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Recent eLetters

Displaying 207-231 letters out of 748 published

  1. 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

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  2. 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

    Dear Sirs,

    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

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  3. Is the surgeon be consealed with the dianogsis?

    Dear authors:

    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!!

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  4. 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.[1] 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.[2]

    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.

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  5. Flawed Study

    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.

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  6. 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.

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  7. 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.

    bw

    Simon Carley Associate Editor EMJ

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  8. Propofol sedation in the ED is not always "conscious"

    Editor,

    Your recently published Best Evidence Topic (BET) report regarding the reduction of dislocated hip prosthesis outlines a comparison of general anaesthesia with “conscious sedation”.[1] However, of the four included papers one used methohexital with or without opioids to facilitate reduction, whilst another was a prospective cohort study of patients receiving intravenous morphine followed by propofol. In the third paper a proportion of patients also received propofol sedation.

    Conscious sedation is defined as “a technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation”.[2] However it seems highly implausible that all the patients receiving methohexital or propofol fulfilled this definition throughout the procedure. Indeed, propofol sedation in the doses described is likely to produce a state of deep sedation,[3] during which the patient does not respond to verbal or simple physical stimuli,[2] and perhaps even a brief period of general anaesthesia. Furthermore, the chance of successful reduction appears, from this BET, to be related to the depth of sedation or anaesthesia achieved: this is problematic for the emergency physician since the deeper the level of sedation the greater the chance of procedural success, but also the greater the chance of anaesthetic complications.

    Whilst the published evidence to date would support the overall safety of deep procedural sedation administered in the Emergency Department,[4] further progress in this important area of our practice will be potentially undermined if we pretend that the use of propofol reliably produces nothing more than a state of “conscious sedation”. In practical terms, deep sedation is difficult to distinguish from general anaesthesia, and the Academy of Royal Colleges recommends that supervision of these two states, in terms of the training and skill of the clinician, should be identical.[2] Unfortunately this somewhat undermines the premise of this particular BET, in that the comparison becomes one of general anaesthesia in the emergency department versus general anaesthesia in the operating theatre. However, providing that the safety of the procedure is identical regardless of its location then earlier reduction in the emergency department confers clear patient benefit, with a reduced period of time spent in discomfort and pain.

    Yours faithfully,

    Jonathan Benger.

    1. Payne N, Jones S. General anaesthesia or conscious sedation for reducing a dislocated hip prosthesis? Emerg Med J2009;26:204-5.

    2. Implementing and ensuring safe sedation practice for healthcare procedures in adults. Academy of Medical Royal Colleges. November 2001. Available at: http://www.rcoa.ac.uk/docs/safesedationpractice.pdf (accessed 5th March 2009).

    3. Gürses E, Sungurtekin H, Tomatir E, Dogan H. Assessing propofol induction of anesthesia dose using bispectral index analysis. Anesth Analg 2004;98:128-131.

    4. Smally AJ, Nowicki TA. Sedation in the emergency department [Anaesthesia outside the operating room]. Current Opinion in Anaesthesiology 2007;20:379-383.

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  9. Propofol is effective but not safe for relocating hip prostheses

    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 [1]. 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)[2]. 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.

    Firstly, 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” [3]. To us, 1mg.kg-1 of propofol in this age group is a dose close to that required for induction of anaesthesia [4], 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”[4] 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 [5]. Monitoring: the level of monitoring recommended for patients undergoing general anaesthesia should include capnography[6]. Fasting: we find it disappointing that in emergency patients suffering pain 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 [7]. 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 [8]. 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) /1000 patients. In this context your described results cannot be remotely construed as demonstrating safety.

    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.

    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. 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

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  10. Reduced frequent attendance: could it be seasonal?

    Dear Editor,

    I read with interest the article by Skinner, Carter and Haxton assessing whether case management of frequent attenders to an urban emergency department reduces frequency of subsequent attendances.1 The case for multidisciplinary management of frequent attenders is well-made and the reported practice of case review and implementation of care plans highly commendable.

    However, a possible considerable limitation to this study is not fully elucidated in the authors’ discussion. While mention is made that the reduction seen in attendances by frequent attenders following case review “may be due to the natural ebb and flow in the presentations of these patients”1, comment is not made on the potential substantial effects of the differing seasons in which the study was conducted (October 2006 to March 2007 control, compared to April 2007 to September 2007 post- intervention).

    Watters et al have previously observed that the number of patient attendances to the Emergency Department at the Royal Infirmary Edinburgh is subject to monthly variation.2 Chi-squared analysis of the total numbers of patients presenting each month presented by Watters et al confirms variation in numbers of patients by month (chi2 = 105.24, p <0.001) even when the varying numbers of days in each month is taken into account (chi2 = 57.03, p <0.001).

    Further to this variation in total attendances is the seasonal variation in presentations of different clinical conditions. The most common documented diagnoses in this group of frequent attenders was stated to include “alcohol-related problems (46%), mental health problems (37%) and chronic complaints such as abdominal or chest pain (40%)”. Other diagnoses included COPD / asthma and drug abuse. However, the presentations of many of these conditions have been shown to be subject to seasonal variation. Arkfen et al’s study of frequent visitors to psychiatric emergency services found that admission was more frequent in inclement weather 3; Halpern et al observed a seasonal variation in emergency department “psychiatric visits” with results supporting the “existence of a Christmas effect”, they also noted that substance abusers were more likely to attend the emergency department during the weeks surrounding Christmas 4.

