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Recent eLetters

Displaying 207-231 letters out of 796 published

  1. Nail polish and pulse oximetry

    To the Editor!

    We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.

    To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized, controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves.

    Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived. Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance.

    To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean values (given in percent) but omit to verify their measurements, e.g. with ABGA.

    Additionally, the presented results also lack standard deviation (SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4]. In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons.

    In conclusion, the present study does not add significant new data for nail polish to the present knowledge.

    References:

    [1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]

    [2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683

    [3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91

    [4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.

    Conflict of Interest:

    None declared

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  2. Is S100-B better then rolling a die?

    Muller et al report that S-100B had a specificity of 12.2% and a sensitivity of 86.4% and conclude that use of serum S-100B as a biomarker for CCT triage may improve patient screening and decrease the number of CCT scans performed. However, if we were to roll a 6-sided die and call the number 6 negative and the numbers 1 to 5 positive we would expect to have a test with similar parameters: 83.3% sensitivity (i.e. positive 5/6 times in those with the disease) and 16.6% specificity (i.e. negative 1/6 times in those without the disease). This illustrates how adopting a low threshold for positivity can produce and apparently high sensitivity at the expense of specificity for an essentially worthless test (like rolling a die). Reporting likelihood ratios overcomes this problem. The likelihood ratios for a positive and negative test based on the estimates of sensitivity and specificity reported by Muller are 0.98 and 1.11 respectively.

    In fact, the performance of S-100B may not be quite as bad as their reported estimates suggest. Based on the data reported in Table 2 the sensitivity is indeed 86.4% (19/22) but the specificity is actually 31.8% (67/211), giving positive and negative likelihood ratios of 1.27 and 0.43 respectively. This is still not much help for decision-making but probably better than rolling a die.

    Conflict of Interest:

    None declared

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  3. Nail polish and pulse oximetry

    To the Editor!

    We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed. To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized, controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves. Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived. Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance. To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean values (given in percent) but omit to verify their measurements, e.g. with ABGA. Additionally, the presented results also lack standard deviation (SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4]. In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons. In conclusion, the present study does not add significant new data for nail polish to the present knowledge.

    References:

    [1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]

    [2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683

    [3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91

    [4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.

    Conflict of Interest:

    None declared

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  4. Response to: Survival after cardiac arrest and severe lactic acidosis (pH 6.61) due to haemorrhage.

    Dear Sirs

    I read, with considerable interest, your case history of a 21 year old man who was stabbed in his buttock and went on to suffer a hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting transfusion and exploration of the wound under general anaesthesia.

    A pH of 6.61 is undeniably low and had he presented at such extremes of physiology to your Emergency Department his outcome would have been worthy of a case report. However, it appears that he presented with no more than cryptogenic shock (Hb 7.1) at worst (though there is no mention of a FAST and IVC assessment being carried out) and one might argue that prompt and aggressive damage control resuscitation with urgent surgery would have avoided a cardiac arrest, rhabdomyolysis, ionotropic support, hospital acquired pneumonia and a prolonged ITU stay.

    Quite why the patient was moved to the emergency unit ward is not clear but you do document that after two hours whilst still awaiting transfusion he arrested and promptly went on to receive a hypothermia inducing 4 litres of gelofusin to compound his already dysfunctional clotting mechanism.

    His age and physiological reserve saved his life - this phenomenon is nothing new.

    I am stunned that in these days of centralisation of trauma services post the damning NCEPOD and NAO reports1 2 as well as the emphasis being placed placed on trauma care nationally, cases such as these still occur in our Emergency Departments. More concerning is that 'our' journal sees fit to publish such horrors that would constitute a SUI in many establishments.

    The case highlights that the human body does have the ability to survive critical physiological insult - it does not mean we should allow our patients to reach these limits if there is no requirement to do so.

    Major HJ Pynn RAMC ST5 Emergency Medicine

    1 Trauma. Who Cares? National Confidential Enquiry into Patient Outcome and Death 2007.

    2 Major Trauma Care in England. National Audit Office. Feb 2010.

    Conflict of Interest:

    None declared

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  5. The good and the harm.

    The principle of 'primum non nocere' stems from the ancient world of Plato. In the 'real' world it is immpossible to act without doing harm. An examination or treatment takes always some time and money from the patient. Taking time and money is the minimum harm that is done. In many cases ther is additional harm.

