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Recent eLetters

Displaying 207-231 letters out of 790 published

  1. 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:

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  2. 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:

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  3. 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:

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  4. 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

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  5. 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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  6. 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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  7. 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:

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  8. 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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  9. 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:

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  10. 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:

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  11. '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??

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  12. 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:

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  13. 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:

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  14. 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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  15. 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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  16. 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

    Conflict of Interest:

    None

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  17. 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

    Conflict of Interest:

    None declared

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  18. 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.

    Conflict of Interest:

    None declared

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  19. 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.

    Conflict of Interest:

    None declared

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  20. Re:A Seventy-Five Year Old Mistake

    I read your letter and understand that you say r22 cant cause phosgene gas. It would be easier to believe this statement if almost everyone that has been soldering in the hvac field weren't overcome with some type of toxin in the process. I just today was soldering in a freezer that uses hp-80 refrigerant and all of the sudden could not breathe. It felt like my lungs weren't working for a half hour or so and I felt dizzy for more than an hour after with my lungs still not feeling right many hours after. This is not the first time this has happened to me, nor every time with hp80, and the reason everyone in the field thinks that phosgene gas is being produced, is they have probably experienced the same fearful, and possibly damaging condition. Also, the hvac field rarely uses propane or butane, almost always actlyene and oxygen. If you say that it isn't being caused by r22 than what is it? Since system lubrication is carried in refrigerant, is this the toxin causing agent? Is it something with the two soldering gases? It is easy to say something "isn't". Giving a reason always seems to be skipped and proves much more difficult.

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  21. Another case of asthma near death averted by chest compression

    The article by Dr. Harrison reminds me of a similar case I treated years ago. A young adult with no prior history of asthma had the first, violent attack of asthma at home and went into respiratory arrest during transport to the emergency service of the small hospital I was working in at the time. The patient arrived unconscious but with carotid pulse still present. The thorax was obviously hyperexpanded and immediate intubation did not allow ventilation: attempts to inflate with air met with great resistance. I therefore proceeded to apply the chest squeezing manouvre: straddling the patient, very gradual but firm pressure with flat, wide-open hands was applied to the anterior thorax pushing the ribs both medially and posteriorly, with air flowing out until the diameter of the rib cage was significantly reduced; expiration by chest squeezing was alternated with inflation of air from the endotracheal tube. As soon as possible adrenaline was administered as well as endovenous hydrocortisone and subsequently salbutamole. Reaction to treatment was swift: spontaneous breathing started little after the use of adrenaline, and in less than ten minutes the patient started reacting to the tube, was extubated and became completely vigilant.

    In less than an hour only mild bronchospasm was present. The patient was transferred for observation and further workup to the main hospital of the area and was subsequently discharged with no untoward effects, in particular no discomfort of the rib cage due to the compressions. I confirm that in the case described chest compression expelled air with relative ease, and that ventilation would not have been possible without this manouvre as no significant expiration was observed after intubation, notwithstanding the evidently hyperinflated thorax. I believe the hyperexpansion to have been due to a muscular effect, perhaps a spasm of expiratory muscles due to fatigue as occurs in common muscular cramps.

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  22. The value of taking a history in patients with chest pain

    In introducing Goodacre et al's paper on low risk chest pain patients, the Primary Survey of the December 2009 issue prompts emergency physicians to reflect on "why [they] take histories at all in this patient group".(1,2) This is, in our opinion, an inappropriate reaction to the results of the study. The patients under investigation were those with a potential diagnosis of a cardiac cause of chest pain, and according to the exclusion criteria were only enrolled if the history and examination in the emergency department had ruled out other serious treatable causes of chest pain such as pulmonary embolism or aortic dissection. As discussed at the end of the paper, it is likely that many patients who had been diagnosed as having a benign non-cardiac cause of chest pain were not included in the study. Additionally, the majority of patients with typical presentations of other conditions such as pneumonia, pericarditis, pneumothorax, cholecystitis, pancreatitis or chest trauma were presumably not included even if chest pain was a major component of the presenting complaint. Therefore the study cohort comprised only those patients with chest pain whose clinical assessment had failed to suggest an obvious alternative diagnosis. Such assessment necessarily involves taking a careful history(3). Of the entire set of patients presenting with chest pain, the study group represents the subset that retains some diagnostic uncertainty despite a careful history.