    It is also known that patients with ischaemic heart disease are more likely to become severely symptomatic during colder temperatures, and “cold stress” contributes to a higher mortality rate from this condition during the winter 5. Winter predominance seasonal variation in presentation rates for abdominal pain is also suspected, and has been demonstrated in children 6. Ballester et al observed “clear temporal patterns of COPD emergency” with more emergencies in winter 7.

    With more than half of the frequent attenders’ documented diagnoses subject to seasonal variation with increased presentations during winter months, it would appear that there is an as yet unaddressed confounding bias in the observed decreased number of subsequent attendances in the (summer) months following case management intervention. I eagerly await the mentioned follow-up study, and will be interested to ascertain whether the results seen so far are indeed sustainable over time.

    E Bateman

    Competing interests: None

    REFERENCES

    1. Skinner J, Carter L, Haxton C. Case management of patients who frequently present to a Scottish emergency department. Emerg Med J 2009; 26: 103-105.

    2. Watters DA, Brooks S, Elton RA, et al. Sports injuries in an accident and emergency department. Emerg Med J 1984; 1: 105 -111.

    3. Arfken C, Zeman LL, Yeager L, et al. Frequent visitors to psychiatric emergency services: staff attitudes and temporal patterns. J Behav Health Serv Res 2002; 29(4): 490-496.

    4. Halpern SD, Doraiswamy PM, Tupler LA, et al. Emergency department patterns in psychiatric visits during the holiday season. Ann Emerg Med 1994; 24(5): 939-943.

    5. Houdas Y, Deklunder G, Lecroart JL. Cold exposure and ischemic heart disease. Int J Sports Med 1992; 13 Suppl1: S179-81.

    6. Saps M, Blank C, Khan S, et al. Seasonal variation in the presentation of abdominal pain. J Pediatr Gastroenterol Nutr 2008; 46(3): 279-84.

    7. Ballester F, Pérez-Hoyos S, Rivera ML, et al. [The patterns of use and factors associated with the patient admission of hospital emergencies for asthma and chronic obstructive pulmonary disease]. Arch Bronconeumol 1999; 35(1): 20-26.

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  11. Original Authors' Response to Dr. Ford’s e-Letter

    Dear Editor,

    We appreciate Dr. Ford’s letter in response to our article entitled “Excessive Use of Force by Police: A Survey of Academic Emergency Physicians.”[1] As he pointed out, almost all respondents to our randomized survey of academic emergency physicians in the US believed that excessive use of force by law enforcement does occur. This is substantiated by statistics from the US Department of Justice in their Special Report - Citizen Complaints about Police Use of Force, in which data from 2002 revealed that 8% of 26,556 citizen complaints of police use of force were sustained. In addition, 34% of the complaints were not sustained due to insufficient evidence to prove that excessive use of force actually occurred.[2] Further in recent years the US Department of Justice has investigated the law enforcement agencies of numerous cities, including Los Angeles, Cincinnati, Washington DC, New York, New Orleans, Detroit, Cleveland, Pittsburgh, Oakland, as well as US Virgin Islands and the New Jersey State Police, for excessive use of force.[3]

    However, we disagree with Dr. Ford’s assessment that police use of force is strictly a “rubric of criminal justice policy.” We believe that police use of force crosses other sectors, and is also a healthcare issue. This is not the only healthcare issue that is also a criminal justice problem and is regularly evaluated in emergency departments nationwide. Child abuse, sexual assault, intimate partner violence, elder abuse, and other forms of assaultive violence (i.e. injuries from stab wounds, gunshot wounds, and hate crimes) are also examples of issues that involve both health care and the criminal justice system. As with suspected excessive use of force by law enforcement, in all these situations emergency physicians cannot determine the circumstances of the events that lead to the patients’ injuries. In our article we clearly stated this. However, it is within our scope of practice, and is considered standard of care to ask about the mechanism of injury and to assess injury patterns for signs of intentional injury and injuries that do not fit with the reported mechanism of injury by either law enforcement or the patient.

    We are mandated by law to report cases in which we suspect injuries due to family violence, in order that law enforcement may investigate the circumstances of the events and make a determination as to whether a crime occurred. Patients who present to the emergency department for evaluation, in whom the healthcare provider has a suspicion of excessive use of force by law enforcement officers, should similarly be reported to an authority responsible for investigating the circumstances of the event resulting in the injuries. Patient presentations which may be particularly concerning are those in which the patient has significant injuries, injuries that are not consistent with the medical history, and significant injuries despite not being arrested. Even Dr. Ford agrees that injuries inconsistent with the history provided should be reported to “the authorities” by the physician.

    We are not aware of any regulations requiring healthcare providers to report injuries from suspected excessive use of force by law enforcement officers. Legislation is necessary to permit healthcare providers to report significant injuries to the authorities in good faith and without legal repercussions. The goal is to prevent unnecessary injuries to individuals during physical encounters with officers, while acknowledging that the amount of force needed will vary from encounter to encounter.

