these patients may have been anaesthetised, we have several concerns regarding this protocol pertaining to training, monitoring, and fasting:
Training: the staff responsible for this procedure had only undergone one hour of in-house training. The Royal College of Anaesthetists mandate to its own trainees that they should undergo an initial assessment of competency before being allowed to give any anaesthetic not directly supervised. This assessment is usually after a full three months. Monitoring: the level of monitoring recommended for patients undergoing general anaesthesia should include capnography. Fasting: we find it incredible that in emergency patients suffering pain (and consequently at higher risk of pulmonary aspiration) that you stated that fasting guidelines were used “as a guide and not a rule”. Evidence on the necessity of fasting for elective procedures are clear after almost 40 years of evidence. Guidelines are less clear for emergency cases as normal fasting times may be insufficient, necessitating protection of the patients’ airway.
More worryingly we refute the interpretation of these data as evidencing safety. It would have been useful to present the incidence of adverse events with confidence intervals (CI). This allows one to estimate the true population incidence of a rare event, which could be as much as the upper level of the 95% CI. We have taken the liberty of doing this for you: 8% (95% CI 2.6 to 13.4) of patients suffered arterial oxygen desaturation, 4% (95%CI 0.2-8) required bag-valve-mask ventilation and 4% (95%CI 0.2 to 2.8) required vasopressors. Therefore your actual population rate may be anywhere between 2.6% and 13.4%. This rate of airway/respiratory events equates to 80/1000 (but could be anywhere between 26 and 134/1000 patients). This compares very unfavourably with those of other non anaesthetic groups (Australian GPs) of 4.1 (95%CI 3.3 to 4.9) /1000 and even less favourably with anaesthetists of 2.6 (95%CI 1.6 to 4.2) /1000. 9 Our department has trained non-medical sedationists to provide true conscious sedation for a different painful procedure (oocyte retrieval for assisted conception), and have audited experience of 3000 patients with an adverse incidence rate of 0.3 (95%CI -0.3 to +0.9) /1000patients. In this context your described results cannot be remotely construed as demonstrating safety. We would also point out that a sample size of thousands not hundreds would be necessary to convince us of the safety of this non-standard technique.
In conclusion we are not surprised that the hip relocation rate is higher with your technique as you have compared propofol anaesthesia with midazolam sedation. We can entirely understand the desire to reduce delays for your patients waiting in pain for hip relocation in theatre. However, our answer to the title of your article “Is propofol a safe and effective sedative for relocating hip protheses?” is a resounding no. It is our interpretation that this technique has not been demonstrated as safe, and would be difficult to justify in the event of a permanent serious complication.
Dr A Puxty, Dr M Sim, Dr KJ Anderson, Professor J Kinsella
References 1. Mathieu N, Jones L, Harris A, et al. Is propofol a safe and effective sedative for relocating hip prostheses? Emerg Med J 2009;26:37–38. 2. Gagg J, Jones L, Shingler G, et al. Door to relocation time for dislocated hip prosthesis: multicentre comparison of emergency department procedural sedation versus theatre-based general anaesthesia. Emerg Med J 2009;26:39–40. 3. UK Academy of Medical Royal Colleges and their Faculties. Implementing and ensuring Safe Sedation Practise for healthcare procedures in adults. Report of an Intercollegiate working party chaired by the Royal College of Anaesthetists. November 2001. http://www.rcoa.ac.uk/docs/safesedationpractice.pdf 4. Dundee JW, Robinson FP, McCollum JSC, Patterson CC. Sensitivity to propofol in the elderly. Anaesthesia 1986;41:482 – 485. 5. http://www.rcoa.ac.uk/docs/CCTptii.pdf 6. http://www.aagbi.org/publications/guidelines/docs/standardsofmonitoring07.pdf 7. Practice guidelines for preoperative fasting and the use of pharmacological agents for the prevention of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology 1999; 90; 896-905. 8. Eypasch E, Lefering R,Kum CK, Troidl H. Education and debate. Probability of adverse events that have not yet occurred: a statistical reminder. BMJ 1995;311:619-620 9. Clarke AC, Chiragakis l, HillmanLC, Kaye GL. Sedation for endoscopy: the safe use of propofol by general practitioner sedationists. Med J of Aust 2002;176:158-61 10. Craig DC, Wildsmith JA. Conscious sedation for dentistry: an update. Br Dent J 2007; 203(11): 629-31
ToPDoG is in progress
I commend the work of Geelhoed and MacDonald in their sentinel dose- finding studies regarding the minimum effective dose of dexamethasone for croup, it does seem to suggest a 'ceiling' effect. This work has been recently followed by a descriptive paper (accepted for publication, not yet published) outlining the experience over 27 years at their institution, clearly demonstrating the real-world effectiveness of the lower dose (0.15mg/kg), which became local policy more than two decades ago. Unfortunately, every Systematic Review by the Cochrane Collaboration has found the numbers of patients enrolled in the initial RCTs of Geelhoed and MacDonald too small to rigorously prove the efficacy of the lower dose of dexamethasone in croup. It is with this background that we have recently started recruiting subjects for a large RCT, the ToPDoG Study: Trial of Prednisolone / Dexamethasone oral Glucocorticoid. This trial aims to settle the question of dexamethasone dose (0.6 vs 0.15mg/kg), and compare the efficacy of prednisolone (1mg/kg)in a three-armed equivalence study. Details can be found at: http://www.anzctr.org.au/trial_view.aspx?ID=83722
Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Geelhoed GC, Macdonald WB. Pediatr Pulmonol. 1995 Dec;20(6):362-8. PMID: 8649915
Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. Geelhoed GC. Ann Emerg Med. 1996 Dec;28(6):621-6. PMID: 8953950
Glucocorticoids for croup. Russell K, Wiebe N, Saenz A, Ausejo SM, Johnson D, Hartling L, Klassen TP. Cochrane Database Syst Rev. 2004;(1):CD001955. Review. PMID: 14973975
Basic Life Support should be kept basic.
