Displaying 482-561 letters out of 739 published
CRP in the Emergency Department
I read with interest the report of a case of pneumococcal meningitis presenting as ankle pain. Although it discussed the management of an interesting and highly unusual patient, I found it hard to follow the logic of the conclusion that "CRP is an important investigation for emergency departments".
As the authors state, C-reactive protein is an acute phase protein. Levels of CRP are elevated in the serum of patients with acute and chronic inflammatory, infective and neoplastic disorders. A recent systematic review by van der Meer et al. examined the evidence pertaining to the contribution of CRP in patients with lower respiratory tract infections (such as pneumococcus). They found that in 12 studies reviewed the relationship between an elevated CRP and a bacterial aetiology of the infection was poor: sensitivity ranged from 8-99% and specificity from 27 -95%. Other studies in which CRP has been used as a diagnostic tool for other conditions have echoed these findings.
An audit performed by myself in a large teaching hospital Emergency Department found that between 250 and 500 CRP studies were being requested per month. These were being requested indiscriminantly for the full spectrum of presenting conditions, from chest and abdominal pain to one patient that presented with a stab wound! Although individual tests were relatively cheap, because of the numbers being requested the total annual cost to the department was almost £13000. As a literature review at the time found no evidence to support the use of CRP in the ED, departmental policy was altered to prevent the requesting of CRP as routine.
I suspect even the most skilled of Emergency Physicians may have found the diagnosis of pneumococcal meningitis based on a presentation of ankle pain difficult, with or without a CRP result. As CRP lacks the diagnostic specificity to be of help in the initial assessment of the patient, I feel that it is misleading to advocate its widespread use based on this case alone.
1. Huntley JS, Kelly MB C-reactive protein: a valuable acute investigation. A case of pneumococcal meningitis presenting as ankle pain Emerg Med J 2005;22:602-603
2.van der Meer V, Neven AK et al Diagnostic value of C reactive protein in infections of the lower respiratory tract: a systematic review BMJ 2005;331:26-9
Serial Troponin-I measurements are unlikely to be useful in acute colchicine toxicity
van Heyningen and Watson reported a case of acute colchicine poisoning, associated with significant cardiovascular compromise, with elevated troponin-I concentrations, resulting in death. Elevation of cardiac troponin concentrations in acute colchicine toxicity has been previously reported. The authors concluded that in future cases serial 12 hourly troponin measurements should be undertaken in acute colchicine toxicity to predict cardiovascular collapse; however they do not provide evidence for this conclusion.
The basis for the author’s assumption for serial measurement of troponin-I concentrations in acute colchicine poisoning, is that troponin concentrations rose in line with clinical deterioration of their patient. However they report in Table 1 that creatinine kinase and aspartate transaminase, alternative markers of myocardial injury, were also elevated in line with the patients deterioration. In addition to elevation of other biochemical markers of myocardial injury, there is clear history of clinical deterioration and impending myocardial collapse
It seems unclear why the authors have focused on serial troponin-I measurements rather than other biochemical or clinical indicators of cardiovascular collapse. Elevated troponin concentrations not only reflect myocardial ischaemia in the context of underlying coronary artery disease. The finding of raised troponin-I concentrations is not unique to colchicine poisoning and may be found in any patient subjected a severe systemic insult secondary to poisoning, trauma, sepsis, or any other condition causing poor myocardial perfusion. In acute colchicine poisoning hypovolaemia, hypotension and poor myocardial perfusion can result from colchicine-induced nausea, vomiting, diarrhoea and cardiac arrhythmias. Elevation of troponin concentrations probably reflects these clinical features rather than direct colchicine toxicity itself.
Raised troponin-I concentrations may indicate a "sick heart" following overdose of colchicine, however this is neither unique in terms of severe poisoning, or likely to be clinically helpful in guiding provision of the meticulous supportive care indicated for these patients.
1.van Heyningen C, Watson ID. Troponin for prediction of cardiovascular collapse in acute colchicine overdose. Emerg Med J. 2005 Aug; 22(8): 599-600
2.Mullins ME, Robertson DG, Norton RL. Troponin I as a marker of cardiac toxicity in acute colchicine overdose. Am J Emerg Med. 2000 Oct; 18(6): 743-4
3.Jeremias A, Gibson CM. Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded. Ann Intern Med. 2005 May 3; 142(9): 786-91
David M Wood
Specialist Registrar in Clinical Toxicology
Shaun L Greene
Associate Specialist in Clinical Toxicology
Paul I Dargan
Consultant Clinical Toxicologist
Alison L Jones
Director and Clinical Toxicologist
Guy’s Poisons Unit
Guy’s and St Thomas’ Hospital NHS Foundation Trust
Paramedics and thrombolytic treatment
I enjoyed reading the paper by Humphrey et al. exploring paramedics' perceptions of their emerging role in providing early thrombolytic treatment in acute myocardial infarction.
There are some areas requiring clarification however. The NHS Plan did not precede publication of the coronary heart disease National Service Framework (NSF), as stated (the NSF was published in March 2000, the NHS Plan the following July). The consideration of pre-hospital thrombolysis where call-to-hospital arrival time delays exceed 30 minutes was taken from the European Society of Cardiology and European Resuscitation Council guidelines  published some years before either the NSF or NHS Plan, and informed both policies. The 'golden hour' referred to in Humphrey et al.’s paper  is in fact a 60 minute call-to-needle time NSF (and European ) standard whereas the true 'golden hour' is measured from the onset of symptoms rather than the time of call for help. Clearly the aim is to start treatment at the earliest safe opportunity.
The authors set out in their table the 'correct' answer to the questions put to paramedics in the questionnaire, but readers are not given the opportunity to see for themselves the evidence on which these 'correct' answers were based, nor was the questionnaire provided for comment or critical appraisal by readers. The availability of both supporting documents on the EMJ website would have added to the value of what is an important and informative paper, the central conclusions of which - that paramedics should be more engaged in the development of new policies and service improvements - are entirely in concert with the views of this reader.
1. Humphrey J, Walker A, Hassan B What are the beliefs and attitudes of paramedics to prehospital thrombolysis? A questionnaire study. Emerg Med J 2005;22:450-451.
2.The pre-hospital management of acute heart attacks. Report of a Task Force of the European Society of Cardiology and the European Resuscitation Council. European Heart Journal 1998;1140-1164.
3. Boersma E, Maas ACP, Deckers JW, Simoons ML Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996;348: 771-775.
It is unfortunate that while we are trying to raise our profile amongst our colleagues the journal continues to allow the use of the term 'casualty department' by our colleagues in other medical specialties!!!
Treating x-rays not patients
I was very disappointed to read R Kotnis et al.'s article on the manipulation of distal radial fractures. They have based their entire article on outdated evidence and opinion that these fractures all require manipulation (their references 4,7,8,10,11). They have ignored more recent, and frankly much better, evidence (their reference 9) that we should have much greater tolerance of displacement in these fractures, particularly in older patients.
They would have been much better employed researching the functional outcome of patients with these fractures rather than trying to treat their x-rays.
Tension pneumothorax - time for a re-think?
I have two comments to make to the interesting and stimulating article by S Leigh-Smith and T Harris on tension pneumothorax.
1. The number of needle thoracocentesis far exceeds the incidence of tension pneumothorax because it can be difficult to distinguish this condition from a large or even moderate size pneumothorax presenting with rapid respiratory or haemodynamic deterioration in patients with poor cardio-respiratory reserve. The concept of: "the chest radiograph that should never have been taken" may also play a role, as it encourages urgent decompression before the diagnosis is confirmed, even in patients that could have tolerated a short delay and benefited from the chest x-ray. However, this is not an easy decision to make and most would err on the side of caution.
2. Recognized complications associated with the procedure of tube thoracostomy were omitted. Tube blockages, kinks and inadequate positioning within the pleural cavity can cause tube malfunction, which is associated with incomplete evacuation of collections and poor lung re-expansion, variables that predispose to empyema, clotted haemothorax and lung entrapment.[2,3] Non therapeutic tube insertions , accidental removals of the tube and excessive pain during the procedure are also significant complications.
1. S Leigh-Smith, Harris T. Tension pneumothorax-time for a re-think? Emerg Med J 2005; 22 (1): 8-16.
2. Millikan JS, Moore EE, Steiner E, et al. Complications of tube thoracostomy in acute trauma. Am J Surg 1980; 140: 738-741.
3. Fallon WF. Post-traumatic empyema. J Am Coll Surg 1994; 179: 483- 491.
4. Schmidt U, Stalp M, Gerich T, et al. Chest tube decompression of Blunt chest injuries by Physicians in the Field: Effectiveness and Complications. J Trauma 1998: 44 (1): 98-101.
Re: incorrect table
We would like to thank our colleagues from St Vincent's Emergency Department. They are right about the error in table IV. At 20 minutes places of systolic and diastolic pressures were exchanged.
Thank you for your interest,
Dr. Zulfi Engindeniz
Treatment of epistaxis in the ED
I read with interest Leong et al.’s article on the management of epistaxis and I would like to add some tips that I would consider useful.
In the treatment of ‘active’ anterior epistaxis, merely spraying the anterior cavity with a combination vasoconstrictor and local anaesthetic is often not enough to stem the bleeding. Using cotton wool, one can form a wick of about five cms long, and, after soaking it in a solution of constrictor / anaesthetic, apply it with a Tilley’s forceps into the bleeding nasal cavity. Ask the patient to apply digital pressure to the nose for about ten minutes. The increased contact to the bleeding point in Little’s area is more likely to stem the bleeding, and can then be localized and cauterized.
The ‘scorched earth’ technique of cauterizing a general area in the hope of stopping the bleed is not to be entertained, as there is increased risk of septal cartilage necrosis. Using a torch and not a headlamp, and failure to use a nasal speculum contributes to the aforementioned. If a bleeding point cannot be identified, cautery should not be attempted. The origin of the bleed might be posterior.
It is advisable to discharge patients with anterior epistaxis (that have been successfully treated) with an ointment/cream. If your department does not have Naseptin, one can advise the patient to put Vaseline on a cotton bud, and gently roll it onto the affected area couple of times a day. This stops the scab from drying out, becoming itchy and then picked off prematurely, leading to rebleeding.
The digital pressure applied to the nose in figure 1(B) is better applied with the fingers in a flexed, fist-like position and the dorsal aspect of the middle phalanx of the index finger resting on the maxilla. The pinch action is then completed by applying the palmar aspect of the interphalangeal joint area of the thumb to the lower part of the nose on the other side.
1. S.C. Leong, R.J. Roe, A. Karkanevatos. No frills management of epistaxis. Emerg Med J 2005;22:470- 472.
The EFAST for post-traumatic pneumothoraces
We appreciate both the effort towards and the conclusions of the recent Best evidence topic report (BET) by Jaffer and McAuley that concluded that bedside clinician-performed ultrasound may detect post- traumatic pneumothoraces. We hope to take the opportunity to follow up on their comments. In terms of methodology, the CT radiologists were blinded to the results of the US. Most importantly, all US studies were performed as the first imaging study, prior to the availability of any other imaging information. It is a very minor point to note that the country of the study should be Canada. We completely concur that further studies regarding the integration of these techniques into the trauma resuscitation are warranted.
Great article but do all packed noses need admission?
I congratulate the authors on the excellent step by step guide to management of epistaxis. A useful guide for juniors to use.
From my experiences in my previous post in Perth, I would disagree that all patients who need packing have to be admitted. Patients who either ourselves or ENT had packed and had no further postnasal bleeding, and were deemed safe for discharge, were sent home to be reviewed for pack removal in 24 hours. If patients are given safe discharge instructions is there a reason to routinely admit this group?
Re: complications following attempted rapid sequence intubation
Dr. Hulme raises several important points. First, Rapid Sequence Intubation is not to be taken lightly even by experience physicians. It is fraught with danger that can be disastrous.
Second, I fully acknowledge that the second dose of succinylcholine should not have been given, but do not feel that this would have played out any differently. This patient had been loosing his airway even before attempted RSI, and would have required one form of definitive airway. As stated in the article, several attempts by the Attending Anesthesiologist at nasal intubation were also unsuccessful.
I also acknowledge that Malignant Hyperthermia should be considered in the differential diagnosis for massester spasm. However, as stated in the discussion, this patient had no other cardinal manifestations of MH. Unfortunately no biopsy was performed, so we will never know if he was susceptible or not.
Finally, discontinuing anesthesia is appropriate during elective procedures (as stated in the article), however this is not always prudent in emergent cases.
MAJ (Dr.) Steven Bauer
Targeting the Targets
In his recent letter to this journal, Dan Ellis writes regarding the growth of See and Treat "the public perception of see and treat will be that it is acceptable to come to the emergency department instead of going to your GP". He continues that we in emergency medicine "are trying to persuade the public that only emergencies should come to emergency departments".
Another key element is that the increase in primary care type attendances to Emergency Departments (ED) are subject to the 4-hour emergency care target.
We, along with most other EDs continue to see a steady rise in attendances. In the second quarter of this year (April-June 2005) our ED saw an increase of 8% compared to the same quarter in 2004. The increase in the number of patients with primary care problems is particularly apparent at the weekend. Procedures for the redirection of such patients to primary care are incomplete, so ED doctors and ENPs are having to assess these patients. These patients obviously fall within the 4-hour target and on occasions great pressure is exerted to distort clinical priorities in order to achieve the target.
How many other specialties are faced with targets that do not specify the patient group? At the very least, GPs and cancer specialists have an obligation to see only urgent requests for appointments in their respective prescribed time frames. Surely it would not be unreasonable to define what constitutes an "emergency" and then limit the 4 hour target for emergency care to that patient group. This would help relieve the mounting pressure on EDs and perhaps deflect some of the pressure to provide primary care services back to primary care service providers.
1. Ellis DY. "See and treat" is great - if you’re a general practitioner. Emerg Med J 2005; 22:234
Herpes Zoster in HIV infected: two first reports (old) of unusual complications
Having read the interesting, detailed and very well written case report by Goddard R , I was reminded of two very unusual manifestations of herpes zoster that had also led me to search for underlying HIV infection. In a patient with HIV infection, herpes zoster can manifest in dramatic manner, that maybe not that well known.[2,3] First is about a patient who had developed herpes zoster rash over T5-6 (RT), which was confirmed by serological tests and Tzank smear. HIV test was also found positive. While in hospital, three days after appearance of herpetic rash, the patient had complained of a vague chest discomfort with giddiness, when a muffled first heart sound along with bradycardiaand non- specific ST-T ECG changes were detected. His ESR, that was 02mm initially, was now detected at 85 mm. Simultaneously the cardiotropic enzymes were studied which also showed elevation and slow return to baseline along with the ESR, consonant with the recovery of this patient.
The next unusual manifestation seen with herpes zoster was that of dermatomal and disseminated rash, afflicting a HIV infected patient , whose HIV status once again came to light following his unusual presentation like in the earlier case above. Both these patients survived their presenting illnesses (despite my best efforts). They received an antibiotic cover for prevention of secondary infection, along with symptomatic therapy and multivitamins, and no cardiac drugs or antivirals were given. Facilities for determining CD4/CD8 counts were not available. They were kept under very close observation and bed rest, with measures ready to intervene if need be.
Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS. Consultant, Family Medicine & Communicable Diseases.