    1. Hutson HR, Anglin D, Rice P, et al. Excessive use of force by police: A survey of academic emergency physicians. Emerg Med J 2009;26:20- 22.

    2. Hickman MJ. Special Report - Citizen Complaints About Police Use of Force, NCJ210296. Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, June 2006. Accessed 2/19/2009. http://www.ojp.usdoj.gov/bjs/pub/pdf/ccpuf.pdf.

    3. Other Justice Probes. USA Today. 4/16/2001. Accessed 2/19/2009. www.usatoday.com.

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  12. Original Author's response to e-Letter

    Dear Sir

    We welcome the interest in our work1 from anaesthetic colleagues. We respond to their areas of concern in turn.

    Pre-procedural starvation is indeed controversial. ASA/RCoA fasting guidelines are designed for elective cases and not necessarily practical for Emergency Department patients who require early intervention, or in whom airway manipulation is rare. A more practical guideline exists2. The incidence of aspiration in emergency department procedural sedation is limited to one case (of a total that includes nearly 4000 patients given propofol3 )with no adverse outcome. Vomiting rates are no different in starved patients (albeit children) and unstarved patients4. We are not aware of any good evidence demonstrating increased aspiration in patients in pain, or in those who have received opiates. In the series, we considered each unstarved patient on merit, weighing the risk of aspiration versus the benefit of early intervention. Following concerns raised by local anaesthetic colleagues we have amended the protocol to follow ASA fasting guidelines; the protocol is now endorsed by our Trust governance committee. We await developments from a proposed joint CEM/RCoA working party with interest.

    We agree that the description of propofol being ultrashort is misleading. The drug is however described as allowing a rapid return of consciousness in doses of 1.5 - 2.5mg/ kg in the TEAM UK manual; a manual resulting from a collaboration of anaesthesia, intensive care and emergency medicine opinion. We note a systematic review comparing propofol and midazolam for emergency department procedural sedation, found no significant difference in their safety profile5. We also note a National Patient Safety Alert recently issued, highlighting midazolam’s potential for harm.

    The complication rate from propofol administration was indeed 12/98 (12%). There were no adverse outcomes however and this is consistent with other studies in the emergency medicine literature. With regard to advanced airway training all eight consultant emergency physicians at the RD&E:

    • routinely manage airway problems in unconscious patients eg those with drug overdose , stroke, sepsis, metabolic disturbance and head injury

    • routinely teach airway skills on adult and paediatric advanced life support courses

    • have acquired anaesthetic experience as part of their training

    • meet the College of Emergency Medicine curriculum standards regarding airway management

    • meet the requirements for rescue of a patient from a deeper level of sedation, as detailed in the statement on safe use of propofol by the American Society of Anaesthesiologists

    • have completed an in-house training programme for the use of propofol in procedural sedation.

    Further, our consultant delivered service gives particular attention to patient assessment, preparation, monitoring, recovery, the presence of appropriately skilled assistance, mandatory recording on a dedicated electronic database and audit.

    We believe that the service we offer our patients is beneficial to them, timely and safe. It is a service that appears well established in Australasian and North American Emergency Departments.

    Yours faithfully

    Gavin Lloyd

    On behalf of the Emergency Department consultants of the Royal Devon and Exeter Hospital.

    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. Green SM, Roback MG, Miner JR. et al. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory Ann of Emerg Med 2007:49;454-461

    3. Green, S. Propofol in emergency medicine: further evidence of safety. Emerg Med Aus 2007; 19: 389-393.

    4. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003; 42: 636-646

    5. Hohl, CM. Sadatsafavi, M. Nosyk B, Anis, AH. Safety and Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review. Acad Emerg Med 2008; 15; 1-8

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  13. Emergency Physicians and Police Brutality

    Hutson et. al's survey of 393 academic emergency physicians (EP's) demonstrated their almost universal sense that the police engage in excessive force.[1] While this result is provocative, it is not as informative as one might think. The opinions of such doctors would certainly be expected to carry great weight in discussions regarding health care issues. However, determinations of the appropriateness of police "use of force" is not such an issue and rather falls under the rubric of criminal justice policy.

    Even if physicians had the necessary training to make such assessments (in this study, 93.7% admit to lacking such training), a detailed investigation reviewing police reports, interviewing witnesses, etc. would be required to come to anything resembling an informed conclusion. In fact, EP's, not being witnesses to the events leading to injured suspects, bring no additional insight to the causes of such injury than any other "after-the-fact" care provider.

    Certainly, physicians of all specialties have a responsibility to identify child, partner, and elder abuse and frequently receive training to this end. This is not, as some might think, analogous to recognizing cases of police brutality. Children, partners, and the elderly should never be the victims of physical or emotional abuse by those close to them. The mere existence of such physical or emotional injuries (which many physicians are certainly able to detect) clearly raises the possibility or even likelihood of such abuse. A suspect brought into the emergency department by law enforcement however falls into a different category.

    The police have an extraordinarily difficult job often interacting with very dangerous criminal suspects. When such suspects are hurt, their injuries may arise out of the normal and appropriate application of physical force. EP's seldom, if ever, possess the information necessary to judge the appropriateness of that force.