    Therefore the principle 'doing more good than harm' seems at first sight a better and more realistic principle but unfortunately what is 'more good than harm' cannot be easily defined. Indeed, what is considered as more good than harm differs from individual to individual, from time to time, from society to society.

    A diagnosis is not only a matter of knowing. The more that is known the more correct diagnoses will be made, but for an individual diagnosis it is ultimately a decision based on less or more firm knowledge, not on certainty. Who has the right (or the duty) to decide where uncertainty is the rule? Perhaps it is (partly) dependent on the circumstances. For many it will seem to be the first right of the well informed patient since he/she will suffer from the potential harms or profit from the potential benefits of the treatment. But even if this principle should be generally accepted there is often lack of time in urgent situations to inform the patient or the patient is not in the possibility to understand the information. Moreover the government and/or insurance companies too will influence the decision by less or more or no reimbursement for examinations and treatments.

    Since it can be assumed that diagnoses are more often accurate with increasing knowledge it can perhaps be stated that doing more good than harm can be defined by the duty of making efforts by the individual as well as by the society to increase knowlegde.

    Conflict of Interest:

    None declared

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  6. What Price 90 Seconds; is "Call Connect" a disservice to 999 users?

    Woollard et al reiterate the view that many of us have for some time, there is no evidence that an 8 minute response target is worthwhile in itself, that it should be replaced with more clinically orientated priorities and that it has had unfortunate consequences. It is interesting to reflect that most other health organisations (whether primary or secondary care) have significantly increased both the breadth and depth of the skill mix of clinical staff over recent years and that ambulance trust policies of employing large numbers of emergency care practitioners with three weeks clinical training runs counter to the approach of other parts of the health economy and most importantly makes little or no sense. By design such personnel are not in a position to be able to make an overall clinical assessment and take responsibility for decisions with the consequence that patients in virtually all cases are transported to a hospital emergency department. At a time when the NHS is struggling to meet demand and contain financial pressures and where the solution is to guide patients (where appropriate) to more suitable and cost effective community health services (including general practice), ambulance trusts need to be concentrating on increasing significantly the breadth and depth of clinical decision making (likely to include nursing and medical disciplines) rather than employing personnel with limited training and rushing to "stop the clock".

    As many colleagues have said to me (once they have understood the level of training of an emergency care assistant), if they became unwell, they would prefer to be seen by a health professional who had undergone significant training and who could undertake relevant treatments at 8 minutes and one second than an individual with a very limited skill mix at 7 minutes 59 seconds! Probably just as important is that those who develop policy, is to consider the effects upon the overall health economy as there are large interdependencies between organisations with the risk that there are unexpected and often expensive clinical and financial consequences.

    Conflict of Interest:

    NHS Worcestershire is involved with commissioning ambulance services in the West Midlands. The author responds in a voluntary capacity for West Midlands Ambulance Service

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  7. GP Co-op and ED Dept Colocation

    I thank the authors for an interesting article. The article states that none of the other 13 GP co-ops are located on hospital grounds close to an ED. This is factually incorrect. The North East Doctor on call service has 2 co-located sites on hospital grounds, Cavan and Navan. In the case of the Cavan centre the GPs are located in the hospital building. In Navan, the site is on the hospital grounds. In both cases, unlike DubDoc, the service extends from 6pm to 8am and both day and night at weekends and public holidays.

    Conflict of Interest:

    None declared

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  8. Posterior reversible encephalopathy syndrome

    Moratalla describes a case of posterior reversible encephalopathy syndrome (PRES) in a female patient after delivery.1 We feel concerned about the accuracy of his diagnosis. PRES (also termed reversible posterior leukoencephalopathy syndrome) represents a clinical and radiological disease entity characterized by reversible vasogenic oedema in the brain, which primarily results from autoregulation failure and endothelial dysfunction.2 The reversibility of vasogenic oedema, as most specifically and sensitively detected by diffusion-weighted imaging (DWI), especially ADC map, preferably involving posterior white matter can unambiguously differentiate typical PRES from differential diagnoses including metabolic encephalopathy, inflammatory demyelinating diseases, etc. Although atypical cases are not uncommon,2 they should be diagnosed with caution, after prudential exclusion of other confounding disorders. However, reversibility, not only clinical but radiological, and vasogenic oedema, as revealed by DWI ADC map, as well as well-acknowledged risk factors that may predispose to hypertension, such as phaeochromocytoma, glomerulonephritis, eclampsia and with cytotoxic and immunosuppressant drugs,2 were not confirmed by clinical and neuroimaging findings to categorize this case into a typical PRES. In summary, PRES represents a clinicoradiological syndrome, the diagnosis of which relies on typical clinical manifestations and neuroimaging findings.