    To ask why we take a history at all in a group of patients that have already been defined by their history is begging the question. Suggesting to your readers that they may wish to reflect on whether they should take a history at all in this group not only overlooks this point, but invites them to miss other obvious and important treatable illnesses in the rush to "exclude MI". It must be remembered that there are many more diagnostic categories than "acute coronary syndrome" and "non-specific chest pain".

    Only a minority of acute coronary syndromes present with a non- diagnostic ECG(4). What Goodacre's study illustrates is that if we take a group of patients with acute chest pain in whom the underlying diagnosis is not clear, a small proportion will be due to unusual presentations of acute coronary syndromes, and that this subset is not identifiable in advance by their symptoms alone. This is useful because it highlights that if an alternative diagnosis is not obvious then there is scope for doubt and that caution is advisable. It is not an argument for abandoning a careful history, which remains in everyday practice our most useful clinical assessment tool.

    References

    1. Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram Emerg Med J 2009 26: 866-870 S Goodacre, P Pett, J Arnold, et al.

    2. Primary Survey Emerg Med J 2009;26:843 Kevin Mackway-Jones

    3. Evaluating the Patient with Chest Pain: The Value of Comprehensive History. Journal of Cardiovascular Nursing. July/August 2005; 20(4): 226-231 Reigle J

    4. Prognostic Value of a Normal or Nonspecific Initial Electrocardiogram in Acute Myocardial Infarction JAMA. 2001;286:1977-1984 Robert D. Welch, MD; Robert J. Zalenski, MD; Paul D. Frederick, MPH, MBA; Judith A. Malmgren, PhD; Scott Compton, PhD; Mary Grzybowski, PhD, MPH; Sophia Thomas, MD; Terry Kowalenko, MD; Nathan R. Every, MD, MPH; for the National Registry of Myocardial Infarction 2 and 3 Investigators

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  23. Simple buckle fracture? Are you sure of the diagnosis before discharge with no follow up?

    I read with interest the Best Evidence Topic report by May G, Grayson A regarding the follow up of buckle fractures.[1] I agree that buckle fractures should not require routine follow up, however systems need to be robust to ensure that the correct diagnosis has been made. Diagnosis may not be as simple as often believed; several studies researching this topic have inadvertently included fractures other than buckle fractures in their trials, later having to withdraw them.[2,3,4] Misdiagnosis occurred across the board; by emergency medicine, orthopaedic and radiology clinicians.[2,3,4] Others have warned of the need of safety nets to be in place, with emphasis on training and hot reporting.[5] With the reassurance that these measures are in place, we should be able to safely treat and discharge buckle fractures from the emergency department.

    1. May G, Grayson A. BET 3: Do Buckle Fractures of the Paediatric Wrist require follow up? Emerg. Med. J. 2009 26:819-822; doi:10.1136/emj.2009.082891

    2. Plint AC, Perry J, Correll R, Gaboury I, Lawton L. A Randomized, Controlled Trial of Removable Splinting Versus Casting for Wrist Buckle Fractures in Children. Pediatrics 2006;117:691-7.

    3. Davidson JS, Brown DJ, Barnes SN, Bruce CE. Simple treatment for torus fractures of the distal radius. J Bone Joint Surg [Br] 2001;83- B:1173-5.

    4. Oakley EA, Ooi KS, Barnett PL. A Randomized Controlled Trial of 2 Methods of Immobilizing Torus Fractures of the Distal Forearm. Pediatr Emerg Care 2008;24:65-70.

    5. Guly HR. Injuries initially misdiagnosed as a sprained wrist (Beware the sprained wrist). Emerg Med J 2002;19:41-2.

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  24. On the philosophy of diagnosis: Authors' response

    Dear Editor,

    We welcome the thoughtful responses of Dr. Challen and Dr. Cattermole to our paper entitled: On the philosophy of diagnosis: is doing more good than harm better than primum non nocere? Dr. Challen makes two principle criticisms of our review to which we would like to respond.

    1. The existence of reality

    Dr. Challen correctly states that outside the medico-scientific realm, the post-positivist concept that one indisputable reality truly exists is not universally accepted. This is particularly so in the social sciences where, by way of an example, constructivists hold that absolute reality exists only in the form of societal and social constructs. While this may be a helpful aid to certain forms of research, it is seldom of benefit in the scientific evaluation of diagnostic technology.