    The authors have concluded that their results "...suggest that national emergency medicine organizations in the USA should become involved, jointly developing and advocating for guidelines to manage this complex issue."

    Obviously, if a police officer's history of the events leading to suspect's constellation of injuries is completely inconsistent with what is observed on physical exam, the physician's course is self-evident: he or she must report it to the authorities. Neither additional "study" nor "guidelines" are required to establish this.

    1. Hutson HR, Anglin D, Rice P, et al. Excessive use of force by police: a survey of academic emergency physicians. Emerg Med J 2009;26:20-22.

    John S. Ford, M.D., M.P.H.

    Assistant Professor of Medicine

    David Geffen School of Medicine at UCLA

    Harbor-UCLA Medical Center

    johnsfordmd@ucla.edu

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  14. Pre-hospital use of ketamine in Mountain Rescue

    Dear Editor,

    Bredmose et al. have published an excellent indictment for the use of ketamine in the pre-hospital phase; a study of 1030 patients is impressive.(1) Mountain Rescue is a small specialist area of pre-hospital care where many physicians have acknowledged the benefits of ketamine for many years.(2) Its versatility and, with careful use, its ability to dissociate analgesia from airway compromise are particularly appealing. For example, having to use simple airway adjuncts after the administration of a drug will frequently prelude many of the rapid extrication techniques such as helicopter winching that the patient desperately requires. The risks of ‘escalating’ to intubation, for example at subzero temperatures with patient’s half buried in snow on a 45º ice slope or 20 metres down a crevasse requires careful consideration.

    A few additional points are worth noting: a) Intranasal S-ketamine (~2mg/kg) has its advocates in extreme conditions where parenteral access is impossible though concerns remain on reproducibility of effect.(3,4) High intranasal doses can produce high plasma concentrations of ketamine. However, the amount swallowed varies and leads to a high variability of effect.(5) b) Bredmose et al. report ~100 patients sedated with midazolam >5 mg.(1) We warn against using excessive midazolam doses for sedation, as this may impair upper airway control. In our practice 1-3 mg i.v. is sufficient to sedate adults for up to one hour. As in this study, most mountain rescue physicians routinely use midazolam and rarely see emergence phenomena. However, they do occur and may require additional midazolam particularly if helicopter evacuation is imminent. c) In many countries, ‘ketamine’ is S-ketamine – the active S-enantiomer unlike the racaemic mixture of R- and S-ketamine used in the UK.(6) Therefore practitioners elsewhere may need to reduce (up to a fourth) the doses quoted.(6) d) In patients with traumatic brain injury, the use of ketamine is still controversial though many mountain rescue physicians use it in preference to other induction agents in the mountain setting.(7) e) As of January 2006, Ketamine became a Controlled Drug in the UK under the Misuse of Drugs Act. (It has been controlled in many other countries for years.) As a schedule 4 part I drug, it does not require the physician to keep a Controlled Drug register nor obey the safe custody criteria of a schedule 2 drug but non-NHS organisations will require a Home Office Licence to possess it.

    Dr John Ellerton

    General Practitioner, Penrith Health Centre, Penrith, Cumbria. CA11 7UL UK and Medical Officer, Mountain Rescue Council

    Dr Peter Paal

    Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria

    Dr Hermann Brugger

    Associate Professor at the Innsbruck Medical University, Austria and President of ICAR MEDCOM, Europastrasse 17, I-39031 Bruneck, Italy

    References

    1) Bredmose PP, Lockey DJ, Grier G, et al. Pre-hospital use of ketamine for analgesia and procedural sedation. Emerg Med J 2009;26:62-4.

    2) Thomas A, Wiget U, Rammlmair G. Treatment of pain in the field. ICAR recommendation No. 10. In Elsensohn F, ed. ICAR recommendations, 1999. p55-7. http://www.ikar-cisa.org/ikar-cisa/documents/2007/ RECM0010E.pdf.

    3) http://www.wolfetory.com/nasal.php.

    4) Weber F, Wulf H, Gruber M, et al. S-ketamine and s-norketamine plasma concen-trations after nasal and i.v. administration in anesthetized children. Paediatr Anaesth 2004;14:983-8.

    5) Malinovsky JM, Servin F, Cozian A, et al. Ketamine and norketamine plasma concentrations after i.v., nasal and rectal administration in children. Br J Anaesth. 1996 Aug;77(2):203-7.

    6) http://en.wikipedia.org/wiki/Ketamine.

    7) Gunning M, Perkins Z, Quinn T. Trench entrapment: is ketamine safe to use for sedation in head injury? Emerg Med J 2007;24:794-5.

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  15. Miscellaneous !

    Dear Editor,

    A survey in the North West of England found a rate of 20% self- reported use of "poppers"( inhaled amyl nitrates) among 16 year olds (www.drugscope.org.uk).

    In the United Kingdom, amyl nitrite is controlled under the "Medicines Control Act" Although possession is legal supplying may be an offence. Other nitrites are readily available in consumer products such as room odorants and leather cleaner. Numerous shops, particularly sex shops, clubs, and shops selling drug paraphernalia sell nitrites as "room aromas" or similar.