    References 1. Moratalla MB. Posterior reversible encephalopathy syndrome. Emerg Med J 2010;27:547. 2. Sharma M, Kupferman JC, Brosgol Y, et al. The effects of hypertension on the paediatric brain: a justifiable concern. Lancet Neurol DOI:10.1016/S1474-4422(10)70167-8

    Conflict of Interest:

    None declared

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  9. prevalence of sudden death in asthma

    The case Dr. Alzetta describes is similar to the ones I described. Although these cases are rare in any one location and undocumented especially after death I believe that taken nationally they are of significant numbers. The evidence lies in a paper written to discover the cause of the dramatic increase in asthma deaths in the sixties by Speizer, Doll et al. They studied all the deaths in England and Wales for six consecutive months using Death Certificates from the Registrar General from 1st Oct. 1966-31st March 1967 in which asthma was the underlying cause. They wrote to the doctors and hospitals concerned for full details of the cases. Most of the cases surprisingly occurred in persons with mild asthma only 59% had ever been admitted to hospital. Death was sudden and unexpected in 80% of cases. In 25% death occurred in less than one hour and only 29% survived more than 24 hrs. That death was commonly sudden is confirmed by the fact that 59% of deaths (109 out of 184) were certified by coroners. In 39% of cases (67 out of 171) the practitioner had not regarded the patient as suffering from severe asthma in the terminal episode. This paper is very important as : 1) it demonstrates the only way that one can collect and study these cases in any number. 2) It is the only record we have of the numbers of deaths due to asthma in that era and the dramatic increase at that time. The reason being that asthma deaths were included with all other types of respiratory diseases until several years late. It is very important that this work is repeated today to discover the prevelance today.

    Conflict of Interest:

    None declared

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  10. Over-bedding or de-bunking

    The paper by Harris and Sharma [1] confirms what many emergency physicians think they know : no beds means no admissions. An automatic plea for more beds needs to be regarded sceptically.

    The authors rightly conclude that "the availability of fully staffed beds is a major determinant of ED overcrowding".

    It is crucial for clinicians as well as planners to realise that availability does not equate simply with numbers. Less could mean more in terms of effect!

    Effective bed capacity is a function of length of patient stay as well as crude bed numbers.

    In turn, length of stay can be a function of three major factors, two active at strategic and the third at operational level.

    At strategic level, the configuration of resources in community settings has an arguable impact on their capacity to 'pull' patients out of in-patient wards. Funders' and planners'distribution of resources and attention , towards elective versus emergency 'activity', is a second strategic factor.

    The operational factor relates to the intensity with which resources downstream from the ED are actually utilised. The 5 day/40 hour pattern of diagnostic sessions, theatre sessions and consultant ward rounds, characteristic of historical UK practice has fitted ill with the 7 day/168 hour pattern of illness.

    The authors' message may be that fewer in-patient beds, more intensively used, could release resources for more effective deployment : in our own Emergency Departments if nowhere else.

    Nicholas Harrop, Consultant in Emergency Medicine, Victoria Hospital, Blackpool, UK.

    Reference

    1 Harris A, Sharma A. "Access Block and Overcrowding in emergency departments: an empirical analysis". Emerg Med J 2010;27:508-511

    Conflict of Interest:

    None declared

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  11. diagnosis of swine flu: wieghting between false positive and false negative

    Editor, I read the recent publication by Mann et al. with a great interest. Mann et al. concluded that " There is a significant risk of harm with false-positive diagnoses and potential delays in appropriate treatment [1]." I agree that there are several problem in diagnosis of swine flu. Several problems can lead to the failure of using any scoring system or algorithm for diagnosis [2-3]. On the other hands, although several new diagnostic tools can be availble, the problem of false positive can be seen. How to manage and weight for risk and benefit on using simple method with possible false negative and new modern tools with possible high cost and false positive should be the topic to be discussed.

    References

    1. Mann C, Wood D, Davies P. An evaluation of the UK National Pandemic Flu Service swine flu algorithm in hospitalised children, and comparison with the UK National Institute for Health and Clinical Excellence fever guideline. Emerg Med J. 2010 Sep 3. [Epub ahead of print]

    2. Wiwanitkit V. Scoring system for diagnosis of swine flu. Heart Lung. 2010 Jul-Aug;39(4):345-6.

    3. Wiwanitkit V.Swine flu: the present pandemic infectious disease. Kulak Burun Bogaz Ihtis Derg. 2009 Mar-Apr;19(2):57-61.