Dr. Akhilesh Kumar Singh MBBS, MD.
Dr. Parul Kushwah MBBS, MISMCD.
1. Goddard R. The reawakening of a sleeping little giant. Emerg Med J 2005; 22: 384-86.
2. Myocarditis in Herpes Zoster. Chauhan R, Singh RP, Hooda AK et al. JAPI 1996; 44(6): 427-28. (PubMed; PMID: 9282569).
3. Dermatomal and disseminated Varicella Zoster lesions in a HIV infected individual. Chauhan R, Singh RP, Hooda AK, Vadhera V, Singh VP, Mabena DMS. MJAFI 1996; 52: 55-6 (IndMed) (http://medind.nic.in/cgi/siss.pl?plrd+MFN-017308).
Complications following attempted rapid sequence intubation
The case report by Bauer et al. highlights that problems occur following rapid sequence induction (RSI) and may lead to invasive procedures. These can cause harm to the patient.
There are other lessons to be learnt that the authors have not elaborated upon.
The presence of fasciculations and flaccid paralysis following the first dose of suxamethonium indicated the onset of the expected effect.
Despite masseter spasm, the patient could be easily ventilated with a bag and mask. Subsequent deterioration in oxygenation after some time resulted in a surgical airway.
A significant learning point omitted from the authors' summary was the administration to this patient of a second dose of suxamethonium in the presence of masseter spasm. This should not have occurred for two reasons.
1. Masseter spasm is an early sign of malignant hyperpyrexia (MH), which has a mortality rate even with dantrolene of around 5%. Suxamethonium is a significant precipitant in susceptible individuals.
2. Repeated doses of suxamethonium change the paralysing effect of the drug from one that wears off within 3-5 minutes ("Phase I block") to one resembling a non-depolarising neuromuscular block ("Phase II block") which lasts significantly longer. It has been long established that this type of block may begin at doses of 2mg/kg.
The appropriate action when unable to intubate, is to maintain oxygenation, call for experienced help and strongly consider terminating anaesthesia. In this case, the need for a surgical airway may well have been avoided.
Repeated doses of suxamethonium can disproportionately extend the duration of paralysis and may add to a developing, potentially fatal condition (MH) caused by the first dose.
The process of inducing anaesthesia and paralysis is not usually as difficult as dealing with the problems that may arise if things do not go smoothly. Practitioners should be aware of the adverse effects of drugs they are using and be able to instigate appropriate methods of dealing with problems before undertaking RSI.
1. Bauer SJ, Orio K, Adams BD. Succinylcholine induced masseter spasm during rapid sequence intubation may require a surgical airway: case report. Emerg Med J 2005; 22: 456-458
2. Lee C. Dose relationships of phase II, tachyphylaxis and train-of- four fade in suxamethonium-induced dual neuromuscular block in man. Br. J. Anaesth., Aug 1975; 47: 841 – 845.
3. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Henderson JJ, Popat MT, Latto IP, Pearce AC; Difficult Airway Society. Anaesthesia. 2004 Jul;59(7):675-94.
Focused emergency ultrasound
As a radiologist, I read with interest the recently published paper by R McLaughlin et al concerning emergency department ultrasound. At the time the article was written, there has been an absence of agreed UK accreditation guidelines. However, recently the Royal College of Radiologist has published ultrasound training recommendations for medical non radiologists. This included Focused Emergency Ultrasound (FEU). Recommendations of training included both theoretical (physics, techniques, anatomy and pathology in relation to ultrasound) as well as practical aspects, which lead to three levels of competency.
There are certainly benefits of FEU but it is important to be aware of the limitations. It is primarily used to answer specific questions. For example, to look for pericardial/pleural effusions, abdominal aortic aneurysms, abdominal free fluid and deep vein thromboses.
There is also the risk of misdiagnosis. Would the practitioner recognise other causes for abdominal pain when scanning for abdominal aortic aneurysm or other causes of leg swelling (for instance Baker’s cyst or a soft tissue sarcoma) when scanning for DVT?
Therefore, education by an experienced radiologist is essential. Training should be adequately funded so that this does not adversely affect the service provision to patients and the training of radiologists and sonographers. Finally, it is important to audit this type of service to ensure and maintain high clinical standards.
1. R McLaughlin, N Collum, S McGovern, C Martyn and J Bowra Emergency department ultrasound (EDU): clinical adjunct or plaything? Emerg Med J 2005; 22:333-335.
2. The Royal College of Radiologists. Ultrasound Training Recommendations for Medical and Surgical Specialties. Jan 2005 http://www.rcr.ac.uk/index.asp?PageID=310&PublicationID=209.
Primary spontaneous pneumothorax: evidence-based revision of management guidelines
The British Thoracic Society (BTS) guidelines for the management of primary spontaneous pneumothorax (PSP) recommend simple aspiration as the first line treatment for all cases of PSP requiring intervention. However, studies in the UK have shown that compliance is poor, and that simple aspiration is under-utilised.[2-6] Henry et al. suggested that poor compliance may be due to an unwillingness to aspirate. Medical staff tends to have concerns over the increased likelihood of failure of simple aspiration for larger pneumothoraces. But are these concerns actually justified?
In a prospective randomised controlled trial comparing simple aspiration (n=35) against chest tube drainage, a logistic regression model did not find any association between failed aspiration and initial size of pneumothorax. Similarly, Markos et al followed 40 cases of spontaneous pneumothoraces (including primary, secondary and iatrogenic) treated by simple aspiration, and found that outcome was not influenced by initial pneumothorax size.
However, other studies have demonstrated a trend that larger pneumothorax size is associated with failed aspiration. These included one prospective study (simple aspiration, n=34) by Ng et al from Singapore; two retrospective audits (simple aspiration, n=43 and n=32 respectively);[2,5] and a series of 41 cases reported by Ansari et al. All these studies included cases of secondary pneumothorax. Nevertheless, none of these studies were able to demonstrate statistical significance for this observed trend.
We showed, in a study recently published, that larger size of pneumothorax is significantly associated with failed aspiration. We retrospectively studied 91 consecutive cases of PSP treated by simple aspiration. All cases were treated at the emergency department of an university teaching hospital in Hong Kong, China, over a two-year period. Our protocol had closely followed the BTS guidelines. The overall success rate was 50.5%. Failed cases had significantly larger sizes of pneumothorax (p <_0.0005. furthermore="furthermore" pneumothorax="pneumothorax" size="size"> 40% was significantly associated with failure (p <_0.005. in="in" a="a" multivariate="multivariate" analysis="analysis" pneumothorax="pneumothorax" size="size" _="_">40%¡¦ compared to size ¡¥21-39%¡¦ independently predicted failure, with an odds ratio of 8.88 (95% CI, 2.49 to 31.63). The success rate for patients with pneumothorax size 40% or larger was only 15.4%.
Based on evidence from this study, our guidelines for the management of PSP, published in 2000, have been revised. For patients with pneumothorax size 40% or above, simple aspiration is no longer the first line treatment, and chest tube drainage is the preferred modality.
1. Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax. 2003;58(Suppl II):ii39-ii52.
2. Soulsby T. British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work? J Accid Emerg Med. 1998; 15(5):317-21.
3. Selby CD, Sudlow MF. Deficiencies of management of spontaneous pneumothoraces. Scot Med J. 1994;39:75-76.
4. Yeoh JH, Ansari S, Campbell IA. Management of spontaneous pneumothorax ¡V a Welsh survey. Postgrad Med J. 2000;76:496-500.
5. Mendis D, El-Shanawany T, Mathur A, et al. Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed? Postgrad Med J. 2002;78:80-84.
6. Courtney PA, McKane WR. Audit of the management of spontaneous pneumothorax. Ulster Med J. 1998; 67(1):41-3.
7. Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with healthy lungs. BMJ. 1994; 309:1338-9.
8. Markos J, Mc Conigle P, Phillips MJ. Pneumothorax: treatment by small-lumen catheter aspiration. Aust N Z J Med. 1990;20:775-781.
9. Ng AW, Chan KW and Lee SK. Simple aspiration of pneumothorax. Singapore Med J. 1994; 35(1):50-2.
10. Ansari S, Seaton D. Can the chest radiograph predict early outcome of spontaneous pneumothorax? (Abstract) Eur Respir J. 1996;9(suppl 23):211.
11. Chan SSW, Lam PKW. Simple aspiration as initial treatment for primary spontaneous pneumothorax: results of 91 consecutive cases. J Emerg Med. 2005
12. Chan SSW. Current opinions and practices in the treatment of spontaneous pneumothorax. J Accid Emerg Med. 2000;17:165-169.
Proactive approach needed for better health: recommendation for annual medical examinations
Like any other machinery, the human body also undergoes deterioration with age. Timely checks, maintenance and corrective actions may lead to better health outcomes. A regular medical examination each year, or more frequently, can serve the purpose of stubbing out the fire before the flame starts. A stitch in time saves nine; timely corrective action can be taken. Catching a problem early shall help improve the overall outcome and would also improve patient satisfaction tremendously. A detailed workout has to be planned for the elderly as illustrated in Box 1:
• History: present illnesses, previous medical illness, hospitalization.
• Family history: chronic ailments, sudden death, medication history.
• Personal history: bowel & bladder, alcohol, smoking, including passive smoking, nutrition and diet.
• Type of medical cover enlisted, medical insurance etc.
• Vital Parameters: Pulse, BP, respiratory rate, standing height, weight, hip-waist ratio, skinfold thickness.
• Mini-mental status exam and rapid psychological assessment.
• Vision and hearing.
• Dental examination.
• Laboratory investigations: Haematocrit, ESR, urine analysis, blood sugar, urea, creatinine, lipid profile, liver function test, thyroid profile, PSA in males.
• Plain X-ray chest.
• Resting ECG.
• Pulmonary function tests.
• Dual energy x-ray absorptiometry for early detection of osteoporosis.
• Dermatological assessment.
• Systemic examination: cardiovascular, respiratory, central nervous system, abdomen including hernia, external genitalia, PR and PV examination (including Papanicolaou smear). Breast examination can be included for females.
There would be a tremendous burden on the health system initially. However, with time it would be realized that having detected any budding problems and having taken due care of it, the overall workload shall reduce tremendously. Depending on the prevailing health status and the burden of diseases, the above recommendation can be suitably altered. This will definitely improve upon the health status of the aged and also lead to better clientele satisfaction levels.
Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD
Consultant, Family Medicine & Communicable Diseases.
Dr. Akhilesh Kumar Singh. MBBS, MD
Sr Resident Neurology
Dr. Parul Kushwah. MBBS, MISMCD
Family Medicine Practitioner.
Limits of agreement and confidence intervals
Dr Müllner is wrong and Johnston and Murphy are correct. The limits of agreement are not a confidence interval but a range within which we expect most differences to lie. We expect for any sample from a Normal distribution that 95% of observations will be within 1.96 standard deviations from the mean. Here, 95 of differences, between arterial and venous potassium measurements will lie between –1.182 mmol/l and 1.394 mmol/l (see Bland and Altman, Lancet 1986; i: 307-310).
The same paper describes what to do if the differences between the two measurements get larger for larger average values, i.e. when the potassium level is greater. From Figure 2. in Johnston and Murphy, this is the case here. A log transformation enables us to estimate the 95% limits of agreement for the transformed data as −0.247 to 0.293. If we antilog these, we get 0.78 to 1.34, meaning that we estimate that the arterial measurement may be as little as 78% of the venous measurement, i.e. 22% smaller, or as high as 34% greater. If we drop the obvious outlier, where there may be some reporting or transcription error, these limits become 17% smaller to 22% greater. Whether this means that agreement is inadequate is, of course, a clinical rather than a statistical decision.
When 'first seizure' is not a seizure
The authors of 'Early management of adults with an uncomplicated first generalised seizure' touch briefly on the important differential diagnoses. However, they suggest that when the diagnosis is in doubt that a psychiatric history should be taken. This is unlikely to yield much in the way of useful information, unless of course the patient is suffering from panic disorder or generalised anxiety disorder. In which case it would be better if the authors had mentioned these specific conditions. A psychosocial history may be more revealing.
Likewise they recommend the possibility of referral to a psychiatrist, I cannot think of any occasion where either a patient presenting with a pseudo-fit or a panic attack would be appropriately referred to psychiatry. On the other hand, referral back to the GP would be entirely reasonable.
One must remember that psychiatry is a speciality and appropriate referral needs to be made for patients with a particular diagnosis which requires specialist intervention. These symptoms are neither life threatening nor specific to any of the major psychiatric illnesses with the exceptions that I have already mentioned. Both generalised anxiety and panic disorder would definitely require continued assessment in primary care before they came to the attention of the overloaded psychiatric services.
We are grateful for your comments on our recent review of tension pneumothorax (TPT) and it is especially useful to have the opinion of someone with as much clinical experience of the condition as yourself. We do not have all the answers and have attempted to highlight some of the difficulties involved in the present understanding of this condition – hence the title of the review; "...time for a re-think"! From a thorough review of the literature we certainly feel that there has been inappropriate extrapolation of evidence between different patient populations leading to a need to question the accepted dogma.
Referring to the incidence of the condition and whether it is a “tension” or “large” pneumothorax: With any pneumothorax until the pleural defect has healed the size of the pneumothorax will be a balance between the rate at which it is accumulating and the rate at which it is being absorbed. Apart from case’s where there is a large pleural defect and these two processes are in perfect balance all other pneumothoraces will be either expanding or resolving.
Expanding pneumothoraces clearly have the potential to continue this process until they cause clinical compromise followed by decompensation and eventual death – but this would appear to be a very rare occurrence. It is however possible that there is a sub-clinical expanding phase in a large number of the pneumothoraces that we presently call “simple” and some of these may even have transiently positive intra-pleural pressure (IPP). Whether this is the case will remain un-answered until the IPP is measured in a large series of patients with pneumothorax – a study we hope to perform. Correlation between IPPs and the patients natural history may help in the risk management of patients with pneumothorax – specifically the questions of whether to aspirate, drain or simply observe patients with a pneumothorax.
The definition of a tension pneumothorax (TPT) depends on where in it’s natural history we define it. The spectrum encompasses: transiently positive IPP, clinically compensated compromise, decompensation and finally pre-terminal. The haemodynamic compromise definition used by ATLS and DSTC is a practical one that highlights the low risk-benefit ratio of draining a possible TPT in a hypotensive patient thus potentially saving a life; a recommendation with which we agree. This is defining TPT at a point after decompensation and may be acceptable for ventilated patients. However, one of the strongest recommendations in our article was (and still is) that TPT should be considered in two groups - spontaneously ventilating (SV) and mechanically ventilated patients – as it has a different natural history and clinical presentation in these two groups.
Hypotension is one of the most reliable signs in ventilated patients but is rare in SV patients. This is supported by the SV animal studies and SV human case reports (of which we now have 29 rather than the 18 cited in the original article). SV patients will manifest severe hypoxia and in many cases respiratory arrest before haemodynamic compromise occurs. Hence in SV patient’s haemodynamic compromise lacks sensitivity and (particularly in trauma) also lacks specificity. Clearly therefore a definition is needed at an earlier stage in the conditions development in SV patients which is why we suggest a clinical definition of: “...‘significant respiratory or haemodynamic compromise (the latter especially in ventilated patients) that reverses on decompression alone’—that is, without chest drain placement.”