    There are a few more points that are useful in the evaluation and management of methemoglobinemia:

    (1) Methemoglobinemia should be suspected in a “blue breathless patient unresponsive to oxygen" and when there is presence of a "saturation gap" (The SaO2 in arterial blood is a calculated value based on the partial pressure of dissolved oxygen and assumes that no abnormal oxygen is present. Therefore the reported oxygen saturation from the laboratory is generally higher than the SpO2 measured with the pulse oximetry, hence accounting for a “saturation gap” (reference 1)

    (2) Methylene blue interferes with the accurate measurement of methemoglobin by co-oximetry. Therefore, following methylene blue administration co-oximetry cannot be used to monitor methemoglobin levels.

    In addition, methylene blue is most effective in intact erythrocytes; efficacy is reduced in the presence of haemolysis. Moreover, in the presence of haemolysis, high dose methylene blue (20-30 mg/kg) can itself initiate methaemoglobin formation (reference 2)

    (3) Methylene blue is an oxidant; its metabolic product leukomethylene blue is the reducing agent. Therefore, large doses of methylene blue may result in higher levels of methylene blue rather than the leukomethylene blue, which will result in hemolysis and, paradoxically, methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency ( reference 4)

    (4) When methylene blue treatment fails to eliminate cyanosis the patient may be deficient in G-6-PDH (prevalent in 10% of African- Americans) or NADPH reductase. In such cases transfusion / exchange transfusion should be considered(reference 4)

    (5) Dextrose should be given because the major source of NADH in the red blood cells is the catabolism of sugar through glycolysis. Dextrose is also necessary to form NADPH through the hexose monophosphate shunt, which is necessary for methylene blue to be effective (reference 3)

    (6) Some drugs, such as dapsone, benzocaine, and aniline, produce a rebound methemoglobinemia, in which methemoglobin levels increase 4 to 12 hours after successful methylene blue therapy (reference 5)

    References:

    1. J Emerg Med. 2007 Aug;33(2):131-2: Mind the gap.

    2. Toxicol Rev. 2003;22(1):13-27:Occupational methaemoglobinaemia, Mechanisms of production,features, diagnosis and management including the use of methylene blue

    3. Eur J Biochem. 1970 Jan;12(1):24-30: Regulatory factors in methylene blue catalysis in erythrocytes.

    4. Br J Haematol. 1983 May;54(1):29-41:Studies of the efficacy and potential hazards of methylene blue therapy in aniline- induced methaemoglobinaemia

    5. N Engl J Med. 1991 Jan 17;324(3):169-74: Glucose-6- phosphate dehydrogenase deficiency

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  16. Is propofol a safe and effective sedative for relocating hip prostheses?

    Dear Sir,

    We read with interest the recent article by Mathieu et al on the use of propofol as an effective sedative for relocating hip prosthesis (1). We would like however, to draw attention to several areas of concern.

    The authors administered doses of propofol up to 2 mg/kg. This is an anaesthesia-inducing dose of propofol, rightly recognised in the discussion. The fact that patients were not routinely starved prior to their procedure is of concern. We may assume, as eight patients experienced airway or ventilatory complications, these patients were unable to protect their airway from pulmonary aspiration. In addition, the prior use of morphine and the experience of pain would both increase the risk of delayed gastric emptying and subsequent aspiration.

    The description of propofol as an ‘ultra-short acting agent’ is misleading. It indeed has a shorter termination half-life than midazolam. Once apnoea has occurred though, time to return of spontaneous ventilation can be unpredictable and severe hypoxia can occur even in pre-oxygenated patients. It should also be noted there is no propofol antagonist should complications occur.

    Finally, the authors conclude that the incidence of significant adverse effects was uncommon, but they quote a rate of 12% (12/98). The Royal College of Anaesthetists consider a complication rate of greater than 10% as very common (2). With such a high complication rate, it is hard to justify the use of this technique by practitioners other than those with anaesthetic or advanced airway training.

    We feel, it would be unwise to consider this practice safe and we would recommend further discussions with anaesthetic colleagues before this practice is widely implemented.

    Yours faithfully

    Dr Marc Davison, Consultant Anaesthetist, Buckinghamshire Hospitals NHS Trust

    Dr Richard Stewart, Specialist Registrar in Anaesthetics, Oxford Rotation

    References

    1) N Mathieu, L Jones, A Harris, et al. Is Propofol a safe and effective sedative for relocating hip prostheses? Emerg Med J 2009;26:37-38

    2) Royal College of Anaesthetists. You and your anaesthetic. Third edition May 2008.

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  17. Author response to e-Letter by Dr. Fayomi

    Dear Editor,

    In his letter, Fayomi states correctly that the use of beta-blockers in the management of cocaine-related acute coronary syndrome is contraindicated (1). We feel, however, that Fayomi has mis-interpreted the information in Table 1, by believing that the authors are advocating the use of beta-blockers in the management of cocaine-related chest pain. The authors have clearly highlighted in the first paragraph on page 823 of the manuscript, that the use of beta-blockers in the management of cocaine -related chest pain (2). The authors have also stated this in other work that they have published relating to cocaine-related chest pain and other cocaine-related toxicity (3,4,5).