    Conflict of Interest:

    no

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  12. The benefit of intravenous magnesium sulphate is not proven in adults with acute severe asthma

    The correct answer to question 2a in the EMQs on magnesium is false, at least with regard to adults. For children it is probably true. The evidence cited to support the answer provided is ten years old [1]. Avid EMJ readers will know that a more recent meta-analysis [2] showed that in adults there was only weak evidence that intravenous magnesium sulphate had an effect upon respiratory function (standardised mean difference 0.25, 95% confidence interval (CI) -0.01 to 0.51; p=0.05) and no significant evidence of an effect on hospital admission (relative risk 0.87, 95% CI 0.70 to 1.08; p=0.22). However, even this latest meta- analysis is effectively out of date. The 3Mg Trial [3] has so far recruited over 400 patients and is now the largest trial of magnesium sulphate in acute asthma. When the 3Mg trial is completed and the results analysed we will have a definitive answer to this tricky EMQ.

    Steve Goodacre

    1. Rowe BH, Bretzlaff J, Bourdon C, et al. Magnesium sulphate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev 2000;(1):CD001490. doi:10.1002/14651858.CD001490. 2. Mohammed S & Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma: systematic review and meta-analysis. Emerg Med J 2007;24:823-830. 3. The 3Mg Trial, ISRCTN 04417063, http://www.hta.ac.uk/project/1619.asp

    Conflict of Interest:

    Chief Investigator for the 3Mg Trial

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  13. Re:'Unstable' buckle fractures

    In reply to Dr Kennedy's comments Salter Harris IV and displaced Salter Harris II fractures are seen in this population, these may be initially interpreted as stable fractures but may require manipulation or observation to avoid long term disability. Misdiagnosis may also occur where a fracture is diagnosed in the absence of any bony injury.

    Conflict of Interest:

    None declared

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  14. Trauma care in England: Londons Trauma System goes live

    We were encouraged by Hughes editorial on Trauma Care in England (1), which highlighted the key points from the National Audit Office publication Major Trauma Care in England (2).

    As an update, the London Trauma System was launched on 6th April 2010. The system is composed of four trauma networks, each with a major trauma centre providing care for the most seriously injured patients, linked in with a number of local trauma units for those patients with less serious injury.

    Each major trauma centres delivers consultant-led care 24 hours a day, seven days a week. It houses all the specialties required to treat serious injuries on-site, access to rapid diagnostics and operating theatres. Ambulance crews use an agreed triage protocol to determine which patients require transfer to the major trauma centres.

    Hospitals within the networks are required to submit data to Trauma Audit & Research Network. A structured clinical governance system, overseen by the London Trauma Board, operates to ensure the highest quality of care is delivered to patients. Within this, the rehabilitation workstream operates to improve the rehabilitation pathway and identify future priorities for development.

    There are plans to roll out trauma networks outside London in the near future.

    References

    1.http://www.nao.org.uk/publications/0910/major_trauma_care.aspx (accessed 14 May 2010)

    2.Hughes G. Trauma care in England. Emerg Med J 2010;27:338

    Conflict of Interest:

    None declared

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  15. To complete the question...

    I read with great interest the Best Evidence Topic by N. Naheed and R. Jenner about the place of rectal examination in paediatric constipation.

    The current NICE guidelines concur with the conclusions worded in the BET and do not advocate a digital examination unless one is a healthcare professional with experience in the specific aspect.

    Whilst I would not suggest that emergency physicians should undertake rectal digital examination on all children attending EDs, I feel there is a place for a formal anal and gluteal inspection.

    This should be undertaken to exclude trivial pathologies, which could lie in the background of a constipation like anal fissures, prolapse, fistulas, displaced anal passage, hairy patch etc.

    There is another very important feature, which should be checked in the very young child and I feel emergency physicians often fail on this point too.

    The anorectal reflex (often called anal wink) should be examined if any suspicion of neurological or locomotor deficit is suspected to exclude involvement of the lower sacral segments of any aetiology.

    As recommended by NICE, the above should be undertaken after explanations had been given and informed consent gained from the patient or parent and in the presence of a chaperone.

    Conflict of Interest:

    None declared

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  16. Be wary of premature extrapolations!

    I read with great interest the Sophia section of the EMJ this month.