The 18 patients included in box 3. had rigid inclusion criteria applied to them – that we should have mentioned in the article – i.e. only case reports where a significant clinical improvement (SpO2, HR, RR, BP) or a persistent outwards hiss of air occurred following decompression alone. We therefore consider them to be in keeping with our definition of a clinical TPT and the data from them to be valid. From these (and the further 11 SV case reports subsequently identified) both tracheal deviation and raised JVP are very rare findings.
Since this article was written we have also seen at least 4 patients with medical and traumatic TPT’s who manifested extreme respiratory distress, markedly deviated mediastinum on CXR and persistent outwards hiss of air on thoracostomy but all of whom had central trachea and flat neck veins – despite persistent checking. With a 50:50 odds ratio of correctly identifying tracheal deviation anyway we must further question it’s usefulness but would be interested to know how much use your team finds both these signs. We plan to do a case series of the clinical signs in SV patients and hope you will enter the eligible ones of your own into it.
We thank you for your useful comments on arterial embolism and freely acknowledge this should have been mentioned. However, we question the incidence of 1%.
The frequency with which TPT is diagnosed in ventilated patients is probably appropriate. Both of us however have experience in SV patients of TPT being over-diagnosed/over-treated in markedly hypotensive patients who are only mildly breathless whilst being under-diagnosed in severely breathless normotensive patients – especially if the examining clinician interprets that their trachea is central and the neck veins are flat. We hope to re-dress this balance by emphasizing the importance of a thorough visual thoracic examination and erasing the assumption that a central trachea has a 100% negative predictive value.
We certainly do not wish to contribute to the present indiscriminate use of needle thoracocentesis and hope that this trend will be reversed. Instead we hope that more accurate consideration of the diagnostic symptoms/signs (particularly in the pre- hospital environment) and in hospital the immediate use of CXR - for dyspnoeic patients in whom pneumothorax is a possibility – will limit decompression to those who really need it. We would also like to see tube thoracostomy as the primary treatment in the majority of cases once the diagnosis is suspected for valid clinical or radiological reasons.
With thanks again for your interest and comments.
Simon & Tim
Oxygen - how much and why?
Mercury: Is it elemental my dear Watson?
CONGRATULATIONS for such a nice, lucid presentation of a case. I just wanted to know with the parameters given "On examination she was alert. The airway was patent. Her pulse was 96, BP 106/71, RR14, oxygen saturations 98% on air." How much oxygen is been given and with what objective parameters as end point?
Umesh Chandra Ojha M.D.
Pulmonologist and intensivist.
Having read Demircan et al. we think there is an error in table 4. We believe that the SBP and DBP results are inverted at the 20 minute mark and the authors should be alerted. Please let us know if we are wrong.
1. C Demircan, H I Cikriklar, Z Engindeniz, H Cebicci, N Atar, V Guler, E O Unlu, and B Ozdemir Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation Emerg Med J 2005; 22: 411-414.
Stilettoed in the Sixties
One of the wonders of emergency medicine is that there are almost as many different causes of injury as there are injury types. It is therefore not surprising that there are a myriad of case reports in the literature describing unusual objects causing injury. However, some stories have already been told.
I read the case report by Stables et al entitled “An unusual case of a compound depressed skull fracture after an assault with a stiletto heel” in the April 2005 issue of the Emergency Medicine Journal, and was struck with the thought that this must have been described before. How could we have come through “The Swinging 60’s” without this incident having occurred? Indeed, after a very brief search of “Google” using the keywords from the article ‘skull fracture ; stiletto heel’, the third result is of a case report in the British Medical Journal by Ahmed on “Stiletto Heel penetrating fractures of the skull” dated 1964.
This highlights two important points. Firstly, it is important to remember that the regular Medline database only includes articles from 1966 to the present day, and it is necessary to search OldMedline for articles prior to 1966, or use Google as an obliging alternative.
Secondly, don’t aggravate a girl with stiletto heels.
Recognising depressed skull fractures before CT scan
We were interested in reading Stables et al.s’ account of a compound depressed skull fracture following an assault with a stiletto heal. They remind us to look thoroughly for a fracture in patients with scalp lacerations where the laceration was caused by some force. We recently had a similar case where a depressed skull fracture, under a laceration, was not found clinically. The fracture was seen on CT scan, performed because the patient had a fit. The incident raised our awareness of the potential for an underlying fracture and may change our departmental practice.
Stables et al comment on the guidelines published by The Society of British Neurological Surgeons in 1998 in which an indication for skull x- ray is a scalp laceration longer than 5 cm. They also mention that the depression is often not appreciated on x-ray, making the point about a need for careful examination of the wound, as the depression might not lie directly below the wound. This is obviously an important point, as this is how fractures can be missed in spite of wound exploration. In future cases in our department, we are likely to consider early CT imaging, as x-ray is unable to help diagnose brain injury.
Trauma calls and the general surgeon
R.G. Dattani and colleagues have raised important issues regarding the role of a General Surgeon within a Trauma Team.
I would disagree that the role of the General Surgeon should be confined to assessing the patients abdomen. The General Surgeon should be just as comfortable as the Emergency Physician in performing the role of Trauma Team Leader. I am concerned that one of the messages of this article is that General Surgical trainees require no training in Trauma Team leadership skills as they would only be required to perform specific technical roles such as a laparotomy.
The description of patients injuries in the article lacked objective measures such as the Injury Severity or Revised Trauma Scores. With the absence of this additional data I do not believe that the authors can make robust general recommendations regarding the constitution of Trauma Teams across the country. In my experience injury patterns differ significantly as one moves from one county to the next and indeed from one catchment area to another. Each hospital has to decide what would be an appropriate trauma response having analysed the type of trauma received.
Neuroimaging in adults with an uncomplicated first generalised seizure – CT or MRI
Neuroimaging is important in the assessment of an uncomplicated first generalised seizure. MRI is the investigation of choice . CT scanning is more readily available to the emergency department and is therefore more likely to be performed . There are however potential problems.
With early seizure clinic follow up, it is likely the specialist would request a MRI and therefore the patient would have received unnecessary irradiation by the CT scan. There is also the issue with resources especially with the increased number of requests of CTs due to the NICE head injury guidelines. However, if MRI is not requested, there may be missed pathology.
Providing that there is no focal neurology and that the patient has fully recovered post seizure, a sensible approach would be to perform an early MRI as an outpatient and then the patient can be reviewed in the clinic with the results. This has certainly worked well within our institution.
1. Scottish Intercollegiate Guidelines Network. Diagnosis and management of epilepsy in adults. April 2003.
2. M J G Dunn, D P Breen, R J Davenport, and A J Gray. Early management of adults with an uncomplicated first generalised seizure. Emerg Med J 2005;22:237-242.
There is a lack of other professionals for ECPs to be compared with
I too enjoyed the paper, "The emerging role of the emergency care practitioner" submitted by S.Cooper et al. I was gratified to see that Suzanne Mason had read the paper and replied.
My thoughts on the suitability of the paramedic and ECP comparison, however, differ from Dr Mason's. Whilst I accept the comments in her letter with particular reference to the training and education of paramedics and thus their ability to carry out a similar role, I have to ask the question, who should we be compared with for the purposes of this type of paper?
The role of the ECP is so relatively new and in real terms one that occupies a unique position within the NHS that comparison with any individual group may well be inappropriate. However the starting point of paramedics is a valid one, not least in terms of the patients seen within the study.
With the forthcoming completion of the SCHARR national study on ECP's I look forward to seeing some further research and evidence on a broader basis. Which will help with future developments of the ECP role across the country.
Tension Pneumothorax - does it really occur that often?
I write regarding the review published in the EMJ , a photocopy of which was presented to me by a student paramedic to comment on. I take this opportunity to submit a rapid response.
You correctly state that the definition of Tension Pneumothorax is difficult to pin down early in your article and that the various definitions contain combinations of various criteria. With this I concur. International ATLS and DSTC consensus currently still require the following: (Commenting on Box 1)
1) Haemodynamic comprimise.
2) Evidence of mediastinal compression - not necessarily SHIFT of trachea, since the effect of air under pressure is to expand, thus exerting more expansile pressure that liquid.
3) Cardiac inability to fill due to this relative compression - which then leads to a raised JVP, which may not necessarily distend the neck veins, but this usually occurs.
The question must, therefore, be posed as to whether the "other" cases of TPT in the human studies such as the London pre-hospital study, were not just large PT's rather than true TPT's - this remains the contention of such people as the great Ken Mattox, which implies they should be managed with chest drain rather than needle. Thus, it must also be questioned if the clinical details summarised in Box 3 can truly be said to reflect the real incidence in true TPT.
I therefore have to take issue with your recommendation in the summary to "de-emphasise" tracheal deviation and venous engorgement, since I feel this will lead to an increased incidence of over-diagnosis of a condition which is already probably over-diagnosed. Rather, it should be emphasised so as to discriminate a large pneumothorax from a tension pneumothorax.
You also fail to include the complication in your Box 10 which is specifically said to be related to NEEDLE decompression, namely arterial air embolism, in patients who do not actually have a TPT (1% incidence according to Mattox in his textbook TRAUMA ).
From personal experience, running a trauma unit in South Africa, where we see 800 - 900 simple PT or HT patients annually and another 400 - 500 with additional injuries, I can say that we consider less than 1% of them to have had a TPT, both clinically (or on history if decompressed by EMS paramedics) and NO fatalities have occurred by waiting for the conventional tube chest drain rather than doing needle decompression in the majority, indeed we (in-hospital) have only "needled" two chests in the last three years!
I would concur that true TPT is more common in the ventilated trauma patient, particularly with rib fractures and we have a policy of ipsilateral or bilarteral prophylactic chest drains in all major rib fracture patients, particularly if they have a co-existent lung contusion.
I thank you for considering these comments.
Dr T C Hardcastle, M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA), General Surgeon (Trauma and ICU)
ATLS and DSTC instructor, Intern program Coordinator: Surgery, Program Manager: Emergency Medicine (U.S.), Operational Head: Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064, Tygerberg Hospital / University of Stellenbosch, PO Box 19063, Tygerberg 7505, Western Cape, South Africa
2 Lorient Close
7560, Western Cape
1. Leigh-Smith, Harris: Tension Pneumothorax - time for a rethink? EMJ 2005;22:8-16.
2. Pneumothorax and systemic air embolism during positive-pressure ventilation. Anesthesiology.1999 May;90(5):1479-81.
Alcohol and drugs with driving
I have read the article by Pileggi et al.  and have following disagreement with the author.
Firstly, The authors have not studied whether the drivers under their study have taken alcohol or psychoactive drugs or not. Drinking and driving causes more accidents and fatalities [2,3]. It is also seen that injury severity score increases with increasing alcohol level . In Spain, alcohol was detected in 50.5% fatalities  and in another study, drugs were found in 19% of fatalities and it was seen that alcohol was the main causative factor conducive to fatal road traffic accidents . It would have been better if the authors have tried to correlate the level of urgent care with drinking and drug use.
Secondly, I don't agree with the statement "we do not expect a high number of fatal accidents in this area." I don't think there are less fatal accidents where at least 424 accidents incur within 10 months' duration and the drivers visit one hospital . The authors have not given the previous data of deaths due to accidents to prove their statement.
1. Pileggi C, Nicotera G, Angelillo IF. Attendance at a hospital emergency department by drivers involved in automobile accidents in Italy. Emerg Med J 2005;22: 246-250.
2. del Rio MC, Alvarez FJ. Alcohol use among fatally injured drivers in Spain. Forens Sci Int 1999; 104:117-125.
3. Seymour A, Oliver JS. Role of drugs and alcohol in impaired drivers and fatally injured drivers in the Strathclyde police region of Scotland, 1995-1998. Forens Sci Int 1999; 103: 89-100.
4. Deutcha SR, Christian C,Hoyerb S et al. Drug and alcohol use among patients admitted to a Danish trauma centre: a prospective study from a regional trauma centre in Scandinavia. Eur J Emerg Med 2004; 11:318-322.
Confidence interval incorrectly explained
While the results of this study appear very useful there are two issues. One is more of a theoretical nature: the interpretation of the 95% confidence interval; the second has something to do with external validity: potential selection bias.
Interpretation of the confidence interval:
In the abstract the authors state that "...the 95% limits of agreement were wide (–1.182 mmol/l to 1.394 mmol/l) — that is, 95% of differences will lie between these limits." This is wrong. The 95% confidence interval means that in 95% of the cases (i.e. if we would repeat such a study many, many times), the average(!) difference will lie within. In terms of clinical practice this means something completely different.
It seems that this observed mean bias and the wide confidence interval are cause by a single or maybe two outliers (patients #1 and #9). This makes the confidence intervals of this study not very trustworthy
Potential selection bias:
Over 10 months 50 patients were recruited. How many were admitted for cardiac arrest and what were the reasons for not having both analyses? Without this information we cannot interpret the findings.
In conclusion, this study is a first step but the findings should be validated in a prospective study before they can inform clinical practice.
Marcus Müllner, MD MSc
We are grateful to Dr. Exton for allowing us to expand on the case we reported recently . Our patient’s past history of widespread vascular disease included previous MI, CABG and heart failure which is why her therapy included enalapril 5 mg b.d., Bumetanide 2 mg od, and Bisoporolol 5 mg od. We were not unduly alarmed therefore to find that her urea had been elevated at 15.3 mmol/l with serum creatinine 135 umol/l three weeks before admission. A degree of renal impairment has always been an acceptable compromise, in our view, for keeping the lungs free of fluid in patients with heart failure, and is anyway a normal haemodynamic response to ACE inhibition. While we would fully accept that salt and water depletion from any cause can lead to acute renal failure, we are struggling to believe as Dr. Exton may be implying, that the Bumetanide was in any way inappropriate in this patient’s case, or that it was the main reason why she developed acute renal failure with life threatening hyperkalaemia. Our patient continues to do well, incidentally, with blood pressure 124/73 mm Hg, serum potassium 4.6 mmol/l, blood urea 9.7 mmol/l and serum creatinine 115 umol/l 2 years after her presentation with acute renal failure, while taking exactly the same medication as before.
1. Life threatening hyperkalaemia with diarrhoea during ace inhibition: Emerg Med J 2005;22:154-155
Assessment score or not !!
ASSESSMENT SCORE OR NOT!!
The LOW COST RES-Q-SCOPE(R) where digital video technology makes life a little easier. The patented and FDA Registered RES-Q-SCOPE(R)is readily available and considered essential in the emergency field, where the emergency needs to be dealt with quickly and effectively. The situations commonly found more frecuently by Paramedics, Medics in the military, First responders, Rescue Units, mass casualties personnel and the Emergency Room. The RES-Q- SCOPE(R) stands to the challenge and is readily available at very low cost. A state of the art Hand Held FIELD VIDEO LARYNGOSCOPE, a low cost self contained, self powered device, with disposability advantages which enables rapid serial intubations in the field. The RES-Q-SCOPE(R) is the only Laryngoscope in the world which is designed to avoid free hand ET uncertainty by actually PRE-LOADING A STANDARD ENDOTRACHEAL TUBE 6-8.5 mm prior to intubation.