Although the definition of Basic Life Support (BLS) does vary between sources, it is probably best regarded as, "a level of medical care that can be used to treat patients with life-threatening illness or injury without the use of any advanced or invasive medical procedures or intravenous access". It should be possible for any rescuer in any situation to render BLS simply by using hands and lungs, although simple improvised items (such as a handkerchief plus necktie or tights to apply local pressure to a bleeding wound) should also be allowed. Some would extend the list of permitted adjuncts to include a face shield/pocket mask or even an oropharyngeal airway. However, to stretch the concept of BLS to include the use of a bag-valve-mask device (BVMD), laryngeal mask airway (LMA) or laryngeal tube (LT) probably strays too far into the realms of advanced life support. If this is the case, then the title of the paper by Dixon et al. was inaccurately worded.
In reality, the BVMD is probably one of the trickiest items to use correctly in prehospital care, and some would say its use requires two persons – one to hold the mask securely against the patient’s face and the other to squeeze the bag. Certainly, to ventilate the lungs correctly with a BVMD without inflating the stomach requires considerable skill.
The authors failed to state which versions of the selected supraglottic airway devices (SADs) were used in the trial. The Laryngeal Tube is available with both a single lumen (LT & LT-D) and dual lumens (LTSII & LTS-D), the dual-lumen versions featuring a gastric drainage channel in addition to the airway tube. With its distal balloon inflated within the manikin’s upper oesophagus, it is hardly surprising that the authors found a low incidence of gastric insufflation with the LT, particularly if the device also featured a gastric drainage channel opening beyond the distal balloon. Also, the authors failed to state which type of LMA was used by way of comparison. If this was a basic LMA (e.g., the LMA Classic, LMA Unique, Ambu LM or Softseal LM) then a direct comparison with any LT device was probably unfair with respect to the rates of gastric insufflation. It would have been better to have compared the LT with either the LMA Proseal or the disposable LMA Supreme or i-Gel airways - all of which have gastric drainage channels like the LT-D. It should also be noted that the correct sizing of a supraglottic airway device is particularly important when attempting to ventilate manikins, and the same size of airway does not always provide the optimum fit with a particular manikin across the entire range of SADs from different manufacturers. An ill-fitting basic LMA will never be a match for a correctly-sized LT on any of its performance characteristics.
Bearing in mind all these points, the authors’ conclusions need to be viewed with a degree of caution.
REFERENCE: 1. Dixon M, Carmody N, O’Donnell C. The effectiveness of supraglottic airway devices in prehospital Basic Life Support airway management. Emerg Med J 2009; 26: 4.
A response from the International Academies of Emergency DispatchIn response to this article it is important to highlight that this system is not used by any ambulance services or EMS systems in the UK or the world - it is over 8 years old and has been replaced multiple times. Also, a later version of the system has demonstrated a sensitivity of 83% for Emergency Medical Dispatchers using MPDS stroke protocol (http://www.prioritydispatch.co.uk/uk/San_Diego_Accuracy_of_Stroke.pdf). A response by the International Academies of Emergency Dispatch to this EMJ article can be viewed at http://www.prioritydispatch.co.uk/uk/documents/StrokeStudyAMPDS.pdf
Whilst we feel that Lindford et al(1)’s work has many admirable points, we also feel it important to point out minor areas about the study which detract from its overall impact.
Whilst details of the subgroups in the sample size of 50 assessors is given, unfortunately there is no similar breakdown in the information about their answer regarding size of burn requiring resuscitation in adults and children, about the fluid used, or about the identity of the Parkland Formula. As burns nurses are not routinely involved in the prescription of fluid for burns resuscitation their inclusion as part of the sample group is questionable.
In the calculations of the correct value of resuscitation fluid, no information is given about who was incorrect in their calculations. Whilst it is stated that 72% correctly assessed the size of the burn we do not know if the 28% who did not were excluded from the assessment of correct fluid resuscitation values.