    In order to provide a diagnosis, we must first accept that there is a disease to be diagnosed. While it is perfectly reasonable to investigate and debate the existence of that disease beforehand we, as physicians, must ultimately accept that specific diseases do exist, that they threaten health and happiness and indeed may lead to death. We must also accept that it is possible for us to recognise the presence or absence of those diseases, albeit imperfectly. This, by definition, is the post-positivist paradigm that must by necessity underpin our scientific approach to diagnosis.

    2. The individualised approach to diagnosis as a refutation of utilitarian ideals

    Dr. Challen comments that, while utilitarian ideals are inescapably embraced in the practice of clinical medicine and can be applied to population-based diagnostics such as screening, they should not be applied to individuals when pursuing a diagnosis. We can certainly appreciate this perspective, but we do not agree.

    Our present approach to diagnostics involves the evaluation of the technology in a sample from a population, from which we may calculate estimates of sensitivity and specificity. These are population-based estimates which we do then apply (probabilistically) to individual patients. This underlies the principle of clinical probability scoring as a supplement to D-dimer testing in patients with suspected venous thromboembolism. Indeed, we may apply similar Bayesian principles to the diagnosis of individual patients on a day to day basis (for example, we may ignore the fact that the chest radiograph is normal if our patient appears to have a high clinical probability of aortic dissection).

    The utilitarian approach we advocate relies on similar principles. As the sensitivity and specificity for all diagnostic tests are imperfect, there is an inevitable compromise to be drawn between false positive and false negative diagnoses. The relative weight that we assign to each of these is currently subjective.

    However, by mapping the sensitivity and specificity to projected outcomes for the patients, it may be possible to appreciate the consequences of implementing any particular diagnostic test more objectively. Further, it would be possible to compare the anticipated consequences using different diagnostic tests and lead to a more informed judgement about which is the preferred investigation.

    In doing this we are certainly not reinventing the wheel. We are simply trying to put it on a better vehicle.

    In response to Dr Cattermole we would say that much of diagnostics and therapeutics is exactly as he describes utilitarianism: the right test or diagnostic strategy, or treatment is one which maximises the aggregate good outcome. In myocardial infarction with ST elevation we could never know for that individual whether thrombolysis would be of benefit, or might be harmful. Looking at the population as a whole more would benefit than be harmed. The same applies for many treatments and diagnostic strategies. Vaccination is inherently utilitarian. The fact that utilitarianism can be used to justify acts which by other standards are immoral does not invalidate the concept.

    Modern medical ethics is not about a single unifying ethical theory. It combines elements of deontology (beneficence and non-maleficence) with justice and autonomy. The NHS is inherently utilitarian in that it aims to maximise the good. We do not have unlimited resources for each patient. We do our best, but there are constraints. Rule out strategies are not infallible but they aim to maximise the good.

    Utilitarianism, as applied to diagnostics or therapeutics, is about the interests of the patient. For most treatments the number needed to treat is more than one. A priori we do not know which patient of the cohort will benefit, so they all get it because overall patients do better with than without that treatment. This is done in the interests of the patient, not of the State.

    Yours faithfully,

    Richard Body and Bernard Foex

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  25. When the Good of the One outweighs the Good of the Many

    I would like to thank Body and Foex for their thought-provoking article, and also Cattermole and Challen for their replies. Too often in the culture of emergency medicine, the philosophical underpinnings of thought and action are neglected. When is there time to reflect?

    One highlight of their discussion of utilitarianism is the inclusion of emotional factors into the weighing of what actions can be counted as Good (or cost-effective). False-positive tests occasion much suffering at times, and this needs to be recognized. Many of our strategies of care would be well served through this form of examination. For example, practitioners who treat indigent patients disrespectfully with the intention of making them reflect upon the error of their ways or use the emergency department less often.

    The challenge of utilitarian analysis is the consideration of all possible ramifications of action, and the subsequent calculation of costs and benefits on all levels - physical, economic, emotional... Faced with such complexity, a return to "primum non nocere" becomes attractive. And yet there needs to be a balance between action guided by ideals and action guided by calculation. It is possible that Hippocrates also said "secundum, consider all consequences of your words and deeds."

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