The RES-Q-SCOPE (R) is a patented and FDA Registered and Listed, multi-function field video laryngoscope, which uses cutting edge digital image technology featuring a multiple positional colour 2.75" LCD screen to externally visualize the intubation process in the field. The RES-Q-SCOPE (R) requires modest learning curve, to slide the device into position to visualize the epiglottis with little effort. The RES-Q-SCOPE(R) is spine injury friendly with minimal need, if any, to re-position the C-spine in case of suspected neck injury. Further, the RES-Q-SCOPE (R) itself, features a channel where a standard endotracheal tube can be easily pre- loaded into the device. SHORT AND OBESE NECKS MAKE LITTLE DIFFERENCE WHEN USING THE RES-Q-SCOPE(R). A light source for external visualization of the intubation process, as the endotracheal tube passes into the trachea. The process can be seen through a small colour LCD screen, which has the ability to adopt multiple positions, so that the PRACTITONEAR CAN BE LOCATED AT THE SIDE OF THE PATIENT OR AT MULTIPLE OTHER POSITIONS AROUND THE PATIENT. A vacuum source can be attached to an external adaptor provided, to assist clearing fluids that may be present in the throat. The same channel can be reversibly, used to provide oxygen if needed. A disposable unit can be easily detached and discarded. Thus, multiple clean intubations, may be performed in the field in a very short time span. The simple attachment of a new disposable unit allows very rapid serial intubation of multiple patients in a disaster theatre or emergency scene. The RES-Q-SCOPE (R) is powered with a rechargeable LiOn long duration battery, also allowing for serial intubations when needed. Additionally an emergency dry cell pack is also available using 4 AA's to power the unit under extreme conditions such as combat settings.
The RES-Q-SCOPE(R) is a product designed to improve the chances of saving a life in a respiratory emergency where it occurs, in the field. It is considered essential in disaster preparation and emergency response of all kinds including combat emergencies. Complete information, description and video of conscious intubation can be obtained by visiting http://www.res-q- tech-na.com (a full kit may cost between $400 t0 $500 USD).
Tension viscerothorax: an important differential for tension pneumothorax
I do fully agree with the authors that acute tension viscerothorax should be included in the differential diagnosis of blunt thoracoabdominal trauma as immediate intervention can be life saving.
On the therapeutic point of view however I have another opinion. In our experience with two cases of acute posttraumatic tension gastrothorax decompression by means of a nasogastrical tube was impossible due to the anatomical changes with the intrathoracic position of the stomach and the trapped air. One can always try to deflate the stomach in this way but we think that emergency surgical repair will be necessary in most cases.
1. Acute post-traumatic tension gastrothorax, a tension pneumothorax-like injury. LJM Mortelmans, GCY Jutten and L Coene. EUJEM 2003; 10:344-46.
Letter to the Editor
We read with interest the recent paper by Reed et al.  regarding the LEMON mnemonic  and its ability to predict difficult intubation in the ED. We are particularly pleased that the authors concluded that this clinical tool was able to successfully stratify the risk of intubation difficulty in the ED, though this was never the intent in its design.
Predicting a ‘difficult intubation’ has proven to be elusive [3,4]. The first problem is in defining ‘difficult intubation’ [5,6]. The process is composed of two interdependent technical skills: exposing the glottis by employing a conventional laryngoscope; and placing an endotracheal tube through the cords into the trachea. The former is generally termed ‘difficult’ if one gets a poor view of the target (Cormack Lehane grade 3 or 4 view) ; the latter, if after an arbitrary number of attempts (usually 3), the tube cannot be placed .
Many authors addressing this issue have attempted to identify anatomical predictors, collections of predictors and even weighted scoring systems of identified factors in an attempt to clearly separate those that can be intubated orally following induction and paralysis, from those that cannot [7-11]. This latter group is ordinarily intubated ‘awake’ employing topical anesthesia and sedation and devices such as bronchoscopes. Varying degrees of sensitivity and specificity have been touted. However, the predictive value in defining who can and who cannot be intubated for all of them is so poor as to be clinically useless [10,12]. Of course, such evaluations are predicated on the fact that the intubation is planned using a standard laryngoscope and blade; a premise that is likely to be severely challenged as video and fiberoptic intubation devices come into broader use.
Though we are pleased that the authors have found LEMON useful clinically in stratifying risk, we have several comments:
> The issue of access through the oral cavity, and exactly how much of the posterior pharynx one can see employing simple manoeuvres like the Mallampati Scale, has been repeatedly demonstrated to be of value in evaluating the airway for difficulty [7,8,13-15]. While Mallampati’s classically described manoeuvre, which requires the patient to sit T M up and cooperatively open the mouth and protrude the tongue, is not generally possible in emergency situations, we believe that evaluation of the tongue/oropharynx ratio is still important. Thus, we advocate using a tongue blade to examine the oropharynx and estimate the Mallampati score, even when the patient is uncooperative or unconscious. The key element is whether the tongue is believed to be too large to permit oral, direct laryngoscopy.
> The failure to evaluate the airway prior to employing paralytic agents is the single most important contributor to airway management failure and a poor outcome. LEMON is primarily intended to ensure and expedite as complete an evaluation as possible recognizing the realities of emergency airway management [5,6,16,17]. The most important aspect of the guideline, though, lies in sensitivity, not specificity. The intent is not to determine, with precision, whether the patient will, or will not be a difficult laryngoscopy. Rather, the goal is to identify every patient for whom laryngoscopy might be difficult, recognizing that in many identified cases, laryngoscopy may well turn out to be reassuringly routine.
> Clarify the dimensions intended to be evaluated by the ‘Evaluate 332’ rule (Fig 1 ‘E’ and Table 1). The intent of this portion of the mnemonic is to focus one’s attention on the geometric principles inherent in direct laryngoscopy.
> The first ‘three’ addresses access to the airway by the oral route and provides information supplemental to that of the Mallampati score
> The second ‘three’ is meant to direct the evaluator’s attention to the volume of the mandibular space, though we recognize that the length from the tip of the chin to the 'chin-neck' junction is but one of the three dimensions.
> The ‘two’ is intended to focus the evaluator on the location of the larynx with respect to the base of the tongue. A distance less that two finger breadths may indicate that the larynx is too high and will be obscured by the base of the tongue; a larynx further down the neck may place it beyond the ‘horizon’ that can be established during oral laryngoscopy.
In closing, we applaud the investigators in performing this study and demonstrating that LEMON was useful as it was intended. However, we also wish to forward a cautionary note with respect to the Mallampati maneuver: we recognize that it may not be possible to perform in all comers, but it is a valuable part of the airway exam, particularly when a patient is found to have a class 3 or 4 view, and it is worth seeking, even if the search is somewhat difficult.
Michael F. Murphy, MD, FRCPC(Anes), FRCPC(EM)
Departments of Emergency Medicine and Anesthesia
Carolinas Medical Center
University of North Carolina
Ron M. Walls, MD, FRCPC (EM), FAAEM, FACEP
Department of Emergency Medicine
Brigham and Women’s Hospital
Harvard Medical School
1. Reed M, Dunn M, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005;22:99-102.
2. Murphy M, Walls RM. Identification of the difficult and failed airway. In: Walls RM, Murphy MF, Luten R, eds. Manual of emergency airway management. Philadelphia: Lippincott, Williams, Wilkins; 2004:70-81.
3. Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard T, Lee H. Interobserver reliability of ten tests used for predicting difficult tracheal intubation. Can J Anaesth 1996;43(6):554-9.
4. Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994;41(5 Pt 1):372-83.
5. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993;78(3):597-602.
6. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98(5):1269-77.
7. Frerk CM. Predicting difficult intubation. Anaesthesia 1991;46(12):1005-8.
8. el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg 1996;82(6):1197- 204.
9. Savva D, Maroof M. Predicting difficult endotracheal intubation. Anesth Analg 1996;83(5):1129.
10. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth 1988;61(2):211-6.
11. Cass NM, James NR, Lines V. Difficult direct laryngoscopy complicating intubation for anaesthesia. Br Med J 1956(4965):488-9.
12. Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia: a prospective blind study. Anesth Analg 1995;81(2):254-8.
13. Langenstein H, Cunitz G. [Difficult intubation in adults]. Anaesthesist 1996;45(4):372- 83.
14. Mallampati SR. Clinical sign to predict difficult tracheal intubation (hypothesis). Can Anaesth Soc J 1983;30(3 Pt 1):316-7.
15. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32(4):429-34.
16. Cheney FW, Posner KL, Caplan RA. Adverse respiratory events infrequently leading to malpractice suits. A closed claims analysis. Anesthesiology 1991;75(6):932 -9.
17. Miller C. ASA Newsletter 2000;64(6).
Puting See and Treat in its Place
I can only sympathise with the author that primary care medicine does not interest him. The good news is that it does interest some other clinicians.
In Leeds (West Yorkshire) we are commissioning a new Walk In Centre that will be strategically placed in front of the Emergency Department. There will be no other way to walk into the department, than through the Walk In Centre. In this way, the primary care patients will be Seen, Treated and Discharged without ever the Emergency Physicians even knowing that they have arrived.
Baby Check on Nicutools
Please note that the web-based version of BabyCheck referenced in this paper has now moved to www.nicutools.org/MediCalcs/BabyCheck.html
Dr Michael Hewson
A limited place for the LEMON score in airway assessment
We read with interest the article by MJ Reed et al. As they have mentioned there have been numerous attempts to devise scoring systems for airway assessment, however these scores have been undermined by low sensitivity and specificity. Furthermore Positive predictive values for these tests range from 4 – 60% , we believe that such a low predictive value has significant implications for airway management particularly in the Emergency Department. With a positive predictive value of 50% at least half of difficult intubations are likely to be unexpected. Whilst the morbidity associated with a difficult intubation is clear to all, some patients may be subjected to unnecessarily invasive techniques that may not be required.
In the words of Levintine “Direct Laryngoscopy with pharmacological adjuncts is very successful, very fast and has low complication rates” . The authors of the study do not state at which LEMON score a patient’s airway is anticipated to be difficult. Assuming a score of >3 the positive predictive value would be 47%. The study quotes a rate of 2% difficult intubations in the Emergency Department; the study rate of 42 difficult intubations in 156 patients therefore seems to be abnormally high, possibly due to the inclusion of grade II laryngoscopic view as difficult. We would question the classification of Cormack and Lehane grade II laryngoscopy as “difficult”, most Emergency Departments are equipped with bougies making it possible to easily intubate with this view .
Although the LEMON score is referred to as an “airway assessment” it is in fact an intubation assessment. No patient dies from failure to intubate, rather it is failed oxygenation. In the absence of an airway assessment with 100% accuracy then airway assessment needs to be holistic. The American Society of Anaesthesiologists published guidelines suggesting airway assessment must also take into account difficulty in ventilation, patient co-operation, potential surgical airway access and maintaining oxygenation throughout airway management procedures as these problems may occur alone or in combination . Whilst anaesthestists have the luxury of time when assessing an airway we feel the limited time in the Emergency department would be better spent considering these issues rather than calculating a LEMON score.
The harsh reality is that there will be no test that has 100% specificity and sensitivity. The only way to deal with the airway in the Emergency department is to be prepared for the unanticipated difficulties: with experienced assistants, difficult airway trolleys and a plan B, all of which should be standard practice. There is little margin for error in airway management. We believe that a test that makes airway management “more likely” to be difficult is of limited value in the emergency department.
Dr S. Dorrian
SHO Critical Care New Cross hospital
Dr S. Nagaiyan
SpR Anaesthetics New Cross hospital
1. Das S, Pearce A. Pre-operative airway evaluation Anaesthesia 2002 Aug; 57(8):824.
2. Levitan RM, Kush S, Hollander JE Devices for difficult airway management in academic emergency departments: results of a national survey Annals of Emergency Medicine 1999 Jun; 33(6): 694-8.
3. Morton T, Brady S, Clancy M Difficult airway equipment in English Emergency Departments Anaesthesia 2000 May; 55(5):485-8.
4. American Society of Anaesthesiologists Practice guidelines for management of the difficult airway Anaesthesiology 2003 May; 98(5); 1269–77.
Answer to your question
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The importance of clinical suspicion in the management of head injuries
We read with interest the recent articles on the NICE guidelines in Head Injury patients. A clinical case that stresses the importance of clinical suspicion is presented.
A 29 year old male presented to the Emergency Department with a history of assault by a metal object. Despite a brief loss of consciousness (LOC), he self-presented complaining of a mild headache and one episode of vomiting. Examination did not reveal any external signs of injury. There were no features warranting an urgent CT scan using the NICE guidelines. Admission was for the LOC and mechanism of injury.
He complained of right sided diplopia and mild headache the following day; but examination was unremarkable. Opthalmology review was normal. Later, he became suspicious of some ward visitors fearing they were his assailants. Psychiatric review concurred post-injury stress syndrome. Again, CT was not indicated using the NICE criteria; but clinical suspicion of the above led to request for a CT Head which revealed a probable subarachnoid haemorrhage with right parietal lobe calcification. An MRI scan demonstrated an arterio-venous malformation (AVM) with a small subarachnoid bleed. Neurology review led to a Magnetic Resonance Angiogram at a tertiary centre. It was likely therefore, that the patient had not been a victim of an assault.
In this era of increasing guidelines, there may be an over-reliance on these, both by medical staff and radiology departments. Our patient would not have qualified for a CT scan when using guidelines alone and may easily have been discharged without investigation. A high index of clinical suspicion led to the subsequent management. This was especially important in our case as AVM’s do have a substantial risk of re-bleed.
The case illustrates that although guidelines should be followed, clinicians should understand their limitations and use them in combination with their clinical skills in the management of this complex group of patients.
We appreciate the thoughtful comments of Dr. Yen et al. regarding the sampling process of our study. In our telephonic survey of doctors, every third case from a list of 194 emergency physicians (EPs) and 330 general surgeons (GSs) was randomly selected to derive our study sample. Enrolled cases with invalid or expired contact information (6 EPs and 11 GSs) were subsequently excluded before formal telephone interviews were arranged. Only respondents of valid telephonic contacts (45 EPs and 64 GSs) were included in the final statistical analysis. As stated in our discussion, there are some limitations with telephonic survey. Nevertheless, this simple research technique offers the biggest cost advantage in the survey of public or experts' opinion within a short time frame, as illustrated in our study.
Important factors in infant head injury.
We read with interest the well written article on infant head injury . We agree with the authors that there is little published data on head injury specific to this age group.
The authors of this study do not comment on the distribution of head injury with age from birth to one year. Our own study of 108 infants, presenting over a two year period, suggests there may be a prevalence of more severe head injury in the younger child . Specifically, 20 (19%) children were under 4 months, and 4 (20%) of these had major head injury. This contrasts with only 1 (1%) major head injury in 88 children over 4 months. Further analysis has revealed that the pattern of causation is different between these two groups. The younger immobile children have predominately been dropped while being carried. This may result in fall from a greater height, and subsequent greater injury.
It is important to recognise that head injuries, presenting to emergency departments, may not be equally distributed through the first twelve months of life in terms of numbers, mechanism of injury and likelihood of serious head injury. We would suggest that children under 4months need especially close attention when presenting with head injury.
J. Gray P. O’Connor S. McGovern
1. Browning J, Reed M J, Wilkinson, A G , Beattie T. Imaging infants with head injury: effect of a change in policy. Emerg Med J 2005;22: 33- 36.