A separate chart is given for use in children under the weight of 36kg, including maintenance fluids, this does not specify a proportion to be given as Dextrose Saline, which would constitute a deviation from the normal Parkland formula. Whether this would result in clinically significant hypoglycaemia is debatable(2), but concerns have been raised in the management of infants undergoing fluid resuscitation for septic shock(3). It may be possible to include this weight-related value within the chart in each weight based row.
The chart makes it easy to select the correct amount of resuscitation fluid to infuse per hour if the patient proceeds directly from injury to Emergency Department with no pause, this is often not the case. Delay in commencement of resuscitation and inadequate initial management may result in a deficit which needs to be calculated and the infusion rate adjusted compared to the value derived from the table, as the authors acknowledge. This is an area where information technology in the form of a web based application hosted on the burns centre website would be ideal.
T.H. McKinnell, MB ChB, MSc, MRCS (Ed)*$
A. Hartley, MB BS, BSc$
K. Allison MB ChB, MD, FRCS (Plast)$
*Royal Victoria Infirmary, Newcastle $James Cook University Hospital, Middlesbrough
1 Lindford AJ, Lim P, Klass B, Mackey S, Dheansa BS, Gilbert PM (2009) Resuscitation tables: a useful tool in calculating pre-burns unit fluid requirements Emerg Med J;26:245-249
2 Murat I and Dubois MC (2008) Perioperative fluid therapy in pediatrics. Pediatric Anesthesia 18: 363–370
3 Parker, MM; Hazelzet, JA; Carcillo, JA (2004) Pediatric considerations. Crit Care Med; 32[Suppl.]:S591–S594)
More questions than answers
One major shortcoming of this comparison of monophasic and biphasic defibrillators for the treatment of out-of-hospital cardiac arrest, which was not fully addressed by the authors, concerns the fact that the defibrillators used were programmed to analyse and deliver up to three stacked shocks in accordance with the AHA guidelines of 2000. Guidelines 2005 revolutionised the treatment of VF cardiac arrest by emphasising the importance of the application of early chest compressions with minimal interruption to these compressions, together with the delivery of an initial single shock instead of stacked shocks. Guidelines 2005 also advised that the energy level for the initial shock from a monophasic defibrillator should be raised to 360 Joules, as opposed to the 200/300/360-Joule pattern used in the study.
Consequently, this study probably poses more questions than it answers. For example, there is no way of knowing if the use of the currently recommended higher energy level for the initial shock from a monophasic defibrillator might have elevated the first-time success rate for monophasic defibrillation in the study to that (or, for that matter, above that) demonstrated by the biphasic units. Therefore, it may be premature to scrap all monophasic defibrillators based on the findings of this study, although it may have driven one more nail into their communal coffin.
CONFLICT OF INTEREST STATEMENT: This author still carries his trusty manual monophasic defibrillator with its integral cardiac pacing facility, and has been reluctant to ditch it until there is clear evidence of the superiority of biphasic AEDs.
MCL calcification not described?
Is this not "Pelligrini-Stieda" disease?
It is correct priority, not diagnosis, that matters at telephone triage
I found the article by Deakin et al interesting but have to feel that the article seems to dwell on whether the Advanced Medical Priority Dispatch system (AMPDS) correctly identifies stroke when the emphasis should have been on whether it can correctly prioritise patients to a catagory A or B who are later found to have suffered a stroke.
The authors themselves identify the fact that ambulance prioritisation is more important for the patient than the actual categorisation made by the AMPDS software. Certainly any system that relies upon information supplied by a lay person cannot expect to make a "diagnosis" of stroke in all cases. If the patient has collapsed and is unconcious use of the appropriate AMPDS algorithm for this is more appropriate in ensuring that the correct response is sent. Based on this the underprioritisation of only 2.9% is not entirely unacceptable and further review could be done to look for any triggers in these calls to indicate a higher likelihood of stroke.
Given that the DH has acute stroke response time set at Catagory B (19 minutes) these patients are getting an appropriate priority of response 97.1% of the time which is the most important thing.
It would be interesting to know how many of these cases were diagnosed as a stroke by the ambulance staff on their arrival and subsequently handed over at the ED.
CT Urography: Clarification
We read with great interest the excellent article in the September 2008 issue of the journal by Ulahannan et al entitled “Benefits of CT Urography in patients presenting to the emergency department with suspected ureteric colic”. They employed a test designated a “non-contrast CT Urogram” and concluded that CT is the preferred test of choice for patients over 40 with suspected ureteric colic. We understand the authors aim, methods and fully agree with the conclusion. However we feel the title and nomenclature are incorrect and potentially misleading to practitioners.