    A few lines draw our attention to a multi-centre prospective randomised study, which compared preoperative cleansing of the patients 'skin with chlorhexidine-alcohol to povidone-iodine for preventing surgical site infection (Darouiche et al).

    The EMJ editors wondered if there would be some useful implications for ED practice.

    The immediate reaction of any ED practitioner reading these lines would be to think we should advocate the use of chlorhexidine in skin/wound cleansing in the emergency setting.

    I feel this would be a premature extrapolation from a study, which appears flawed to me.

    First of all, despite being a multi-centre study, the selection of the involved institutions was performed by one of the authors, which undoubtedly could have led to some recruitment bias.

    The operating surgeon could technically not be blinded to the study, as the povidone solution is well recognisable from its brownish colour. Some further bias could have been introduced at this particular stage too.

    When the authors looked at the results, they found a statistically significant difference between the cleansing agents overall in favour of chlorhexidine.

    It is well known that statistical and clinical significance are two completely different entities and one should be very cautious when trying to extrapolate from the results of a study that included a different population subgroup than ours.

    This study was performed in an operative setting recruiting patients who were undergoing clean-contaminated surgery; not the typical ED population!

    The type of wounds we see and manage in the ED is usually the superficial, minimally contaminated type; any other type usually requiring surgical referral.

    A recently published and later updated review of the current medical literature even suggests the use of tap water over normal saline or povidone for cleansing of minor wounds in the ED (Thompson and Lecky).

    After the above thoughts, I wondered if we can extrapolate any valuable clinical implication useful for the ED physician at all.

    References: Darouiche O.R., Wall M. J., Itani K.M.F., Otterson M.F., Chlorhexidine- alcohol versus povidone-iodine for surgical site anti-sepsis, New England Journal of Medicine 2010;362:18-26

    Thompson S, Lecky F: Tap water is an adequate cleansing for minor wounds, www.bestbets.org, http://bestbets.org/bets/bet.php?id=24

    Conflict of Interest:

    None declared

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  17. 'Unstable' buckle fractures

    Hamilton et al in commenting about use of removable splints in childhood wrist fractures mention that there may be misdiagnoses in these 'unstable' fractures. How on earth can a barely visible Taurus or greenstick fracture of a child's wrist be anything but stable??

    Conflict of Interest:

    None declared

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  18. generalists cannot afford the luxury of being ignorant

    The luxury of being relatively ignorant of the latest developments outside the "comfort zone" of one's highly specialised field of expertise is one which can be indulged only by specialists in highly esteemed disciplines such as cardiology (the heart being a highly emotive organ), and neurology (neurology being the equivalent of "brainy"). Generalists, such as frontliners in emergency medicine, have to make do with encyclopaedic knowledge because that is the only kind of knowledge which matters when you are the first port of call for undifferentiated life and death emergencies, hence the need for 24/7 services of an emergency librarian

    Conflict of Interest:

    None declared

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  19. A systematic review or a review of the literature?

    I read with great interest the review regarding pre-procedural fasting in emergency sedation.

    Whilst the findings of it are re-assuring for the emergency physician, there are certain points that need to be highlighted about the methodology used.

    First of all, the validated procedure to conduct a systematic review is to use two authors to separately browse the relevant literature applying inclusion criteria and a third one should resolve disagreement. I failed to find such a process in this article.

    The extraction of data is nicely outlined but the authors should certainly have contacted the so-called grey literature in order to identify any ongoing and unpublished studies and by doing so, minimising the risk of missing on important data.

    The MESH terms and text words used in the search strategy seem relevant to the topic but I wonder if the term <deep sedation> is to be included at all. The sedation we aim for in the Emergency Departments is conscious procedural sedation when airway reflexes are known to be maintained keeping the risk of aspiration to a minimal level. Including deep sedation in the search might therefore be inadequate. It is well known that this is a state that is difficult to reach for a variety of reasons but I wonder if including the above term is not an extrapolation.

    The aim of a systematic review is to identify and include all papers relevant to a particular clinical topic but this needs to be done in a standardised, validated and reproducible way.

    In view of the above, I am not sure the authors can call their work a systematic review (as they do in the abstract), the term <review of the literature> appears more appropriate to me.

    Conflict of Interest:

    None declared

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  20. Regarding the JRCALC Airway Managment Report and the subsequent College of Paramedics position paper.