2. O’Connor P, Gray J, McGovern S. Trends in head injury in children under 1 year old presenting to an Emergency Department. (poster presentation accepted 3rd European Congress of Emergency Medicine, Leuven February 2005).
Auditory and visual prompts during CPR in the Emergency Department
We read with interest Williamson et al.  study on the use of audio prompts in automatic external defibrillators to improve cardiopulmonary resuscitation (CPR) in untrained & trained lay subjects. We report a study from an emergency department (ED) using trained ED staff (doctors & nurses) and paramedics.
Through our own departmental video audit we have observed great variability in the rate of external cardiac compressions (ECC); median 140 compressions per minute (cpm) & range 100-180 cpm. This rapid rate of ECC is of concern since it is faster than the recommended 100cpm . Studies suggest that rescuers may fatigue after only 1 minute of CPR  and there is an associated decline in the quality of chest compressions with time .
We undertook 2 separate studies to test specifically whether a piece of music influenced the rate of ECC when compared to nothing and a metronome and another study to test whether using a specially adapted clock compared to a metronome influenced the rate of ECC. In both studies participants were video taped whilst performing CPR on an intubated resuscitation manikin for 3 minutes in the resuscitation bay of the Emergency Department and the rate of ECC subsequently analysed by using video playback.
In the first study 50 participants were randomised in blocks of 5 to listen to a minute of silence followed by a second minute of a randomly selected piece of music and then a final minute of a recording of a metronome set at a 100 beats per minute (bpm). Participants were not told that the metronome was set at 100bpm. Three pieces of music had a rate of 100bpm and one much less than 100bpm and another much faster than 100bpm. In the second study 43 participants were randomised (blocks of 10) to two groups either metronome or ‘resuscitation-clock’. The metronome group listened to a minute of silence followed by 2 minutes of a recording of a metronome set to 100bpm. The ‘resuscitation-clock’ group listened to a minute of silence and were then asked to look at the ‘resuscitation-clock’ and use it to help time the rate of ECC. The resuscitation clock was essentially a normal clock with the numerals removed and the figures 25, 50, 75 and 100 placed at 3, 6, 9 & 12 o-clock respectively.
In the first study the rate of ECC was not statistically different between either the silence, music or metronome groups (Freidmans test X2=3.6, p=0.16), range 54-156, median 116cpm. Those participants who had received formal CPR training within 3 months of taking part in the study did not have a statistically different rate of ECC compared to those without recent training (Mann-Whitney U test=139. p=0.14). In the second study the metronome group achieved the target compression rate with a mean of 99.8 (95% CI 99.2 to 100.4), compared to clock group mean 106.9 (95% CI 101.6 to 112.2) and the control (silence) group mean 114.6 (95% CI 109.6 to 119.3).
We concluded that without the use of auditory prompts trained ED personnel are poor at performing ECC at 100bpm even if recent formal CPR training has taken place. The use of a simple auditory prompt can help trained personnel perform ECC at the correct rate.
1. Williamson et al. Effects of automatic external defibrillator audio prompts on cardiopulmonary resuscitation performance. Emerg Med J 2005; 22: 140-143.
2. Lockey A, Nolan J. Cardiopulmonary resuscitation in adults. BMJ 2001; 323:819-820.
3. Javier Ochoa F, Ramalle-Gomora E, Lisa V, Saralegui I. The effect of rescuer fatigue on the quality of chest compressions. Resuscitation 1998;37:149-52.
4. Ashton A, McCluskey A, Gwinnutt CL, Keenan AM. Effect of rescuer fatigue on performance of continuous external chest compressions over 3 min. Resuscitation 2002; 55:151-155.
Inappropriate random sample ?
We read the paper by Chong et al.  with great interest. However, we have some doubts regarding their random sample. They had a list of 194 emergency physicians (EPs) and 330 general surgeons (GSs). Every third case in the list was selected. There should be about 64 EPs and 110 GSs in their study sample. However, exactly 90% of the expected numbers of physicians composed their EPs (58) and GSs (99) samples. Is this a coincidence or systematic error ? Although there may be no significant change to their final results, we believe a solid study method is necessary to make any contribution to science.
1. Chong CF, Wang TL, Chang H. Evaluation of blunt abdominal trauma: current practice in Taiwan. 2005;22:113-115.
Diuretic induced renal failure
Clearly the ACE inhibitor in this case is significant in light of this lady's acute (presumably mixed "pre-renal" and "renal") renal failure. However, this was not due solely to one drug and I suspect that her illness highlights a more significant problem i.e. that of the widespread use of loop diuretics and the balance between fluid offload and renal function. Although the precise nature of her vasculopathy and rest of her medical history is not given I would suggest that this is the least appropriate of her medication - unless good evidence existed of poor LV function etc. Her electrolytes three weeks prior were not normal and I would have thought that diuretic therapy at that stage should have been reviewed or her electrolytes repeated sooner. Diuretic induced renal failure - or at least "renal impairment" - is much more frequent in acute admissions than once per month. Furthermore, they are often prescribed to patients who seem neither to have significant relevant symptomatology or appropriate monitoring in place.
Alan D Exton
Reporting Gunshot wounds
Whilst I very much enjoyed the article on whether to report gunshot wounds to the police, I feel that an important aspect has been ommited. Patients that present with gunshot wounds are clearly vulnerable to further attack. This could potentially place both them, and those people caring for them, in serious danger. I remember hearing of a case in South Africa where a man with serious gunshot wounds was being attended to by a paramedic at the side of a road. A "passer-by" approached the paramedic and asked whether the man was going to be ok. When the paramedic said "yes", the assailant pulled out a gun and finished the patient off. This has implications for all of us working with patients in this group. As a nurse I would have (and have in the past), no hesitation in reporting attacks such as these to the police. Indeed i would suggest that we have a duty to do so.
ATLS: there are alternatives.
I was heartened by the courageous but constructive critique of the ATLS Course by Driscoll and Wardrope . It promises an end to my lonely position as ATLS-Skeptic, which began in 1999 when I suggested that, while ATLS was “the greatest reformation in trauma care” in the late twentieth century , it was “an American solution in a British context” (your readers may have noticed the subsequent regrettable trend in which car occupants who are one minute squabbling vigorously about responsibility for a collision are, the next, abruptly strait-jacketed in yellow plastic). I fretted that the Course was based on a dubious notion that trauma is a “surgical” disease, that it had become The New Dogma, and was suspiciously clubby (“I’m an ATLS Instructor and you’re not”). But my real concerns were that:
(1) the ATLS Course represents a major drain on scarce human and educational resources (how many days do consultants in emergency medicine spend away from their departments on these courses?; how much is the NHS spending on the course fees?);
(2) ATLS only addresses the initial part of trauma care and is not a panacea (injury prevention and rehabilitation are at least as important);
(3) while evidence-based medicine is something to which we all now aspire, the massive changes in the ATLS Manual since its inception is a worrying illustration of the dearth of serious science underpinning what ATLS promotes.
I share Driscoll and Wardrope’s disappointment at the continuing exclusion of emergency physicians from the development of ATLS. But happily, five years after I quit the NHS, the Royal College of Surgeons in Ireland has addressed my concerns with a set of Clinical Guidelines  that I believe recognizes the realities of trauma care in these islands.
May I invite your readers to peruse a document  which is by no means perfect but which reflects their daily experience, along with that of their anaesthetic, surgical and other colleagues? The sheer number of consultants and trainees in emergency medicine who contributed to this important document may reassure those of your readers who feel a little excluded, by the ATLS “elite”, that their contribution to trauma care is in fact incalculable. I hope it may also offer some encouragement to those who believe that there are other options in trauma care on this side of the Atlantic, and that Emergency Medicine will show the way.
Chris Luke, Department of Emergency Medicine, Cork University Hospital, Ireland. firstname.lastname@example.org
(1) Driscoll P, Wardrope J. ATLS: past, present, and future. Emerg Med J 2005;22:2-3
(2) Luke L C. ATLS: has the end become the means? CPD Anaesthesia 1999;1(2):94-96
(3) Clinical Guidelines Committee, Royal College of Surgeons in Ireland. Initial Management of the Severely Injured Patient. Dublin, November 2003. www.rcsi.ie/postgraduate_surgery/surgical_guidelines_protocols/Initial_Mgt._of_the_Severely_Injured_patient/index.asp?
N2O and your Brain
I am interested in the nurological effects of N2O. At a seminar that I attended 6 years ago it was brought out that N2O was very similar in nurological side effects as wine. It was stated by a medical professor that N2O did indead kill about the same amount of brain cells due to the lack of oxegen to the brain cells. Recentlly a inter-office discussion resulted in that question being raised again. Does N2O kill brain cells(although it only be a few)? Doing resurch I have come acrossed two different views on that. Can you clear up this matter with factual proof and references?
Patently awaiting your response,
Shock and circulatory support in the Emergency Department
I enjoyed the article on shock and circulatory support in the Emergency Department. Early and aggressive resuscitation of patients with shock is known to improve outcome, as shown in the Emmanuel Rivers et al paper used as the first reference. I was disappointed, however, to find an important component of that study had not been mentioned.
Following the establishment of an adequate central venous pressure and mean arterial blood pressure, the next step of the protocol was to measure the patients’ mixed central venous saturations. This was used as an indication of the oxygen delivery and consumption. If the ScvO2 fell below 70%, the patient was given red blood cell transfusions to achieve a haematocrit of at least 30% to optimise oxygen delivery. If ScvO2 remained below 70% after these measures, dobutamine was administered to improve cardiac output. This method of balancing systemic oxygen delivery and consumption was shown to improve subsequent oxygen delivery to tissues, pH, lactate, base deficit and severity-of-illness scores.
The optimisation of the three parameters in the first six hours of presentation significantly reduced mortality(2) .Dr Rivers said himself of goal directed therapy, “Mainly the key is to look at three things: volume, pressure and oxygen delivery (via central venous oxygen)…”. While Graham and Parke’s review covered the first two, it was a shame that the equally important third was omitted.
1. Graham C, Parke T. Critical care in the emergency department: shock and circulatory support. Emerg Med J 2005;22: 17-21.
2. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77.
Carbon monoxide treatment
In our collection we have several examples of resuscitation equipment for casulaties suffering from carbon monoxide poisoning where a mixture of oxygen and carbon dioxide is used. The historical information with the equipment suggests that the use of pure oxygen can lead to the slowing of breathing and so the CO2/O2 mix is more effective as the patient continues to hyperventilate.
In the 1999 paper on mass CO poisoning no mention is made of either the potential problem with pure oxygen or the use of CO2/O2 mixtures. Is this because the understanding of the problem has moved on? Please could you enlighten me as to whether the historical science linked to the objects has been discredited and what the current position is?
SOCRATES old but wise
I thank Simon D. Carley for his kind words relating to the work of the SOCRATES team. I acknowledge that updates of the included reviews are now available on many of the reviews we regarded as relevant. As I am sure you are aware this is inevitable given the size of the study and the inevitable delays in such a volume of work finally being published. I am sure the Journal readership on seeing a review of particular interest to them will as you have done access the most recent update.
(On behalf of the SOCRATES Team P Gilligan, A Khan, M Shepherd, G Lumsden, G Kitching, A Taylor, H Law, J Brenchley, J Jones, and D Hegarty)
Variation in speed is important.
We accept, as pointed out by Dr Campbell, that our retrospective findings could be confounded by many factors. Nonetheless our Doctors were on average seeing 154 less patients per six months by the end of the study period.
The concept of developing "ideal practice patterns" is an interesting one and would in itself merit debate. Certainly from the patient's perspective the time waiting to see a Doctor and the time from arrival to discharge or admission are taken as indicatiors of efficient practice and are significantly impacted upon by the speed with which Doctors see patients. The questions raised with regards to the implications of a Doctor's speediness for quality of care, education and longevity need to be addressed independently of our study and probably using a qualitative approach. The fact remains that the Senior House Officers in the second half of our 5 year retrospective study were seeing fewer patients in their six months in Accident & Emergency than they used. In a predominantly Senior House Officer delivered service this has implications for the future delivery of Emergency Care.
(1) P Gilligan, RN Illingworth, S Crane, D Hegarty. Are accident and Emergency senior House Officers getting slower? Emerg Med J 2004; 21: 646. doi:10.1136/emj.2004.014787
Of course ATLS needs to be reformed, and perhaps we could start by abandoning the tortured ABCDE mnemonic.
Many major trauma patients are conscious and in this situation the first thing to do is take a brief History. Breathing and Airway are part of the same process, and surely the patient should be immediately Exposed to allow examination. And if Disability means a core neurological examination, then please can we say so.
As to the ATLS course itself, this takes too long and this causes problems filling faculty places. This in turn limits the number of courses held, and how many providers can be trained. With modern distance learning techniques it should be possible to do most of the coursework beforehand, requiring only a 36hr event to teach practical skills and to examine.
(1) Various articles. EMJ 2005; 22: 1: 2-7
Re: Simpson's Paradox
Thanks to Dr Yen and colleagues for their interest. We agree that the possibility of a case-mix or wound complexity change could account for bias in this before and after study. However, knowing our case-mix we feel this is unlikely. Most of our wounds are simple skin lacerations and anything more complex than this goes to theatre with general or plastic surgery. It would be unusual for a wound to require more than 6 stitches in our department. The study would be more robust if we had graded wound complexity, recorded the number of sutures and length of operation and matched the two groups. We cannot however at this stage go back to retrieve this data as it will not all be recorded. Randomization would have been useful but very difficult to perform. Randomizing patients would require the doctors to use alternate methods ( traditional suturing v safe suturing) on each patient which is biased in itself. Randomizing the doctors would require half the doctors in the department to use the safe method which creates an ethical problem for the others, and as these staff work side by side one group would tell the other what they were doing thus introducing bias.
Randomizing two separate hospital units would introduce case-mix and cultural bias.
Regardless of the results of the study it was disappointing to note that needle-handling with fingers and a slightly casual attitude to needle -handling persisted after the training. This is a concern for us. This is partly related to the low level of blood-borne virus in the local population, <1% for Hep C and lower than this for Hep B and HIV. It would be interesting to perform the study in a unit where anxiety about blood-borne virus infection was higher and see if compliance and perforation rates were any better.
Flows through beds not occupancy
The article by Cooke et al.  on the relationship between A&E performance and average bed occupancy is based on data collected in 2002. Other have recognised an association between occupancy and delays in emergency care in USA and Australia. Recently there have been significant advances in our understanding of that relationship and we believe some of the recent results are worth reporting. In 2003 and 2004 the Department of Health conducted a number of detailed surveys of Acute trusts' operations (some focussing on A&E activity, most recently focussing on flows into and out of beds). The A&E surveys revealed that two of the major causes of delay were related to the process of getting patients into beds, thus providing more direct evidence that the state of beds affects A&E performance. We also observed that these delays were concentrated at certain times and on certain days. However, we were prompted to get more detailed evidence about the flows through beds because the observed correlation with A&E performance was so weak. Surely we should be seeing a stronger effect if beds are such the major cause of A&E delay?