Advanced 3D CT can now offer a number of distinct studies of the urinary tract with specific protocols which are designed around various clinical questions (e.g. Routine CT, Urinary Stone CT, Renal CT Angiography (CTA), Dynamic Renal Mass CT and CT Urography (CTU). Much has been written in the literature regarding CTU[2, 3], and there is more than one way to perform this test. There is however one common theme: in a CT Urogram, contrast material must be administered to demonstrate the urothelium-lined tract.
The CT Urography working group of the European Society of Urogenital Radiologists has recently provided very comprehensive and most welcome guidelines on CT Urography. They define a CTU as “a diagnostic examination optimized for imaging the kidney, ureters and bladder. The examination involves the use of multidetector CT with thin-slice imaging, intravenous administration of a contrast medium and imaging in the excretory phase”. ‘Direct’ CTU is performed by administering contrast through nephrostomy, urostomy or bladder catheter. Urinary stone CT performed for detection of renal, ureteric or bladder stones is a non- contrast study and should not be referred to as “non-contrast CT Urography”, as the authors repeatedly do in their article. Most institutions do not give intravenous contrast routinely to patients for investigation of acute ureteric colic.
CT Urography is reserved for those patients in whom it is important to define the urothelial tract with contrast (e.g. investigation of hematuria, urothelial neoplasms, differentiating parapelvic cysts and assessment of ileal diversion). In summary, CT performed for the evaluation of urolithiasis in the setting of acute renal colic is a renal or urinary stone CT and is not a CT Urogram. Labelling it as a CT Urogram is a patient safety issue under current guidelines. If a contrast-enhanced scan is performed instead of a urinary stone CT it is a reportable event as it involves a misadministration of a drug, radiation exposure for the wrong test and a possible needless IV access. While we welcome this paper, we also feel that nomenclature is important for all readers and hope this clarifies any confusion.
References: 1. Ulahannan D, Blakeley CJ, Jeyadevan N, Hashemi K. Benefits of CT urography in patients presenting to the emergency department with suspected ureteric colic. Emerg Med J, 2008. 25(9): p. 569-71. 2. McNicholas MM, Raptopoulos VD, Schwartz RK, Sheiman RG, Zormpala A, Prassopoulos PK et al., Excretory phase CT urography for opacification of the urinary collecting system. AJR Am J Roentgenol, 1998. 170(5): p. 1261-7. 3. Kawashima A, Vrtiska TJ, LeRoy AJ, Hartman RP, McCollough CH, King BF Jr. CT urography. Radiographics, 2004. 24 Suppl 1: p. S35-54; discussion S55-8. 4. Nolte-Ernsting C, Cowan N. Understanding multislice CT urography techniques: Many roads lead to Rome. Eur Radiol, 2006. 16(12): p. 2670-86. 5. Van Der Molen AJ, Cowan NC, Mueller-Lisse UG, Nolte-Ernsting CC, Takahashi S, Cohan RH. CT urography: definition, indications and techniques. A guideline for clinical practice. Eur Radiol, 2008. 18(1): p. 4-17.
A low GCS does not equate to a compromised airway reflex
Sibbald and colleagues raise the important point that sedation often verges on the edge of general anaesthesia during emergency department sedation in response to Vardy et al’s audit of ED sedation practice(1,2). They do, however, make the false assumption that a GCS of 8 or less is equivalent to the loss of airway reflexes.
Moulton et al(3,4), in two papers describing the relationship between the GCS and gag and cough reflexes in the same institution as Vardy’s study, showed that even in conscious patients with a GCS>8 who had been given narcotics, the gag reflex was suppressed in 64% compared to 8% of similar head injury patients. Even patients who had a GCS of 14 or 15 and were exposed to ‘tranquilisers’ (not defined) had an impaired gag reflex. Airway reflexes should be reassessed independently of the GCS as the GCS alone is unable to indicate a loss of airway reflexes.
The significance of present airway reflexes may be an indication of a reduced risk of aspiration, although even that is not completely assured(3). Duncan et al showed that even in poisoned patients with a decreased GCS, endotracheal intubation was not necessarily required(5).
The definition of coma as a GCS of 8 or less does not include any reference to airway reflexes. The assumption that comatose patients require intubation after head injury is not unreasonable, but this practice has often been uncritically extended to other conditions such as poisoning, in addition to head injured patients. It may be that we should be considering intubation for patients with a GCS of 12 or less, in specific situations such as poisoning, or avoiding it is other specific patient populations with impaired consciousness.
Much more basic research is needed to unravel the complex relationships between GCS, airway reflexes and the subsequent incidence of aspiration and intubation.