    For each of the clinical scenarios in table 1, those participating in the study were asked to state if the antidote/treatment and route of administration were correct; for some of the scenarios an inappropriate antidote/treatment and/or route of administration was stated. Those participating scored a correct mark for those scenarios where the antidote/treatment and/or route of administration was incorrect if they correctly identified this. The scenario of cocaine-related chest pain and the suggested antidote/treatment of IV Metoprolol was one of the scenarios in Table 1 in which an inappropriate antidote/treatment was suggested, and therefore the correct answer for this scenario was for participants to state that this was incorrect.

    References:

    1. Fayomi O. Management of Cocaine Associated Chest Pain. EMJ on line http://emj.bmj.com/cgi/eletters/25/12/820 (last accessed 23rd December 2008).

    2. Lidder S, Ovaska H, Archer JR, Greene SL, Jones AL, Dargan PI, Wood DM. Doctors' knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity. Emerg Med J. 2008; 25: 820-3

    3. Wood DM, Hill D, Gunasekera A, Greene SL, Jones AL, Dargan PI. Is cocaine use recognised as a risk factor for acute coronary syndrome by doctors in the UK? Postgrad Med J. 2007; 83: 325-8

    4. Greene SL, Dargan PI, Jones AL. Acute poisoning: understanding 90% of cases in a nutshell. Postgrad Med J. 2005; 81: 204-16.

    5. Wood DM, Dargan PI, Hoffman RS. Management of cocaine-induced cardiac arrhythmias due to cardiac ion channel dysfunction. Clin Toxicol (Phila). 2008 Sep 24:1-10. [Epub ahead of print]

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  18. Respectful disagreement

    To Distinguished Physicians,

    I have read excerpts form you article “ Police Use Excessive Force, ER Docs Say” January 1 2009, Volume 26, Issue 1 . Although I haven’t read the whole article, I do believe your study is flawed. For the purposes of this study, how did you define excessive force? Did you allow the individual doctors to subjectively define the term excessive force. Law enforcement officers are authorized to use force in apprehending a criminal. The definition of justifiable force employed by most agencies is minimum amount force necessary to effect a lawful arrest. This is a very easy definition when you have a compliant person who doesn’t resist. What about when the person does resists? Tries to assault the officer? If an officer defends himself from that assault and injures the criminal, what do you think the criminal is going to say to the ER personnel? I don’t think you will hear the criminal say “I violently resisted being arrested and tried to assault the officer” rather I believe you will here “The officer hit me for no reason.” There are an infinite amount of variables that determine the minimum amount of force used in the field all of which the ER staff is not privy to. An unintentional false allegation based upon what the criminal tells the doctor can stall a dedicated officers career, preventing promotions and pay raises. If the patient feels they are the victim of excessive police force, there are many legal routes for them to file a complaint. The role of the ER staff is not to judge if there is a victim of suspected excessive police force, but to treat and document the patient’s injuries. If the patient files a complaint, those records will without a doubt be subpoenaed.

    As for the handcuffs, they are not constructed to be “user friendly”. They are made to ratchet closed. If the handcuffs are not double locked, the prisoner themselves can make them tighter either accidentally or intentionally. Prisoners have been known to tighten the handcuffs to bolster there claim of excessive force. Even if the handcuffs are double locked, the radius and ulna can be pinched in the oval open of the handcuffs causing pain and making it look like they are too tight. This is caused by the prisoner trying to move around in the handcuffs and trying to slip out of them.

    Sincerely,

    Thomas Byrnes

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  19. Management of Cocaine Associated Chest Pain

    Dear Sir,

    I read with great interest the article by Liddler et al on the appropriate use and administration of antidotes for recreational drug toxicity. I would however like to seek clarification from the authors for their justification in the use of iv Metoprolol in scenario 4 ( 42 – Year old man with ingestion of two lines of cocaine presenting with ischaemic chest pain, ECG changes-ST depression and a BP of 175/95mm Hg). Use of beta blockers in this situation is contraindicated, as stated in a recent scientific statement from American Heart Association1. and a point that the authors acknowledge in the discussion section of their article. Given the current widespread recreational use of cocaine in the UK and that it is reported that up to 40% of cocaine users who present to the ED report chest pain, I would thank the authors for addressing this important clinical management point.

    References:

    1. Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. McCord J, Jneid H, Hollander JE, et al. Circulation. 2008;117:1897-1907

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  20. Cricothyrotomy Pig Model Flawed

    EDITOR, As an anaesthesiologist, I must respectfully disagree with the conclusion reached by Cho et al. that “[t]he porcine model is a more useful training tool than the manikin model for cricothyrotomy with PCK [Portex cricothyrotomy kit] because of its reality and similarity to human anatomy.”(1)

    Animal models have been shown previously to produce poor cricothyrotomy placement accuracy by students.(2) Manikin models have been shown to reduce cricothyrotomy attempts and improve successful placement rates. One study including manikin models demonstrated that, by the fifth attempt, 96 percent of participants were able to successfully perform a cricothyrotomy in 40 seconds or less.(3) Another study found the TraumaMan simulator “superior” to using animals for surgical airway placement instruction.(4)