    Firstly may we welcome the many excellent points raised on all sides. As active Pre-hospital Care practitioners we agree that there are important, unresolved issues regarding intubation(1). As practising Anaesthetists, while we acknowledge that intubation is not the only technique, we would consider the proposed withdrawal of intubation and the reliance on supra-glottic devices(1) to be premature for two reasons. Firstly, we take issue with the quality of evidence that suggests intubation per se is harmful. Many of these papers relate to systems/standards of care that we would not endorse - and although evidence is ultimately lacking, it seems reasonable to propose that a cuffed endotracheal tube placed without disruption of local anatomy or systemic physiology is likely to be beneficial in appropriately selected patients. Secondly, LMAs not only have a failure rate of their own(2), but they are unsuitable for certain patients.

    With regard to the training issues raised - our assessment of College and theatre placements confirms that the psychomotor component is often over-emphasised. We feel that matters could be much improved even within the current constraints. We agree that training using bougies and ETCO2 would redress certain issues, but even more important is the development of critical thought processes. We advocate: i) An airway assessment that aims to select the least invasive appropriate technique. ii) Maximising airway success by using all available aids at the first attempt. iii) A post-management strategy that actively looks for ineffective ventilation. Iv) A Plan A/Plan B approach that identifies and pre-prepares a rescue strategy should the first choice fail. Additionally, introducing laryngoscopy-assisted LMA insertion would improve skill, optimise LMA placement(3), and provide an insight into the ease or difficulty of intubation if subsequently required.

    Finally, the proposed strategy of a highly trained cadre with currency in advanced airway management that deploy as part of a critical illness response seems ideal; but only if they can provide comprehensive cover extremely rapidly.

    In conclusion, we would argue that, pending better evidence, intubation is still of value but should be perceived as the high-risk rung in an airway management ladder, only utilised if the alternatives are ineffective or inappropriate. As this would often be needed expeditiously we believe that the skill set should still reside within the Ambulance service but with specialised Paramedical or Medical reinforcement where available. Concerns about complications would certainly diminish with improved equipment, monitoring and decision-making developed through improved training.

    REFERENCES

    1. Joint Royal Colleges Ambulance Liaison Committee. JRCALC Airway Management Report, June 2008. http://jrcalc.org.uk/airway17.6.8.pdf

    2. Tolley P et al, Comparison of the use of the laryngeal mask and face mask by inexperienced personnel. British Journal of Anaesthesia 1992; 69: 320-321

    3. Elwood T, Cox R. Laryngeal mask insertion with a laryngoscope in paediatric patients.. Canadian Journal of Anaesthesia 1996 May; 43(5):435- 437

    Conflict of Interest:

    None declared

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  21. Pre-hospital assessment and management of chest pain needs improving

    We read with interest the article by Figgis et al highlighting the need for improvement in the pre-hospital management of chest pain. It is concerning that only 20% of patients had a 12-lead ECG and that 64% of paramedics surveyed felt that they had received insufficient training on ECG interpretation [1].

    Of particular concern is the inability of paramedics to identify ST elevation myocardial infarction (STEMI) implying, therefore, that a significant proportion of patients are failing to be considered for pre- hospital thrombolysis. Pre-hospital thrombolysis has been shown to significantly decrease the time from chest pain to thrombolysis (104 mins vs 162 mins, P=0.007) and all-cause mortality (odds ratio 0.83, CI 0.7- 0.98), compared to in-hospital thrombolysis in a large meta-analysis (n=6434) [2]. In cases where the decision on whether to undertake pre- hospital thrombolysis is unclear, or in areas where primary coronary angioplasty is the preferred mode of reperfusion, an inability to identify ST elevation would prevent paramedics pre-alerting the Emergency Department of an incoming STEMI. This will prolong the subsequent door-to- needle time and door-to-balloon time respectively.

    In keeping with the authors views that further paramedic training is needed to more accurately assess and treat patients with acute coronary syndromes, we would like to bring to attention the issue of isolated posterior myocardial infarction (PMI). Isolated PMI accounts for up to 7% of all STEMI [3]. The American College of Cardiology guidelines suggest that indirect changes are seen in the anterior leads (ST depression and dominant R-wave in V1-V2) on the standard 12-lead ECG which should raise suspicion of PMI. Posterior leads (V7-V9) are then required to confirm the diagnosis of PMI [4]. We recently conducted a study of West Midlands Ambulance Service paramedics. A total of 20 paramedics were surveyed, and none were able to identify potential PMI based on analysis of a 12-lead ECG demonstrating ST-depression and dominant R-wave in V1-V2 in the context of chest pain. Training paramedics on the use of posterior leads and the diagnosis of PMI, and the inclusion of PMI into the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines could further improve the management of acute coronary syndromes.