Our survey of bed flows explained much of this paradox. We asked trusts to record the timing of all arrivals and departures from their beds (classified by some simple categories such as elective or emergency admissions) over the course of a week. For those trusts who provided reasonably consistent data (many were unable to do so) we were able to calculate an hourly bed availability. This hourly position generated major insights, some of which we describe below.
* The reported weekly bed occupancy (which is measured at midnight Thursday) is unrepresentative of the actual occupancy across the week. For there to be no delays, sufficient beds need to be available 168 hours every week, not just in the 1 hour sampled for the national returns.
* Hourly occupancy can vary greatly across a single day (sometimes moving from the 70%s to the high 90%s or more). The highest peaks tend to occur in the middle of the day but are often cleared by the evening (see graph).
* Different days (and weeks) may show very different peaks in occupancy. Often only one or two days in a week show extremes of occupancy likely to result in knock-on effects in A&E.
* The fluctuations in bed occupancy are not primarily the result of the randomness of A&E admissions (which are predictable within bounds). The dominant driver is the variability and unpredictability of elective arrivals (which, in many trusts, occur at the worst possible time of day or day of week) and the lack of coordination of the controllable flows (discharges and elective arrivals) with emergencies and with each other. It is not uncommon to observe very low levels of discharge over a weekend. Emergencies continue to arrive, therefore using up beds. Then, first thing on Monday morning, the peak arrival of elective patients occurs (coinciding with the daily emergency peak and perhaps 4 or 5 hours before any discharges). The result is very poor bed availability by lunchtime on Monday.
A separate analysis of changes in performance over a six month period showed no correlation between this and change in bed occupancy (as collected in national data in Cooke's study, using same methodology, correlation coefficient r2=0.097, p=0.24). This reinforced our belief that to gain useful insight into the relationship between bed occupancy and performance we need to study the detailed hourly flows across the week.
Our observations explain both why bed availability is such a big issue for A&E and why the reported statistics do not reflect the strength of the relationship. Also, we can see from our datasets that relatively small variations in any flow can have large consequences for peak bed occupancy so shortages may appear to be quite sporadic (perhaps occurring one week in 4 rather than all the time).
But the most important message from our work is that big improvements are possible if trusts are prepared to manage their beds actively. The extreme peaks we observed in bed use were always the result of a failure to coordinate different flows. While there is little trusts can do to manage emergency flows into beds, these are relatively predictable. Discharges and Elective admissions are-or should be-mostly within the control of trusts. Improved coordination (eg more morning discharges and more afternoon arrivals) can reduce or eliminate extreme peaks in bed occupancy.
The nationally reported point availability of beds does not provide adequate information for the operational management of beds through the week. Hospital Trusts need a complete picture at least hour by hour if they are to manage beds so that beds are available when needed. The benefits of better coordination will reduce the frequency of both A&E delays and cancelled elective activity (even though these have often been seen as opposing goals). The goal of policy now needs to move beyond the improved supply of beds to the improved management of the flows through beds.
1. Cooke MW, Wilson S, Halsall J, Roalfe A. Total time in English accident and emergency departments is related to bed occupancy. Emerg Med J. 2004 Sep;21(5):575-6.
2. Alan J. Forster, Ian Stiell, George Wells, Alexander J. Lee, and Carl van Walraven The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition Acad Emerg Med 2003 10: 127-133.
3. Dunn R. Reduced access block causes shorter emergency department waiting times: An historical control observational study. Emerg Med (Fremantle). 2003 Jun;15(3):232-8
Declaration: All the authors are either employed by or partially funded by the Dept of Health.
Helicopters in Mountain Rescue
Black, Ward and Lockley are absolutely correct in stating that: ‘The decision to use a helicopter is not straightforward, and a number of important geographical, physiological, and pathological factors need to be considered.(1)’ In mountain rescue (MR) these factors combine to give a very challenging environment where the outcome of the casualty, safety of the aircrew and the mountain rescuers have to well thought- out. There is no doubt that helicopters have an essential role in MR as demonstrated regularly by RAF, Navy and Coastguard helicopters. Casualties with time-critical injuries can be transported to definitive (hospital) care in minutes rather than the hours it can take by the traditional carry-off and ground ambulance (GA) route. However the expansion of Air Ambulance services has given rise to some concern within MR though their introduction heralds a new and hopefully improved service to all that enjoy wild and remote places.
Helicopters operating in an Emergency Medical System (HEMS) have two times the accident rate and 3.5 times the fatality rates of helicopters operating in other capacities. The risk factors have been documented and include night flying and poor weather.(2) From the MR perspective, this is reflected in the death of rescuers. The International Commission for Alpine Rescue (IKAR) has an incomplete data-set that shows an alarming 29% of rescuers dying in helicopter accidents (n = 130); while 21% die in avalanches, 13% in falls, and 11% by drowning. The UK has the lowest percentage of rescuer’s death from helicopter accidents - 1 of the 5 total deaths. IKAR has also published a paper on the medical considerations in the use of helicopters.(3)
Critical incidents have been identified in the past and continue. Many have a common and recurring theme. From the medical perspective these are an incomplete assessment and protection of the casualty (recently focusing on spinal care) and an understanding of the medical resources and equipment available from MR. From the operational perspective many more serious critical incidents have occurred from poor communication and planning of the helicopter role and, recently, the duplicity of helicopter response.
In response to these concerns, the Lake District Search and Mountain Rescue Association (LDSAMRA) has agreed a protocol with the Great North Air Ambulance that places the Mountain Rescue Team Leader in a central position in control of the incident. The Team Leader is best placed to make operational decisions because he/she is likely to have an intimate knowledge of the incident location (critical for assessing landing possibilities), weather conditions (including cloud cover), and other resources in the area whether it be a mountain rescue vehicle or personnel including Doctors. Such factors cannot be adequately considered remotely, and Team Leaders have many years of experience in making these assessments.
1) Black JJM, Ward ME, Lockey DJ. Appropriate use of helicopters to transport trauma patients from incident scene to hospital in the Unitied Kingdom: an algorithm. Emerg Med J 2004;21:355-361
2) Nicholl J, Turner N, Stevens K, et al. A review of costs and benefits of Helicopter Emergency Ambulance Services in England and Wales (2003). http://www.shef.ac.uk/uni/academic/R-Z/scharr/mcru/reports.htm
3) Tomazin I. Kovacs T. International Commission for Mountain Emergency Medicine. Medical considerations in the use of helicopters in mountain rescue. [Review] [25 refs] High Altitude Medicine & Biology, 2003. 4(4):479-83
Authors response to Kounis & Kounis
We thank Kounis & Kounis for their interest in our article. Their insights into the link between allergic mechanisms and coronary disease are interesting. However, the level of evidence supporting their extrapolations of this and other animal data to human anaphylaxis is limited.
Different species exhibit different patterns of organ involvement during anaphylaxis . Animal data can only be regarded as hypothesis generating, and unfortunately human data is scarce. Studies of artificially sensitised isolated animal cardiac tissue and small animals have only a limited application to immediately life-threatening multisystem allergic events in intact humans with naturally acquired IgE- mediated allergy.
Although cardiac dysfunction during human anaphylaxis (including ECG changes and global suppression of myocardial function) has been reported, the significance of these above other well-recognised events, seen in the majority of cases and all physiologically antagonised by adrenaline, remains uncertain. An understanding of global issues –upper airway compromise and bronchospasm causing hypoxaemia, distributive shock, hypovolaemic shock, reduced coronary and cerebral perfusion, and reflex mechanisms– are probably more important in terms of emergency management.
Thus, the keys to treating the vast majority of cases continue to be; the supine position, adrenaline, oxygen, and fluid (volume) resuscitation.
In the context of human anaphylaxis, it is incorrect to state that "today it is almost certain that cardiac damage is the primary event". Kounis & Kounis back up this statement with a single piece of original research, which looked at artificially sensitised guinea pigs .
As we point out in our paper, there are several mechanisms that may explain our observations of a cardiac effect during severe human anaphylaxis. These include direct mediator actions on the heart, supported by our observation in one case of ECG changes in the absence of hypotension. But, we also observed that diastolic hypotension was an early feature in those experiencing hypotension (as illustrated by case 1), indicating systemic vasodilation to be important. Neurocardiogenic reflex responses to the resulting reduction in venous return may partially explain the association between death and the upright position (which exacerbates venous pooling) observed by Pumphrey . Fisher has also demonstrated the importance of massive fluid loss by extravasation that occurs during anaphylaxis in humans .
Kounis & Kounis refer to two deaths following the administration of adrenaline . However, these deaths involved the administration of massive intravenous boluses that can only be interpreted as major errors in management. In our response to previous correspondence we have outlined why the intravenous route (by infusion, not bolus administration) may be the best option in experienced hands .
To quote Fisher, "In severe anaphylaxis adrenaline by any route is better than none" . How this is achieved depends on the level of expertise at hand.
1. Kemp SF and Lockey RF. Anaphylaxis: a review of causes and mechanisms." J Allergy Clin Immunol 2002; 110(3): 341-8.
2. Felix SB, Baumann G, Berdel WE. Systemic anaphylaxis-separation of cardiac reactions from respiratory and peripheral events. Res Exp Med 1990; 190: 239-252.
3. Pumphrey RS: Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003, 112:451-452.
4. Fisher MM. Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anaesth Intensive Care 1986; 14(1): 17-21.
5. Pumphrey RSH. Lessons for management of anaphylaxis froma study of fatal reactions. Clin Exp Allergy 200; 30: 1144-1150.
6. Brown SGA, Blackman KE, Heddle RJ. Authors response to Gori et al. [electronic response to eLetter by Gori et al. Risks of Overzelous Adrenalin Administration http://emj.bmjjournals.com/cgi/eletters/21/2/149#277] emjonline.com 2004http://emj.bmjjournals.com/cgi/eletters/21/2/149#333
7. Fisher M: Treating anaphylaxis with sympathomimetic drugs. BMJ 1992, 305:1107-1108.
Etomidate for sedation in the emergency department ?
I read with interest the excellent review article by Oglesby on whether etomidate should be the induction agent of choice for rapid sequence intubation in the emergency department . There is growing interest, especially in the United States of America in the use of etomidate in the emergency department for sedation during painful procedures.
Etomidate has the properties of rapid onset of action, rapid recovery, minimal cardiovascular disturbance and relative lack of respiratory depression. It has been used to provide sedation for procedures such as joint reductions, fracture manipulations, electrical cardioversion and wound debridement . Typical initial doses are around 0.1mg/kg given slowly with further boluses as necessary. When comparing patients undergoing reduction of anterior shoulder dislocation the time to recovery from sedation was significantly reduced when compared to midazolam . Etomidate also seems to have high patient satisfaction with one survey finding that 95% of respondents would be extremely happy to have etomidate for their next procedure .
The most frequent side effect of etomidate when used as a sedation agent is myoclonus affecting between 20-45% of patients and appears to be dose related, although not associated with post procedure myalgia. As with other sedative agents etomidate can induce a degree of respiratory depression leading to oxygen desaturation and necessitating supplemental oxygen. Vomiting and pain on injection may also be side effects. The level of sedation produced by etomidate is usually beyond that of conscious sedation (verbal reponsiveness maintained) and is often described as deep sedation (loss of responsiveness). Etomidate may briefly result in the loss or reduction of protective airway reflexes.
In the emergency department, etomidate like other anaesthetic induction agents eg. propofol may offer advantages over more ‘traditional’ sedation agents (eg.midazolam) in terms of speed of action and recovery from sedation however their use may be associated with adverse events.
1. Oglesby AJ. Should etomidate be the induction agent of choice for rapid sequence intubation in the emergency department ? Emerg Med J 2004; 21: 655-659.
2. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother 2004; 38: 1272-7
3. Burton JH, Bock AJ, Strout TD, Marcolini EG. Etomidate and midazolam for reduction of anterior shoulder dislocation: A randomised controlled trial. Ann Emerg Med 2002; 40:496-504
4. Vinson DR, Bradbury DR. Etomidate for procedural sedation in emergency medicine. Ann Emerg Med 2002; 39: 592-598
J France, Emergency Department, Great Western Hospital, Swindon SN3 6BB, UK
Re: Bonferroni correction for multiple comparisons
I would like to thank Dr Shyr-Chyr Chen (1) for his warning about Bonferroni adjustments in multi comparisons about the article by Chen et al. (2). But to accentuate the some disadvantages of Bonferroni adjustment is required for the readers to interpret the results of the study better.
We use the alpha level (0,05) to accept or refuse the null hypotesis. When more than 2 independent tests are performed, the chance of at least one test being significant is no longer 0,05. Because of this, many author suggest performing Bonferroni adjustment by alpha/n (n is the number of comparisons). But Bonferroni adjustment may create more problems than it solves. Bonferroni method adjusts the alpha value according to the foresight that all null hypotheses are true simultaneously. But after then, we can not assess the each variable in its own right. Another disadvantage of Bonferroni adjustment is to increase the possibility of making type II error (to accept the null hypothesis when it is wrong actually). This may cause an interpretation of assuming an effective procedure not to be better than placebo.
Bonferroni adjustment should be applied when we are interested in the universal hypothesis. If we are interested in a specific hypothesis, Bonferroni adjustment has restricted application. In multi group comparisons, to define why and what tests were carried out and which level of significance was preferred should enable the reader to commend conclusions of the study more properly (3).
1. Shyr-Chyr Chen, Zui-Shen Yen, Shey-Ying Chen, et al. Bonferroni correction for multiple comparisons.2004 Nov 2.
2. Chen TA, Lai KH, Chang HT. Impact of a severe acute respiratory syndrome outbreak in the emergency department: an experience in Taiwan. Emerg Med J 2004;21:660ÝV662.
3. Perneger TV. What is wrong with Bonferroni adjustments. BMJ 1998;16:1236-1238
Thank you for your positive review of Trauma Care A Team Approach. It is refreshing to hear that the patient-focused team approach is valued and that this text has broadened your view of Trauma care. In this changing world of health care it is essential that care focuses on the patient journey and experience. Due to the improved response to traumatic injury and the excellent training now available for teams managing care within the 'golden hour' increasing numbers of injured people are surviving severe injuries. The expertise required for continuing care and rehabilitation is often underestimated but the contribution of all team members in health care settings where the injured are cared for is invaluable. If there any others out there who want to know more about the person-centred approach to the care of the injured please consider dipping into this text. Once you have tried it you may get hooked!
Emergency Care Practitioners should not be compared with paramedics
I enjoyed the article by Cooper et al. and was delighted to see some evidence being published outlining the role of the Emergency Care Practitioner (ECP). However, I have some concerns about the study. I was puzzled as to why the authors chose to compare the ECPs with paramedics. The role is entirely different with ECPs being equipped with additional skills enabling them to undertake an in-depth evaluation of a patient and treat them accordingly, leaving them at home where appropriate and wihtout reference to another clinician. I am not aware that paramedics are trained to this level, and therefore cannot understand how a comparison can be made. The authors also commented on the differences in chief complaints that the ECPs attended, but surely this is the whole point of ECPs? They are specially trained to deal with minor illness and injury and therefore the reponse should be directed at these patients in order to ensure maximum benefit from the role. This paper would have been more relevant and interesting if the authors had compared the whole patient episode, rather than part of it. This may have allowed some conclusions to be drawn about the potential benefit an ECP might have for the patient in terms of time saved and appropriate clinical decisions made to avoid the emergency department.