    However, one of the most important criteria in determining cricothyrotomy competency is the assurance that a patient will survive after the procedure — a critical factor that the authors cannot measure with their static pig model. Appropriate training methods assess the student’s ability to appropriately oxygenate and ventilate patients. One study using a computerized Medical Education Technologies, Inc. (METI) Human Patient Simulator for emergency hypoxaemia found that cricothyroid cannulas were successfully placed 100 percent of the time, as confirmed by capnography.(5)

    1. Cho J, et al. Comparison of manikin versus porcine models in cricothyrotomy procedure training. Emergency Medicine Journal 2008;25:732- 4. 2. McCarthy M, et al. Accuracy of cricothyroidotomy performed in canine and human cadaver models during surgical skills training. Journal of the American College of Surgeons 2002;195:627-9. 3. Wong D, et al. What is the minimum training required for successful cricothyroidotomy?: A study in mannequins. Anesthesiology 2003;98: 349-53. 4. Block EF, et al. Use of a human patient simulator for the advanced trauma life support course. The American Surgeon 2002;68:648-51. 5. Vadodaria BS, et al. Comparison of four different emergency airway access equipment sets on a human patient simulator. Anaesthesia 2004;59:73 -9.

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  21. GCP is for all health professionals involved

    I enjoyed reading the commentary on Good Clinical Practice and welcome the efforts of the College of Emergency Medicine to make training in this important area available to emergency physicians.

    I think, however, it is important to recognise the imnportance of other disciplines - nurses and paramedics being key examples- in emergency care research, and perhaps to foster collaboration with relevant partner Colleges, to increase access to GCP training, particularly as efforts increase to recruit patients to clinical trials in the pre-hospital setting.

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  22. Salbutamol worth trying

    I read with interest the BET ‘Is nebulized salbutamol indicated in bronchiolitis?

    Perhaps this is the wrong question. As emergency physicians(EP) perhaps the more pertinent question is 'Does salbutamol decrease need for hospital admission?'

    We have addressed this question in an RCT which compared adrenaline to salbutamol.1 We found that salbutamol decreased the need for admission. This decrease was sustained at three days post emergency department (ED)discharge. The effect was similar across all levels of disease severity. (Prior to our study we had suspected that only in those with moderate disease would likely see a benefit large enough to affect need for admission). The results were unchanged regardless of sensitivity analysis for age less than 12 months, RSV status or prior episodes.

    So for EPs the answer is clear, initial ED treatment with salbutamol results in more successful discharges than does adrenaline.

    For inpatient services the question is murkier. Admitted infants are a selected sicker group who presumably failed ED treatment. Once admitted, there is a myriad of non-disease factors that influence time to discharge.

    Researchers have attempted to address this by using scoring systems. Few of the bronchiolitis scoring systems used have actually been validated. Many scoring systems consider only respiratory status. This is problematic because an 11 month old happy wheezer who is devouring everything set in front of him can be assigned a ‘sicker’ score than a tiring dehydrated 2 month old with less dramatic wheezing.

    Finally, absence of evidence of an effect is not evidence of absence of an effect. The numbers involved in the cited inpatient studies were small. The four largest studies cited had between 89 and 128 patients, but each divided their sample into four groups. The remaining studies cited had between 21 and 83 patients. Consequently important, particularly categorical, outcome differences could have been missed.

    Since salbutamol clearly decreases admissions from the ED,and solid evidence for inpatients seems lacking, it seems reasonable to at least try it in the inpatient setting also.

    1. Walsh P, Caldwell J, McQuillan KK, Friese S, Robbins D, Rothenberg SJ. Comparison of nebulized epinephrine to albuterol in bronchiolitis. Acad Emerg Med 2008; Apr;15(4):305-13.

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  23. Nitrous oxide can be made more effective and predictable using a closed breathing circuit

    Dear Sir,

    We read with interest the study by Babl et al “limited analgesia efficacy of nitrous oxide for painful procedures in children” published in the EMJ November 2008 Vol 25 No 11.

    Central to the protocol and management is the use of clinical assessment to determine adequacy and depth of analgesia/ sedation. We agree with this wholeheartedly and support this method as it emphasises the importance of conscious sedation as an adjunct to therapy, rather than unconscious sedation to compensate for inadequate analgesia. However it is worth recognising that the inspired concentration (in your study stated as 50-70% N20) does not relate to effector site concentration (in this case the central nervous system) unless a steady state has been achieved, the period of equilibration being approximately ten minutes. Without a closed breathing circuit being used there will inevitably be a significant entrainment of air resulting in a further reduction in real versus expected nitrous oxide concentration. This means that the nitrous oxide concentration achieved in the children in your study will be significantly lower than the settings on the machines would suggest and be unpredictably variable.

    In our experience using a closed mask system (such as a T – piece or close fitting demand mask) and end tidal gas monitoring provides a breath by breath analysis of end tidal nitrous oxide and oxygen concentration. These are analogous to arterial blood levels and thus reflect much more closely the effector site concentration.

    As a second point we note that all 8 patients who received codeine (which has a sedative effect) within two hours of sedation were not excluded from the study, although it was stated in the protocol that those given sedatives would be excluded.