Dexter Y S Chan
Colin A Graham
Accident & Emergency Medicine Academic Unit Chinese University of Hong Kong Trauma & Emergency Centre, Prince of Wales Hospital Shatin, New Territories, Hong Kong
1. Sibbald NM, Jackson MJ, Howie A. How deep is your sedation? Emerg Med J 2009;26:389
2. Vardy JM, Dignon N, Mukherjee N, Sami Dm, Balachandran G, Taylor S. Audit of the safety and effectiveness of ketamine for procedural sedation in the emergency department. Emerg Med J 2008;25:579-582
3. Moulton C, Pennycook A, Makover R. Relation between Glasgow coma scale and the gag reflex. BMJ 1991;303:1240-1241
4. Moulton C, Pennycook AG. Relation between Glasgow coma score and cough reflex. Lancet 1994;343(8908):1261-2.
5. Duncan R, Thakore S. Decreased Glasgow coma scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009 Mar 7 [Epub ahead of print].
How will your Junior Doctors react?
Four years on from 7/7 I believe the issue of major incident awareness has still not been properly addressed. Wong in 2006 highlighted the inadequacy of Registrar awareness with their major incident contingency plan and their role. This year I set out to establish Junior Doctor’s (FY1 + FY2) awareness at Wrexham Maelor Hospital using a similar questionnaire.
Greater than 90% of Junior Doctors did not know what would be expected of them during a major incident.
No Junior Doctor knew what to do if bleeped about a major incident. No medical or surgical Junior Doctor would attend to their ward first, 13% of FY1’s and 38% of FY2’s would report to A+E. Switchboard would receive calls from 17% of FY1’s and 6% of FY2’s, and A+E 13%, 19% respectfully.
12.5% of FY1’s believed their role would be triage. 17%, 25% of ward FY1’s, FY2’s believed they would be working in A+E.
Of all the Junior Doctors, only 12% of surgical FY1’s and 25% of medical FY2’s would attend to existing patients, only 25% of the surgical FY2’s would shortlist patients for discharge.
These findings, 2 years on from Wong’s report still show a dangerous lack of awareness by doctors on major incidents. Not only did our Junior Doctors not know what to do, their choices on the day would be highly detrimental. However, after organised teaching, all Junior Doctors knew who to ring, where to go and what to do during a major incident.
It could seem ‘it’ll never happen to us’ is the line that keeps major incident training off the induction programme. Can we afford this innocence? Staff unaware of their roles and responsibilities will turn a major incident into a major disaster.
It’s good, but is it utilitarian? A response to Body and Foëx
Body and Foëx are to be congratulated on their thoughtful analysis of the philosophy of diagnosis in emergency medicine(1). They raise some issues which would bear further examination.
The philosophy of truth
As Body and Foëx point out, our continued use of “gnosis” in diagnosis implies an ongoing assumption of an inherent knowledge and a positivist paradigm briefly expressed as “reality exists”. Their discussion of the post-positivist paradigm quite justifiably highlights the flaws of applying this to medical practice; any “reality” is interpreted by the subjectivity of observers. However, even post- positivism has its limitations; it still relies on the premise that reality exists, merely that human imperfections render it effectively undetectable; therefore we continue to hunt for the “square ROC curve”. The multitude of scientific papers presenting sensitivities, specificities, confidence intervals and all the other components of our statistical arsenal all take as a given that a “true” population mean, or a “gold standard” diagnosis is in fact there to be identified or made if only we as physicians could make our trial or our test good enough.
Outside the medicoscientific sphere, however, such post-positivism does not necessarily hold sway. As Huxley recognised: “It is the customary fate of new truths to begin as heresies and to end as superstitions”(2). Medical historians and sociologists have repeatedly adopted a paradigm wherein “illness” and “disease” are constructs of the society in which they occur; as Brown argues “illness” and the diagnosis of such represents an interaction between societal acceptance of condition and the biomedical definition of the same. This includes the medicalisation of normality (for example relabelling PMT as late luteal phase dysphoric disorder), and the social acceptance of medically non-accepted conditions (Gulf War syndrome)(3). Revisionist historians equally identify phases of interaction between symptomatology, political and social institutions and disease labelling(4). It is not therefore a given that an absolute reality in fact exists.
If we accept that “truth” may at times be subjective, equally so must be an acceptable level of inaccuracy; can we as physicians reasonably decide what is an acceptable risk (whether of diagnostic error, potential harm, or of a disease itself)? The use of decision analysis in evaluation of diagnostic tests assumes a known (or identifiable) cost or utility for each option; while this may be tenable on a population basis (certainly to a post-positivist for whom the population will provide the requisite confidence intervals), it is not intuitively applicable to each patient.
The philosophy of virtue
We are of course familiar with classical utilitarianism of the Benthamite variety: “the greatest happiness for the greatest number” in our emergency departments, in the form of the triage nurse. In no way can it be of personal benefit to the patient with paper cut to wait 3 hours but there is a clear population health benefit if the patient having an acute MI is seen immediately.