1. S Cooper, B Barrett, S Black, C Evans, C Real, S Williams, and B Wright The emerging role of the emergency care practitioner Emerg Med J 2004; 21: 614-618
A Nation Divided
Corfield et al. (1) demonstrate improvements in door-to-needle time with a relatively simple organisational change. Other examples of innovation can be found across the country (2). Driving these changes in England and Wales is the national service framework which sets a standard of 60 minute from calling for professional help until the initiation of thrombolysis(3). The Myocardial Infarction National Audit Project (MINAP) demonstrates the success of this approach.(4)
The only current standard, which applies in Scotland, is that set by Quality Improvement Scotland (QIS). This is a door-to-needle target of 30 minutes for the delivery of thrombolysis in the context of an acute ST elevation myocardial infarction.(5) There is no standard set for call-to-needle and furthermore there is no national audit framework to monitor progress. In our own area whilst we achieve and exceed the current QIS target with a median door-to-needle time of 24 minutes for patients presenting to the A&E department, if the National Framework target for call-to-needle is applied we would fail to achieve the standard by 27% (median call-to-needle time 76 minutes). We can see no reason why the pre-hospital phase of the treatment of AMI has been ignored by QIS. Without this as an audit standard, many departments do simply not collect the data and the opportunity for local organisational change is lost.
If national targets are to affect the performance of the National Health Service, they need to be applied to the entire United Kingdom.
1. A R Corfield, C A Graham, J N Adams, I Booth, and A C McGuffie Emergency department thrombolysis improves door to needle times Emerg Med J 2004 21: 676-680
2. Department of Health. Review of early thrombolysis. London: Department of Health, 2003, http://www.doh.gov.uk/heart/thrombolysis/review/thrombolysis_3.pdf
3. Department of Health. National service framework for coronary heart disease. London: HMSO, 2000, 28–35. http://www.doh.gov.uk/pdfs/chdnsf.pdf
4. Royal College of Physicians of London. Myocardial infarction national audit project. London: Royal College of Physicians of London, 2004, http://www.rcplondon.ac.uk/pubs/books/minap/index.htm
5. Clinical Standards Board for Scotland. Secondary prevention following ST elevation myocardial infarction. Edinburgh: Clinical Standards, 2000. 29–32. http://www.clinicalstandards.org/pdf/finalstand/Chd.pdf
NICE head injuries guidelines - expensive? Yes, but what are the alternatives?
I read with some surprise Dr Leaman's article on the impact of the NICE guidelines on a district general hospital. I am truly confused at the level of anxiety this topic is causing in the UK. In most other developed countries, the use of skull x-rays have long been abandoned in favour of selected use of CT scans in patients with head injuries.
While I appreciate the increased resource implications inherent in the extablishment of these guidelines, I really do not see that there is a viable alternative, apart from reliance on an outdated mode of investigation (skull x-ray) in what should be a first world setting.
In our paediatric department, we started relying on a modified version of the American Academy of Pediatrics guidelines since 2001. The use of skull x-rays have dramatically fallen, while there has only been a modest rise in the use of CT scans for minor head injured patients.
I do agree with the Dr Leaman's point regarding out of hours scans, but we really have no firm evidence on which to base our assumption that patients requiring a scan can always wait until the morninig. On the other hand, implementation of the NICE guidelines, along with careful audit will provide us with such data, at which time we can safely modify the guidelines to suit local practice.
It is time that the UK falls into line with modern practice regarding the management of head injuries, even if this means an increase in resource use.
1. A M Leaman. The NICE guidelines for the management of head injury: the view from a district hospital. Emerg Med J 2004; 21: 400.
SOCRATES is not as old as it looks!
I welcome the addition of SOCRATES to the EMJ. In years past I have found the Cochrane database to have little relevance to my practice. It is perhaps a sign of both the changing nature of "typical" emergency practice and the cochrane database that there is an increasing number of relevant reviews. I thank the SOCRATES team for doing the time consuming work of finding the relevant ones.
I was initially concerned that many of the reviews appeared to be quite old (2000-2001). However, when I checked this on the Cochrane web site I found that they had all been updated in 2003-2004. For example, the review of theophylline, aminophylline, caffeine and analogues for acute ischaemic stroke  was referenced as 2000. However, it was most recently searched in November 2003 and substantially updated in March 2004. A similar situation exists for all the other cited reviews, all of which were updated in 2003 or 2004. The age of a review would certainly affect the way in which I interpret the published summary. Would it therefore be possible to include the date of the most recent search or amendment in SOCRATES as I believe this may help the readership in interpreting the review.
1. P Gilligan, A Khan, M Shepherd, G Lumsden, G Kitching, A Taylor, H Law, J Brenchley, J Jones, and D Hegarty SOCRATES 1 (synopsis of Cochrane reviews applicable to emergency services) Emerg Med J 2004 21: 584-585.
2. Bath PMW. Theophylline, aminophylline, caffeine and analogues for acute ischaemic stroke (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
We read with great interest the paper written by McAdam et al . However, we have some doubts regarding their interpretations due to the study was not a randomized study. One of the key assumptions was that they assumed the sutures were performed in a similar or identical environment during pre- and post- intervention periods. If this assumption is not true, Simpson's Paradox should be considered before interpreting the results.
They found the crude rate of glove perforations was higher in the post-intervention stage. However, some potential factors may confound this result. For example, the rate of glove perforations was found higher in complex surgeries . It is possible that there were more complex sutures in the post-intervention stage. Although the non-touch suturing technique effectively reduced the rate of glove perforations, the crude rate of glove perforations in the post-intervention stage was still higher. However, if we compare stratum-specific (simple and complex sutures) rates, it is possible that the rate of glove perforations in simple or complex sutures is lower in the post-intervention stage.
To prevent Simpson's Paradox and to improve the internal validity of the study, we would suggest them to provide some important characteristics of the patients who received sutures in the emergency department during pre- and post- intervention periods. We believe that these essential information will help to clarify our concerns and will also support further interpretations with less bias.
1. McAdam TK, McLaughlin RE, McNicholl B. Non-touch suturing technique fails to reduce glove puncture rates in an accident and emergency department. Emerg Med J 2004;21:560-1.
2. Barbosa MV, Nahas FX, Ferreira LM, et al. Risk of glove perforation in minor and major plastic surgery procedures. Aesthetic Plastic Surgery 2003;27:481-4.
RSI and crichothyrotomy success rates
A paper by Mizelle et al. found that (in the USA)success rates for prehospital:
- RSI by non physicians varied from 76%-98%
- Crichothyrotomy by non physicians varied from 0%-4%
Are either of these procedures carried out by non-physicians in UK?
Bonferroni correction for multiple comparisons
We read with great interest the paper by Chen et al . However, we believe there is a serious methodological error in the interpretation of the results.
They did not apply Bonferroni correction when they made multiple comparisons between two groups. The Bonferroni correction is a statistical adjustment for the multiple comparisons [2,3]. The alpha level used in the study was 0.05 and they made 13 comparisons. In order to ensure that the overall chance of making a Type I error is still less than 0.05, only the p value less than 0.0038 (0.05/13) will be considered statistically significant. Instead of being interpreted as significantly different, the proportions of mechanical ventilation, AAD, length of stay > 2 hours, and upper abdomen sonography are not significantly different between two groups if we apply Bonferroni correction.
Furthermore, they did not test the effect of adequate infection control measure. We believe it is not appropriate to make the conclusion that the impact of severe acute respiratory syndrome on quality of medical care can be minimized when adequate infection control measures are applied.
(1) Chen TA, Lai KH, Chang HT. Impact of a severe acute respiratory syndrome outbreak in the emergency department: an experience in Taiwan. Emerg Med J 2004;21:660¡V662.
(2) Guyatt G, Jaeschke R, Cook D, et al. Therapy and understanding the results: hypothesis testing. In: Guyatt G, Rennie D, eds. Users¡¦ guides to the medical literature. Chicago, IL: American Medical Association 2002:335-7.
(3) Pocock SJ, Geller NL, Tsiatis AA. The analysis of multiple endpoints in clinical trials. Biometrics 1987;43:487-98.
What about variation in speed between physicians?
The letter by Gilligan and colleagues suggests that SHO's in emergency departments are getting slower, seeing far fewer patients in a standard full shift rota than in previous years. Using 'before-after' comparisons can be confounded by factors such as increased patient acuity, or increased availability of slower tests. Decreased access to actually seeing patients, because ED beds are 'blocked' by admitted patients waiting for hospital beds an also reduce the numbers of patients we are able to see. Practice patterns and patient expectations may also have changed.
I was most interested in their comparisons between SHO's of different sex or different clinical interest, because further examination of these could contribute to our understanding of what elements of practice could be embraced to teach 'ideal' practice patterns for doctors who wish to work in emergency.
The aspect of 'productivity' (defined for this letter as 'number of patients seen per unit time'), of the variation in 'speed' between emergency physicians is an uncomfortable one to address, and has been neglected. In a one-year (01.07.01 to 30.06.02) audit of a group of 22 academic emergency physicians at a 70 000 visit/year emergency department, we found that the number of patients seen per hour varied from 2.3 to 4.8 patients/hour. This variation was found to be consistent when times were compared for high- and low-acuity patient areas .
These variations leaves us with many questions unanswered, including whether ‘fast’ care is of an inferior quality to ‘slow’, whether ‘fast’ physicians teach trainees less effectively, or whether there is a difference in clinical longevity between physicians performing at different speeds?
Regardless of these answers, we need to recognise that the physician is often the bottleneck in the system, and physician productivity is a significant determinant of department overcrowding. Physician practice patterns undoubtedly contribute to this, and safe strategies for managing patient flow need further research . Although rapid transit of patients through the ED should not be achieved at the cost of good, appropriate patient care, an ideal standard should be developed appropriate to patient acuity, that can be used for training and quality management purposes.
(1) Campbell SG, Maxwell DM, Sinclair DE. Is individual Emergency Physician efficiency a significant determinant of ED overcrowding. (Abstr) CJEM 2003;5:202.
(2) Campbell SG, Sinclair D. Strategies for managing a busy emergency department. CJEM 2004;6(4):271-6.
Re: Authors' response
We must accept that our original analysis, which assumed statistical independence between observations obtained from staff within the same hospital, might not be justified. To explore this possibility we have computed Intra Cluster Correlation Coefficients (ICCs) using estimated components of variance obtained from an analysis of variance in which hospitals were treated as random effects within a nested sampling design.
With regards the total score at sixty seconds the between hospital component of variance was negative and hence the estimated ICC was set to zero. The ICCs and variance inflation factors (VIFs, assuming an average cluster size of 15) for all four outcome measures are presented below:
Score @ 60 seconds
Total score overall
Proportion with max score at 60 seconds
Proportion with max score overall
As pointed out, the consequences of positive ICCs is that the reported p- values, which ignored the clustering effect, will tend to be biased downwards. A subsequent analysis, which adjusts for clustering within the study, produced elevated p-values for all outcomes with that for the score at 60 seconds remaining significant at the 5% level.
We did however, state in the paper that the results were at best of marginal significance, statistically. The ceiling of a maximum of 8 correct causes may have reduced the ability to demonstrate a significant effect, if one exists. Despite these p value discussions, the paper remains of importance for two reasons. Firstly, it points out that despite the best of intentions, the use of a device to augment recall may potentially lead to adverse effects; 78% house officers could recall hypothermia, which in UK an uncommon cause with a long treatment wheelbase, whilst only 35% remembered hypoxia, a more common cause with rapid treatment. Secondly, such devices may be subject to study of their effectiveness, albeit with difficulty.
Reply to letters
We thank Dr Menon for his thoughtful understanding of our solution to the development of EM in our country. We find it interesting that he believes that the system we developed out of necessity is potentially applicable to the UK and other countries with similar models.
We would like to thank Dr Gaber for his insightful questions, and will attempt to answer them one by one.
First we would provide a clarification. The "grandfather clause" does not pertain to residency training. Rather, it was the way to recognize the status of physicians who had been working for prolonged periods of time in the ED and were still active in the ED at the time of specialty recognition. Thus, they were formally declared to be the teachers for the young incoming generation. We fully realize that this formal recognition did not turn them overnight into the "true" emergency physicians we are trying to educate in the new specialty.
The residents in EM in Israel chose to train in EM for two main reasons: most of them wanted to work in the ED because they had the opportunity to become true professionals in the broad aspects of EM. A few others, on the other hand, came because they had heard that the new specialty made jobs available. Most EM residents are not particularly young and do have families. They had trained in their first specialty, usually spent 3 years in the armed forces, and are mature and actually well-trained physicians by the time they start their training in the ED.
The acceptance of EM as a new specialty is still partial and slow to come by. There is still a lot of resistance from the established specialties. The new generation of Emergency physicians is changing the old way of interacting with the specialties. They do this assuming more and more of the patient care previously done by the various traditional specialties.
EM is not, unfortunately, well paid, it is not particularly glamorous, yet the residents currently in training mostly chose to train in EM, due their personal preference for the specialty. They are allowed to supplement their income by working in their private clinics after hours, and in fact most could not have survived financially without this extra income. This work has the added benefit of maintaining the skills they had gained in their first specialty, which are also useful in their work in the ED. Clinical hours in the ED are mostly usually approximately 30/week.
Re: Ice, Pins and Sugar: Are they meant for reducing paraphimosis
In response to the letter from Dr Raveenthiran, I feel that there are a number of issues to be addressed. Firstly, many BETs are written not to reflect and reinforce current practice in emergency departments. Often, as in this case, this is a response to advice recieved upon referring to the appropriate specialty. Many techniques require questioning whether they are acccepted practice or otherwise. As such the bestBETs procedure, looks at available evidence on a practice, appraises and shows that evidence and derives a clinical bottom line.
Secondly, in an attempt to cast as sensitive a net as possible for that evidence, some BETs authors choose to include accepted spellings from different countries (eg tumour or tumor) and also the more common mis- spellings. The efficacy of this method was shown as the second paper (published in the Annals of the Royal College of Surgeons of England) quoted used the incorrect spelling "paraphymosis" in the title and throughout.
Thirdly, there is some difficulty in changing the bottom line as suggested. Evidence has been found, and although this evidence appears poor with no control group and may be confounded by inadvertant pressure to the glans (particularly in the pins group). As with all BETs, the available evidence is presented in which reader's can draw their own conclusions. Based on the evidence provided, the clinical bottom line we reached was one we felt most appropriate to that evidence available, it cannot simply be dismissed as it disagreed with our belief when we approached the subject.
Re: Regurgitation of Best Evidence?
I would like to thank Drs Glazebrook and Probst for pointing out a potential source of confusion. I also considered gastric lavage innapropriate management of overdose for multiple reasons, which gave me cause to review the evidence. The fact it's use is still occasionally suggested in clinical practice remains a personal concern.
At the time of the initial authorship of the BET concerned, gastic lavage was being performed for a number of drug groups in overdosage, in particular ions, NSAIDs and tricyclic antidepressants - for which lavage was advocated due to the poor absorbtion of these drugs by charcoal. BETs were performed on all these drug groups and the clinical bottom line reflects a response to our initial clinical problem. In response to the above letter all of the gastric lavage BETs on the website will contain links to national poisons information service for up to date advice. Clinical bottom lines are being updated to avoid the potential for ambiguity.