    We agree with your findings that nitrous oxide is a useful adjunct in conscious sedation in painful procedures in children. We suggest this could be made more effective and predictable delivering nitrous oxide within an anaesthetic closed circuit in the Emergency department using end tidal gas monitoring.

    Licence for PublicationThe Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd to permit this article (if accepted) to be published in EMJ and any other BMJPGL products and sublicences such use and exploit all subsidiary rights, as set out in our licence (http://emj.bmjjournals.com/misc/ifora/licenceform.dtl). Competing Interest: None declared.

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  24. viva potatoes [ a sonopleardo models]

    Dear Editor

    Several models had been suggested for ultrasonographic training for intervention {1,2}.

    The main criteria of the models should be more or less simulate the human body organs, cost no much and easily prepared, {3}.

    For three years of trying in this field in my radiology laboratory the potatoes models were on the top of all ,{4}.

    After boiling of the potatoes the trainer can do any model you imagine.

    For example

    == For venous access models, a tunnel can be created in it and filled with ultrasonographic gel

    This tunnel can be created at different distance from the surface of the potato And the degree of difficulty can be changed by selecting the shape of the potato. the distance of the tunnel, the diameter of the tunnel and the direction of the substance in the tunnel . The longitudinal scan appear like a vessel and the transverse scan will appear like a cyst.

    ==For an abscess or collection models a different size of cavities can be done inside potatoes and filled with gel or jelly.

    == For simulation of liver bilary radicals recent boiled potatoes show a central network of branching tunnels of small calibers that resemble bilary radicals. The old boiled potatoes this water in is tunnels is replaced by air that looks like the pneumonia in consolidated lung or pneumobilia in liver organ . An embedded nerve under water will be used for nerve injection simulation.

    ==A tunnel filled with air is used to simulate a pathway to an underlying target covered by dense echogenic tissue.

    ==A blood filled cavity in well boiled potato model will simulate a recent hematoma in brain or any suggested organ. == Small tongue depressors penetrate the entire thickness of potatoes and a cavity created under them filled with air will simulate a lung model. When the cavity filed with water it will simulate a pleural effusion model.

    ……………A thick layer of cooked potatoes overlie a cup of water with heavy small balls on its floor will be used as a pleardo table and when the needle is pushed by ultrasound giddiness to attack the balls then you start the game of potatoes sonopleardo

    [1]C Brown, B McNicholl, and R Wright Ultrasound simulator for venous access Emerg Med J 2008; 25: 122

    [2]Arne Rose Ultrasound venous access simulation - the Italian Job http://emj.bmj.com/cgi/eletters/25/2/122#5810, 31 Jan 2008

    [3]=Chris M Turner Cost per use of USS http://emj.bmj.com/cgi/eletters/22/8/608-b#1875, 9 Jan 2007

    [4]Mahamoud M Gabal Critical cases direct our needs and skills http://emj.bmj.com/cgi/eletters/22/8/608-b#1830, 8 Dec 2006

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  25. In Support of observational Pain Tools for Emergency Medicine Triage in Children

    PLEASE NOTE THIS IS A RESUBMISSION FOR PRINTING PURPOSES WITH THE NECESSARY PERMISSIONS AS REQUESTED EMERMED/2008/069971 - Notify Author Re: Deficiencies

    We read with interest this article by Shavit et al comparing the Alder Hey Triage Pain Score with a subjective scoring tool. The finding of a discrepancy in scoring between the tools, with the AHTPS scoring lower, is entirely consistent with the similar finding we reported in our paper (archdischild.2004;89;625-630). The conclusion drawn by the authors that this indicates that observational scoring should not be recommended is not justified. The findings may reflect the fact that the observational tool is not fully refined and the weighting for the different elements needs further research and development.

    In the Shavit study pain scores were lower at triage assessment than in the waiting room. It was suggested that the reason for this was that Triage was a more reassuring environment. The inference made from this is that pain scoring is significantly influenced by anxiety. However, while this is likely, a subjective tool would be more affected by anxiety than an observational tool (AHTPS) and indeed the difference between the scores in the different settings reflected this. In order to eliminate as much of the anxiety element as possible subjective tools were initially developed in the situation of recurrent or procedural pain on the basis that there is an opportunity to explain the scoring tool prior to the painful event. This is not the case with children presenting at the ED with acute pain, which is why we do not think this type of scoring is appropriate for the ED setting where children in pain cannot be expected to consider and accurately interpret a new task. In addition there are some children who deny pain on subjective tools because of fear. This is why we still maintain that subjective scoring is inappropriate for A&E Triage. We also believe that it is possible that our tool underestimates pain and that it requires further research and refinement especially to re examine the parameters of the tool and their relative values to see how it can be improved. This area should be further explored before such methods are rejected. The need for a valid pain scoring tool is to indicate the appropriate level of analgesia to be prescribed. We acknowledge that the area of pain assessment is very complex and are committed to providing the best pain management to all children and would welcome interest, from others, in work to further refine the AHTPS. "The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in EMJ editions and any other BMJPGL products to exploit all subsidiary rights, as set out in our licence(http://emj.bmjjournals.com/ifora/licence.dtl)."

    Competing Interest Please list Competing Interests if they exist, if not please include the

    following statement; Competing Interest: None to declare.

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