    REFERENCES

    1. Figgis K, Slevin O, Cunningham JB. Identification of paramedics compliance with clinical practice guidelines for the management of chest pain. EMJ. 2010;27:151-5.

    2. Morrison LJ, Verbeek PR, McDonald A, et al. Mortality and Prehsopital Thrombolysis for Acute Myocardial Infarction. JAMA. 2000;283(20):2686-92.

    3. Melendez LJ, Jones DT, Salcedo JR. Usefulness of three additional electrocardiographic chest leads in the diagnosis of acute myocardial infarction. CMAJ. 1978;119:745-8

    4. Cannon CP, Battler A, Brindis RG, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndrome Writing Committee). JACC. 2001;38:2114- 30.

    Conflict of Interest:

    None declared

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  22. Another cause of falsely high readings

    Peritoneal dialysis patients can also have falsely high bedside glucose estimations. Icodextrin in the dialysate can pass into the blood where it is metabolised to maltose. Maltose reacts with glucose sticks utilising the glucose dehydrogenase with coenzyme pyrroloquinolinequinone (GDH PQQ) assay to give a falsely high reading. Kits using glucose oxidase or hexokinase are less affected. Again the blood gas analyser will reveal the true hypoglycaemia.

    Reference Riley SG, Chess J, Donovan KL,and Williams, JD. BMJ 2003; 327(7415): 608- 609

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  23. Paramedic Airway Skills

    Dear Editor

    I was extremely interested in these papers in this months EMJ. [Joint Royal College Ambulance Liaison Committee Airway Working Group commentary The College of Paramedics (British Paramedic Association) position paper regarding the Joint Royal Colleges Ambulance Liaison Committee recommendations on paramedic intubation (Prehospital airway management)].

    I wonder if anyone could tell me what are the professional credentials of the members of the Airway Working Group in Pre-hospital care and their experience in working outside the comfort of the resus room or theatres. I have worked since the mid/late 70's on the roadside, was involved at the same time as Robin Glover in teaching Ambulance personnel advanced procedures such as cannulation, intubation and defibrillation. He to the Cambridge area and I to the Suffolk area. I have also taught proper paramedics in Suffolk, East Anglian and Kent ambulance services.

    I still do BASICS, teach ATLS, ALS, in the past BTLS and PHTLS as well as Instruct instructors, so am very familiar with the Principles of Education and training. I have also been involved in teaching on human simulators as well. I have done probably more prehospital and resus room intubations over 33 years than any of the 'experts' on the panel. I have also done Anaesthetics in my even earlier years. Intubating in a Race gravel trap also features strongly in my 30 years on the circuits.

    It beggars belief that they can base their decisions on such poor quality research and literature reviews, especially American papers. Also that they are not even attempting to investigate the new technologies that have been and are available for making ET intubation safer.

    As an A/E consultant I have had the benefit of working night and day, summer and winter, hot and freezing cold, wet and dry at roughly more than 10,000 call outs plus working on many of these patients in my unit together with countless more to which I was not called out to the scene.

    I really feel that the comments I have made about the experience of the panel are made from the standpoint of being infinitely more skilled than anyone around today. I have been on call 24/7 since the 70's except when on annual leave.

    I sincerely trust someone somewhere will take your papers to heart and do some proper research

    Kind regards

    Alan Jones

    GMC 1315246

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  24. Effects of bed height on the performance of chest compressions- Clinical application of results

    Editor- I would like to start by congratulating Cho and colleagues (1) on undertaking a study that addresses an area of cardiopulmonary resuscitation (CPR) which potentially, could for such a simple intervention have such a dramatic impact on the quality of CPR delivered. There are surprisingly few papers published on this area, and the 2005 ILCOR guidelines (2) were based largely on expert opinion with little evidence base.

    The statistical relationship between a bed height at the knee level and the effectiveness of CPR is clear. The concern is the application of these results to the clinical setting. Having recently completed similar work within this area, I would suggest you would find it difficult to locate a hospital bed/trolley with mattress which is able to drop to the average person's knee level. So as a result, we may be continually subjecting patients to sub-optimal chest compressions, even if the beds are dropped to their lowest levels. Perkins et al suggested resuscitation carried out on the floor when compared to the bed is superior (3). Again, application of this not really possible on a daily basis and certainly not advocated by ILCOR guidelines.