I remain unconvinced that classical utilitarianism reflects acceptable practice in diagnosis. The application of a test to a population (in the manner of national screening programmes) is utilitarian, trading off the negative aspects of an imperfect test (in terms of false positives, anxiety and unnecessary further investigation) against the benefits of early disease detection. It does not, however, translate well to individual patient diagnostics. We recognise that treatment decisions must be individualised, even where decision analysis demonstrates a clear benefit of one particular option on a population basis; why else do we insist on informed consent for surgery or thrombolysis? Some diagnostics are already individualised; pre-test counselling is mandated in clinical genetics and for HIV testing; what is so different about the diagnostics we use in emergency medicine, other than the timescale?
I would argue that good practice diagnostics would be more consistent with reasonable consequentialism, whereby an action is considered to be morally right if it has the best reasonably foreseeable consequences. Thus siting an intravenous cannula, although inconsistent with primum non nocere, can be the morally right action if by doing so the patient can receive life-saving or health-enhancing therapy. Equally, performing a contrast CT brain to identify the underlying lesion in a patient with spontaneous intracranial haemorrhage would be considered morally appropriate (assuming that the patient consents if able) even if the patient then had a fatal anaphylactic reaction to the contrast medium (unless, of course, their previous allergy was known to the physician!).
Clearly we are all aware that we work in a resource-constrained environment and that a degree of utilitarianism is inevitable and in fact justified; however it should not be used to justify the neglect of individualised clinical reasoning in the management of each patient. I would hope, as Body and Foëx have suggested, that by a closer analysis of our philosophical paradigms we can, as they say, “move towards enhanced understanding”.
1. Body R, Foex B. On the philosophy of diagnosis: is doing more good than harm better than ‘‘primum non nocere’’? Emergency Medicine Journal 2009;26:238-40.
2. Huxley T. The coming of age of the Origin of Species. Science and Culture and Other Essays. London: Methuen, 1881.
3. Brown P. Naming and framing: the social construction of diagnosis and illness. Journal of Health and Social Behavior 1995;35(Extra):34-52.
4. Jordanova L. The Social Construction of Medical Knowledge. Social History of Medicine 1995;8:361-81.
Saving the AAAs- a Battle that can be won
I fully endorse this notion and conclusion by the authors that we need to suspect and diagnose this pathology very early "when the patient is stable”, since diagnosing a ruptured AAA in an unstable patient usually, means that we have lost the battle already. Suspecting and diagnosing early and "then rushing for theaters" is the only way forward for saving all these lives and I strongly feel that we will save many lives. Those who have worked in an Emergency Department (ED) for long enough are well aware of the usual course of events for the elderly patient presenting to the ED with back or flank pain, sometimes with a history of renal stones/colic decades ago. And it all stops there with the patient getting labeled as renal colic-that is until the patient crashes and then the reality dawns to everyone, albeit too late. As the authors already have concluded (also supported by other previous studies) that once decompensation occurs there is a high mortality. For myself I can say that I feel it is my “duty” to at least suspect and consider the possibility of a AAA in most elderly patients presenting with appropriate clinical scenario. In the Emergency Department where I am working, we have electronic records. There is a column titled "worst possible diagnosis" in differential diagnosis list. Obviously for a flank/backache, one of the most serious diagnoses is AAA. This is one way of training and sensitizing people to this ominous entity. There will be many others and it is up to medical community to do everything to prevent mortalities where possible.
The other approach proposed by the authors is to "get ahead of the disease" by initiating population based screening for the susceptible population. This can be effectively implemented in countries where there is good primary healthcare infrastructure. Once the ball gets rolling, patients presenting to EDs will themselves alert all the ED staff that they have a AAA (Hopefully the ED staff will continue to retain the capacity to suspect this condition where patients may have slipped through the safety net of screening). This study has essentially reiterated what is already known but in the current scenario that this diagnosis is often missed with a fatal outcome, it is a good reminder that the medical profession needs to do more in this regard.
With reference to your article I want your comments on the following idea - Keeping in mind that time is muscle, recommendations to have chewable asprin in Pocket's of people with IHD at all times (who have no contraindications to asprin) - Pharmaceutical companies to design a pack with two tablets resistant to weather conditions and easy to keep in pocket - may be giving the name "pocket asprin" people might understand the extreme importance of taking the tablets on priorty on having symptoms and this might be very helpful in third world countries where urgent care is not avaliable.
aggregated versus raw Hes data
I was delighted to read the Hughes article, and while I agree that the published aggregated data is of little overall interest I would like to highlight the fact that clinicians can obtain the raw local data, which although it can be a tortuous complex procedure, can be of great use.
I managed over ten years ago to work with the HES team to develop a large A&E anonymised raw Hes dataset which I have used, and still do, to teach basic data analysis techniques in a number of Academic Health Informatics courses (Edinburgh university and the RCSed), ranging in level from CPD/post graduate diploma to MSc. The teaching material and SPSS dataset are freely available at: http://www.fhi.rcsed.ac.uk/rbeaumont/virtualclassroom/hes/index.html.
The students, who are usually medics, have always been extremely excited by the data and have frequently make very pertinent suggestions for its more regular clinical use in fact some years ago a ‘clinicians hes desktop’ project was conceived which unfortunately seems to have mysteriously disappeared.
Thank you once again for highlighting what I consider, if used appropriately, to be a hidden treasure. Robin Beaumont
Unexplored issues relating to body stuffers
Dr Meng Aw-Yong 468 Fulham Palace Road London SW6 6Hy 11th May 2009
Letter in response to Booker RJ, Smith JE Rodger M. Packers, pushers and stuffers- managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. EMJ Vol 26 No 5 May 2009. Pages 316-320
The article in EMJ May 2009 on packers, pushers and stuffers by Booker et al is an invaluable and timely one especially for those involved with this particular group of patients. I must outline my conflict of interest as I am a Forensic Medical Examiner (FME) in the Metropolitan police and have examined a high caseload, probably close to 15,000 over the years. I am also in the unique position to be working as a Staff Grade in EM in the main receiving hospital for the drug packers flying in via Heathrow.
There are several issues, which I would like to clarify and expand upon. These are the minimal reference to body stuffers, the consequences of an investigation by the Independent Police Complaints Commission (IPCC) and Coroner’s inquest arising from of any custodial death and the ethics of discharging a patient with the potential risk of sudden death. In the medical jurisprudence environment drug pushers are referred to as “stuffers”. The maximum sentence for possession with intent to supply class A drugs is life imprisonment and an unlimited fine. Henceforth many body packers or stuffers are likely to refuse to divulge any incriminatory evidence, refuse treatment and/or admission. Furthermore they face severe punishment or death from the drug dealers should they fail to deliver the goods. On the issue of conservative management of body packers, I will quote from a series of presentations at the Royal Society of Medicine in 2008 on body packer and stuffers. Mr Mohsen, consultant surgeon, presented the results of a review of 2508 suspected body packers, in a period between January 2000 and January 2005, presenting to Hillingdon Hospital. The patients were from the HM Revenue and Custom detention Unit (HMRC) at Heathrow. Those with a negative abdominal x-rays were returned to Customs in Heathrow and only symptomatic body packers (61) were kept as inpatients. Abdominal pain was the commonest presenting complaint with 4 presenting with symptoms of cocaine toxicity. There was an 8% failure rate in conservative management with 0.3% rate of surgical intervention similar to that reported in previous studies.
We are unable to detain patients with capacity in hospital against their wishes but the ethical dilemma is whether we should allow patients to go home or return under arrest to a customs facility with no medical backup, where there may be considerable risk to their health. If admitted in hospital, they may be disruptive to the daily workings, as they require 24-hour one to one supervision, as many will swallow any emerging drugs to eliminate the evidence and the security risk posed from the dealers. Customs officials tend not to like the inconvenience and loss of officers on hospital guard.
Police officers and FMEs fear a death in custody. Any death in custody quite rightly is rigorously examined and will ensure the closure of a custody site, the banning of police officers from any contact with the public, the possible involvement of the doctor in negligence claims, dismissal from work or a GMC referral. The costs alone are estimated at about £1 million per case.
Drugs stuffers refer to those who swallow illicit drugs to evidence while on the verge of being arrested. This is a much more serious situation as it is unplanned with often inadequate packaging. Doses can be significantly higher than what the stuffer normally takes, together with poly-drug overdose and the unknown effect of adulterants. This is a regular occurrence presenting to FMEs and subsequently ED. Although Booker refers to scant evidence of deaths from drugs stuffers, a review of the Deaths in Custody data reveals 12 deaths from drugs in 1999 with 4 alone from airway obstruction. Havis et al found 43 drug related deaths in police custody (England and Wales) between 1997-2002. Of those 16 cases involved internal drug concealment, 8 were witnessed swallowing/concealing drugs and 5-showed airway obstruction. The Good Practice Guidelines for FMEs in the Metropolitan Police stipulate that if “A prisoner who has or is suspected of having swallowed drugs, must be treated as having taken an overdose and an ambulance should be called”. . The caveat to the ED doctor is when the police bring a “stuffer” to hospital soon after arrest. The stuffer will usually deny swallowing any drugs for the reasons outlined above. And there may little or no signs of drug intoxication. However several hours later as the wrapping becomes unwrapped or is dissolved by stomach acid dissolves there may be a sudden rush of drugs to the body potentially resulting in death. Furthermore as these cases are medicolegal in nature accurate and copious documentation is essential. Therefore the discretionary factor in Booker’s advice is that stuffers should be asymptomatic with a minimum 6 hours FROM the time of ingestion irrespective of any denial of drug swallowing. What if the detainee refuses to stay wishing to expedite the criminal process and be released? If discharged we merely displace the risk and responsibility to the hapless Custody Sergeant and FME who face serious risk? Although there is strong evidence supporting the conservative management of body packers there still remains the questions of sending them home or to custody with little or no medical facilities. I suggest that police authorities and the HMRC collaborate and built special units attached to ED thereby providing continuous and immediate medical care should the need arise. There also remains an opportunity for researching the safe parameters for stuffers and developing guidelines for Emergency Departments.