    The solution may be to eliminate the human component to chest compression all together, by using one of the various automated devices available now. Initial studies were very encouraging and demonstrated not only their safety but also possible survival benefits (4,5). The slow uptake of these devices probably stems from not only their cost implication, but the results of the large randomised prospective ASPIRE trial (6), which demonstrated that the use of Autopulse was associated with a worse neurological outcome and a trend towards worse survival, when compared to manual CPR.

    So the answer in the mean time is a little bit more low-tech and a little bit more 'ER' esque; I would suggest we go back to kneeling on the bed when performing CPR. In this position the clinician can keep their arms straight and with the advantage of their upper body weight can perform effective chest compressions. It is always worth remembering, that in the real world good quality chest compressions are not simply dependent on the depth of chest compression. The vital role of chest recoil and the thoracic pump effect are not addressed with compression plates and manikin studies and form a key component of successful resuscitation.

    1. Cho J, Oh JH, Park YS, et al. Effect of bed height on the performance of chest compressions. Emer Med J 2009: 26; 807-810

    2. International Liaison Committee on Resuscitation. International Consensus on cardiopulmonary resuscitation and emergency cardiovascular science with treatment recommendations. Part 2. Adult basic life support. Resuscitation 2005; 67: 187-201

    3. Perkins GD, Smith CM, Augre C, et al. Effects of a backboard, bed height, and operator position on compression depth during simulated resuscitation. Intensive Care Med 2006;32:1632-5

    4. Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2005 Jan-Mar;9(1):61-7.

    5. Krep H, Mamier M, Breil M, Heister U, Fischer M, Hoeft A. Out-of- hospital cardiopulmonary resuscitation with the AutoPulse system: a prospective observational study with a new load-distributing band chest compression device. Resuscitation. 2007 Apr;73(1):86-95. Epub 2007 Jan 24.

    6. Hallstrom A, Rea TD, Sayre MR, et al: Manual chest compressions vs. use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest. JAMA 2006. 295(22):2620-2628.

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  25. Blended learning in the ED, and national guidance.

    I read the article by Roe et al with great interest, particularly because as a trainer of junior doctors in the Emergency Department I recognise many of the barriers to effective teaching as described in the article.

    Locally we have appreciated the poor attendance by Foundation trainees at weekly teaching sessions, mainly as a consequence of increasingly anti-social rotas. The delivery of high quality work-place based training is also becoming more difficult due to increasing service demand, Foundation doctors working 4-month posts, and the limits imposed by the EWTD.

    To address this we have introduced a blended learning package consisting of core e-learning modules and a series of linked work-place based assessment (WPBA) templates. The modules and WPBAs have been selected to allow us to deliver all the competencies outlined in the NICE guidance "Acutely Ill Patients in hospital (CG50)". Foundation trainees in our department are given protected time at work (equivalent to approximately 34 hours dedicated study time in 4 months) to complete the e -learning modules, and then to return to the shopfloor to spend time with a senior doctor completing the linked WPBAs. This time can also be used to reflect on the e-learning session, and allows further discussion and an opportunity to answer questions. To make this process more robust the senior doctors are allocated timetabled afternoon sessions to deliver the WPBAs. At the end of the sessions the trainees are invited to update their eportfolios with the recently completed WPBAs.

    What feedback have we received? The blended learning package was introduced in August 2009, and feedback from the first cohort of FY2s was very positive. 16 of 20 FY2s completed a questionnaire at the end of their 4 month post. 88% stated that the modules were appropriate to their learning needs and were of a high standard, 82% felt that the WPBA templates were appropriate to their learning needs, 93% said that feedback from the WPBA sessions was useful, 82% stated that the blended learning package provides high quality education. Overall, 87% of the FY2s would recommend the training they received in our department to colleagues, and 67% stated that teaching in our department was of a higher quality than experienced in previous posts.

    And what do our senior doctors think of blended learning? Most have found the delivery of training on a one-to-one basis in the work-place to be a satisfying experience, and the timetabled sessions provide evidence of active personal involvement in teaching and training, which is increasingly important for our CPD returns!

    In conclusion, the development of our blended learning package has allowed us to deliver a comprehensive education programme following national guidance in a 4 month period. Feedback from trainers and trainees is encouraging, and we endorse blended learning as an effective mode of delivery of postgraduate medical training in the ED in the 21st Century.

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    None declared

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