Sentencing Guidelines. http://www.sentencing-guidelines .gov.uk/guidelines/other/courtappeal/default.asp? T=Cases&catID=6&subject=POSSESSION%20WITH%20INTENT%20TO%20SUPPL Y
Shamir OC, Williams EW, Evans NR and Johnson P. Occupational hazard: Treating cocaine body packers in Caribbean countries International Journal of Drug Policy. Vol 20, Issue 4, July 2009, P 377-380. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VJX- 4THB4C8- 1&_user=10&_coverDate=07%2F31%2F2009&_alid=915345136&_rdoc=1&_f mt=high&_orig=search&_cdi=6106&_sort=d&_docanchor=&view=c&_ct=301 &_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=05b793 3fbd7fd30cda8309a1a9fdc1d4
Goertemoeller H and Behrman A. The Risky Business of Body Packers and Body Stuffers.. Journal of Emergency Nursing. Vol 32, Issue 6, Dec 2006, P 541-544 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJ5- 4MD8SYX-P&_user=5932406&_origUdi=B8CY1-4RSHRC2- 4&_fmt=high&_coverDate=12%2F31%2F2006&_rdoc=1& Concealment of drugs by police detainees: lessons learned from adverse incidents and from routine clinical practice. S Havis, D Best and J Carter. JCFM Vol 12 No 5 p237-241
Is the surgeon be consealed with the dianogsis?
I am impressed with your article, because in our country, the major part of surgeons still believe analgesics would mask the physical findings and delay the time of accurate diagnosis.
In your article, I have a question that patients were examined by surgeons not involved in their care while they were waiting for operation. I wondered if the surgeons had already known the diagnosis of patients or if they were concealed? The other question is that if the patients before being scheduled to receive operation had any analgesic or not.
I will be glad to know and that will help me do my job well.
Thank you very much!!
Rapid Ultrasound for Shock/Hypotension (RUSH)
We greatly enjoyed reading the ACES ultrasound protocol by Atkinson et al. to evaluate patients with hypotension of unknown etiology. We have been using a similar protocol for a few years with the addition of pneumothorax windows to examine for spontaneous or iatrogenic pneumothorax as the cause for shock.
We call our protocol the RUSH exam, an acronym for Rapid Ultrasound for Shock/Hypotension. We find this title acts as a mnemonic tie-in with the FAST exam for trauma. When teaching our protocol, we use the acronym HI-MAP to remember the steps of the exam. (Heart, IVC, Morison’s/abdominal views, Aorta, Pneumothorax). This also describes the sequencing of the examination. While we believe ACES is aces, we submit that adoption may be quicker with RUSH.
1. Atkinson PRT, McAuley DJ, et al. Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg. Med. J. 2009;26;87-91.
2. Weingart SD, Duque D, Nelson B. Rapid Ultrasound for Shock/Hypotension. EMCrit.org. [http://emcrit.org/ultrasound/The%20RUSH%20Examfinal.htm]. accessed 3/5/2009 2141.
The Supreme Court stated in Graham v. Conner "The test of reasonableness under the 4th Amendment is not capable of precise definition or mechanical application." That means it is very difficult to judge a use of force (a better term being response to resistance) without knowing all the information known to the officer at the time the force was used. While your study may indicate a number of injuries resulting from contacts with police officers, I do not see how you can represent these injuries as being the result of excessive force when you had no information to judge whether the force used was justified or not.
It would be no different than taking a survey of patients asking them if they felt the doctor treating them overcharged them or not. While each patient may indeed have an opinion, that opinion would be of little value without some objective facts upon which to evaluate the question.
I fail to see the benefit to anyone of publishing this study.
Good Work: Take the Next Step
Thank you for your effort. The most important revelation is that there are no requirements to report obvious abuse, and there is no data collected. Most claims of abuse by police are not objectively investigated by the police themselves, few ever reach a criminal prosecution, and the only realistic "investigation" and prosecution of excessive force and gratitutious violence is by private lawyers in civil cases. This, unfortunately, is the only open window into the well oiled system of concealment of incidents of escessive force by U.S. police.
Re: Not Cas, not A&E but Emergency Medicine
John Ryan raises an interesting question from an editorial point of view. Like him I suspect that I refer to my own department as an emergency department, and see myself as an emergency physician. I am a proud member of the College of Emergency Medicine and despite familial protestations refuse to watch historically named BBC dramas on principles of nomenclature.
Hau on the other hand uses the terms terms 'Accident and Emergency', and indeed 'Casualty'. As the handling editor for that issue of the journal I must accept the criticism for allowing it to pass. In the past I have challenged such historical terms as a reviewer and as an editor. However, on this occasion I did not as the authors are referring to their own department and arguably have a right to refer to their own department in any way they choose.
Simon Carley Associate Editor EMJ
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