ED RSI in the UK - the growing evidence base is not inconsistent
We would like to thank Dr Oglesby and colleagues for their helpful comments , and for highlighting their data on complication rates for ED RSI  which were published subsequent to the submission of our paper .
We share entirely their reservations regarding propofol as an induction agent in ED patients. It is our observation that it is associated with a greater incidence of hypotension than other agents in inexperienced hands, and that junior anaesthetic staff consistently demonstrate a remarkable predilection for its use. This is an example of the inappropriateness of directly applying theatre-based anaesthesia practice to the critical care setting, and we continue to hope that our data might contribute to the development of more tailored anaesthesia training for critical care and emergency physicians.
We note that the larger Scottish study demonstrated a greater proportion of physiologically compromised ED patients than ours. However this does not negate our observation of ‘relative cardiovascular stability and normal respiratory function of ED patients’ compared with patients intubated in the ward and ICU settings. This might also be the case in Scotland if such a comparison between clinical areas were to be made. The point has been made by Dr Oglesby and colleagues in their own paper that ‘the lack of internationally accepted definitions of complications of RSI means that studies of emergency airway management...cannot be compared on an equivalent basis’, and the complication of ‘critical desaturation’ was not defined in their paper. Bearing these limitations and our stricter definition of hypotension in mind, ED complication rates were not in fact markedly dissimilar between our studies, whereas complication rates on the ICU were three times higher than in the ED.
We applaud the approach of having a senior anaesthetist or intensive care specialist present during ED RSI. Although this may well be achievable in the teaching hospital setting, many district general hospitals may not have an available anaesthetist, let alone a senior one. The challenges of Hospital at Night and European Working Time compliant rostering may further deplete this supply, and only by the development of joint protocols as recommended by Dr Oglesby can this vital patient need be met. In our current practice setting we have pursued a similar course with a joint anaesthesia / emergency medicine Standard Operating Procedure for Rapid Sequence Intubation which we would be happy to share with anyone hoping to develop their ED RSI program.
(1) Rapid response: The who, where, and what of rapid sequence intubation Angela J Oglesby, Mark J D Dunn, Alasdair J Gray, Diana Beard, Dermot W McKeown, Colin A Graham (10 August 2004)
(2) Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20:3-5
(3) Reid C, Chan L, Tweeddale M. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Emerg Med J 2004;21:296-301
Ice, Pins and Sugar: Are they meant for reducing paraphimosis
I read, with interest, the article by Jones and Teece . The authors have attempted to find the best out of three procedures, which more or less resemble home remedy. They should not be offered in a modern scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis .
In paraphimosis, as soon as the constricting ring of prepuce gets stuck to the coronal sulcus, vascular spaces of the glands are engorged due to venous impedance. This tumescence of glands is the real hindrance for reduction. Therefore, manual squeezing of the glands or needle aspiration of the vascular spaces is essential for reducing the stuck foreskin. (2) If left untreated, lymphatic blockage causes delayed onset of oedematous swelling of inner preputial layer. Thus, oedema is the result and not the cause of irreducibility. Very often this cause-effect relationship is misunderstood. Many authors, who erroneously incriminated preputial oedema, attempted to dissipate it by a variety of techniques such as multiple puncture of swollen foreskin, injection of hyaluronidase, application of hygroscopic agents such as granulated sugar and use of ice packs. All of them are either useless or unnecessary. Application of ice is probably dangerous as it carries the risk of spasm of penile end-artery and gangrene. If some hygroscopic agent has to be applied I wonder if it is the sweetness of sugar that made it preferable over salt!
The spelling PARAPHYMOSIS used by the authors for Medline search is nonexistent. PARAPHIMOSIS is derived from the Greek word ‘PHIMOS’ meaning muzzle (Verb). The Greek word ‘PHYMA’, which means a tumor, has no relevance to the restraining foreskin. The clinical bottom line of the paper needs to be modified as, “Ice, pins and sugar have been claimed to aid reduction of paraphimosis, but there is no evidence to show any of them really works.” Unless these primitive methods are discouraged, one would not be surprised to read in Emergency Medical Journal, after sometime, an article entitled “Dipping in honey aids reduction of paraphimosis” - for honey is also hyperosmolar and hygroscopic as sugar!
(1) Jones KM, Teece S. Ice, pins and sugar to reduce paraphimosis. Emerg Med J 2004; 21: 77-78.
(2) Raveenthiran V. Reduction of paraphimosis: a technique based on patho-physiology. Br J Surg 1996; 83: 1247.
Head injury transfers
The letter by C D Okereke  “Head injury transfers: arm of greatest delay” confirms that considerable delays persist in the transfer of patients with traumatic brain injury from district general hospitals to regional neurosurgical units. Our own data indicates that emergency craniotomy for traumatic brain injury was achieved in only 1 out of 24 patients  within the recommended four hour target  and we are currently investigating how transfer strategies can be refined to meet this target.
Mr Okereke poses two questions: Why see the scans images before sanctioning a transfer? Are there concerns relating to the radiologists interpretation of the scans?
From a neurosurgical perspective, I agree with Mr Okereke that it is not always necessary to see the CT scan images before transfer. There is a population of patients who need urgent transfer to the neuro-surgical unit irrespective of the interpretation of the CT scan by the neurosurgical unit. For example, patients with deteriorating levels of consciousness and a space occupying haematoma should be accepted at the time of referral not at the time of review of the CT scan. There are exceptions to this rule, however, notably patients who are hypotensive with ongoing blood loss who may require urgent extra-cranial surgery and patients in whom the prognosis is deemed hopeless from the onset. In these patients it is essential to see the scan to determine the suitability and timing of transfer. Mr Okereke eludes to taxi transfer of images which inevitably leads to delays. It is of paramount importance that district general hospitals have an electronic image link with the regional neurosurgical unit.
Should it be a matter of policy that all isolated severe head injuries (GCS <_8 be="be" taken="taken" directly="directly" to="to" the="the" neurosurgical="neurosurgical" centres="centres" p="p"> Whilst this concept would reduce delay in the definitive management of patients with severe head injuries there are a number of concerns in implementing such a policy at the present time. Firstly, two of the major factors in determining outcome are the presence of hypoxia and hypotension as secondary insults. Comatose patients therefore require urgent placement of a definitive airway (cuffed tube in the trachea) and fluid resuscitation. This is likely to be achieved more rapidly by transferring patients short distances to district general hospitals than by longer primary transfers to neurosurgical units unless patients can be intubated at the scene which requires both the expertise to place the endotracheal tube and to administer sedating and paralysing drugs. Such expertise is not yet universally available. Secondly, it is often difficult in the field to distinguish between patients who are comatose with an isolated head injury from those who are harbouring other injuries, for example, thoracic, abdominal or pelvic haemorrhage. The priority in these patients is to treat shock with urgent extra-cranial surgery. Thirdly, it is not currently logistically appropriate that all patients with isolated head injuries are transferred to regional neurosurgical units. There is a population of patients who present with an isolated head injury who may not require neuro-critical care, for example those with a seizure and normal CT scan. There is also a population of patients with devastating injuries with no chance of survival in whom transfer is clearly inappropriate.
In summary, I agree with Mr Okereke that the concept of transferring all patients with isolated severe head injuries directly to neurosurgical centres is attractive but at present would produce significant problems. However, given the evidence that specialised neuro-critical care has the potential to improve outcome in patients with diffuse injury as well as those with mass lesions [5-7] we should be ensuring that all patients likely to benefit should be transferred. Direct transfer to neurosurgical units may become possible in the future but would require widespread implementation of personnel with the ability to intubate patients in the field which requires expertise in the use of sedation and paralysis, rapid transport systems from the field to the regional neurosurgical unit (distances in some regions in excess of 100 miles), capability for extra- cranial surgery in all regional neurosurgical units and an expansion in the number of neuro-critical care beds.
PJ Hutchinson Academic Department of Neurosurgery, University of Cambridge, Addenbrooke’s Hospital, UK
Address for correspondence: Mr PJ Hutchinson University of Cambridge Department of Neurosurgery Box 167 Addenbrooke’s Hospital Cambridge CB2 2QQ UK Telephone +44 1223 336949 Fax +44 1223 216926 E-mail email@example.com
(1) Okereke CD. Head injury transfers: arm of greatest delay. Emerg Med J 2004;21:397.
(2) Sergides IG, Howarth S, Whiting G, Hutchinson PJ. Is the recommended four hour target from injury to emergency craniotomy for head injury achievable? Br J Neurosurg 2004;abstract in press.
(3) Royal College of Surgeons of England. Report of the working party on the management of patients with head injuries. London: RCS, 1999.
(4) American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. Chicago: American College of Surgeons, 1997.
(5) Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med 2002;28:547-53.
(6) Polderman KH, Tjong Tjin Joe R, Peerdeman SM, Vantertop WP, Girbes AR. Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med 2002;28:1563-73.
(7) Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury improved by an organised secondary insult program and standardised neurointensive care. Crit Care Med 2002;30:2129-34.
Regurgitation of Best Evidence?
While I normally find the Best BETs both informative and useful, I was surprised at the publishing of one concerning gastric lavage in drug overdose .
Gastric lavage is both dangerous and without benefit in all but a few overdoses. The 1997 Joint Position Statement made by the American Academy of Clinical Toxicology, and the European Association of Poisons Centres stated that gastric lavage should never be routinely used .
A statement on the National Poisons Information Website (TOXBASE) indicates that gastric lavage should only be considered in a case of a potentially life-threatening overdose taken within the last hour of a poison that is not adsorbed by charcoal.
To state that gastric lavage is no better than charcoal as a clinical bottom line at reducing toxicity following aspirin or non-steroidal anti- inflammatory drugs is at Best misleading.
(1) Teece S. Gastric lavage in aspirin and non-steroidal anti- inflammatory drug overdose. Emerg Med J 2004;21:591-592.
(2) American Academy of Clinical Toxicology and European Association of Poisons Centres. Gastric Lavage. J Clin Toxicol-Clin Toxicol 1997;35:711-719.
Back to the future-superspecialisation in ED
I think the model the Israeli medical services had adopted in the development of emergency medicine is brilliant and something we should deliberate adopting as modelling for the future of emergency medicine. It's not a new idea as the Casualty Surgeons in the UK and countries affiliated to this model in other parts of the world did way back in the 1960's develop as a group of specialist orthopaedic surgeons/general surgeons with an interest in emergency care. Where it differed was they no longer continued their primary speciality as there was no way to undertake both because of the small numbers of individuals involved. It effectively deskilled this group of people in their primary speciality. They remained in the emergency departments initially in a leadership/administrative capacity but over the years increasingly more in clinical delivery of service. New trainees undertaking emergency medicine as a primary speciality are coming with breath but not depth of the spectrum of medicine.
We are effectively the last bastion of emergency care generalists but because of our hospital based practice risk being labelled referrologists as extended continuity of care has not been a feature of emergency medicine practice. This hybrid model that the Israeli medical service has adopted is one solution I think merits serious examination in the development of career models and syllabuses in emergency medicine.
The consultants of the emergency department could be general surgeons, orthopaedic surgeons, anaethetists, physicians, general practitioners who have dual specialisation and share the running of the emergency department after finishing specialist training in both. They are identified early in the basic training to fulfil this dual training. In later years they can fall back on their primary speciality as the high intensity activity of the EM starts to take its toll with increasing age. It will also encourage movement which can be a problem in parts of the world where emergency department specialist are seen as public hospital based without much lateral movement to the private sector/private hospitals.
EMERGENCY DEPARTMENT, WEEKENDS, AND TEMPORAL PATTERN OF OCCURRENCE OF ACUTE MEDICAL DISEASES.
We read the interesting paper by Mirò et al , who found that in the emergency department (ED) weekends are not characterized by a loss of effectiveness compared to workdays. The possible reduction in staff and loss of attention on weekends is a topic still under debate. A recent study  analyzed the six more common urgent procedures usually utilized in acute care hospitals, and found that only 5% of these were performed on the weekend. However, though these procedures are not performed on weekend for scheduled activities, they are promptly available in the case of urgency. In the recent past, traditional estimates of emergency physician have been first based on merely quantistic analysis (volume of patients seen in ED), and successively improved by the utilization of multivariate formulas considering other parameters, eg, lenght to stay, intensity and type of services. However, determination of emergency physician workload derives from several considerations, and it’s not the same to face with a myocardial infarction or a minor trauma .
But the problem is: which kind of urgent diseases are more likely to occur on weekend?
Several studies have shown that weekend time is less likely to be interested by acute cardiovascular events. Myocardial infarction occurrence is increased by approximately 20% on Monday compared with other days of the week , and also cardiac arrests are higher on Mondays, with lowest numbers over the weekend . Again, a significant Monday peak in the occurrence of ischemic stroke has been reported as well . It has been speculated that the transition from the quiet life on weekends and the patients’s activity (or change in activity) on Mondays may be responsible for the lower occurrence of myocardial infarction and stroke on Saturday and Sunday and the peak on Monday. This could explain why, despite the possible condition of both reduced staffing and availability of services during weekends, the adjusted odds of death for patients admitted on weekends is only slightly increased (OR: 1.03, 95% CI: 1.01 to 1.06) , and suggest a lower severity of cases admitted on weekend. Since acute diseases referring to the hospital respect a temporal pattern of occurrence, it is possible that quantity and quality of ED staffs might take into account the increased demand of specific facilities in certains hours of the day  and days of the week as well. Only as an example, it could possible to suggest a “monday-load” staffing pattern for ambulances equipped with high-trained personnel staffs transporting cardiovascular patients. The maximum demand on facilities and professional health expertise may occur during different days of the week and varying depending on diseases itselves.
(1) Mirò O, Sanchez M, Espinosa G, Millà J. Quality and effectiveness of an emergency department during weekends. Emerg Med J 2004;21:573-4.
(2) Bell CM, Redelmeier DA. Waiting for urgent procedure on the weekend among emergently hospitalized patients. Am J Med 2004;117:175-81.
(3) Willich SN, Lowel H, Lewis M, et al. Weekly variation of acute myocardial infarction. Increased Monday risk in the working population. Circulation 1994;90:87-93.
(4) Peckova M, Fahrenbruch CE, Cobb LA, et al. Weekly and seasonal variation in the incidence of cardiac arrests. Am Heart J 1999;137:512-5.
(5) Manfredini R, Casetta I, Paolino E, et al. Monday preference in onset of ischemic stroke. Am J Med 2001;111:401-3.
(6) Cram P, Hillis SL,Barnett M, Rosenthal GE. Effects of weekend admissions and hospital teaching status on in-hospital mortality. Am J Med 2004;117:151-7.
(7) Manfredini R, la Cecilia O, Boari B, et al. Circadian pattern of emergency calls: implications for ED organization. Am J Emerg Med 2002;20:282-6.
Convincing senior doctors to train in EM
Dr Halpern's article about the development of EM training in Israel is quite informative and can be relevant to many other countries in the middle east.
However, I would like to enquire about how senior physicians who are already trained in their respective specialties and run their own private clinics were persuaded to leave all that and enter another 2.5 years of EM specialist training - the so called 'Grandfather clause'.
I'm sure this wasn't an easy task to do. Is EM in Israel still looked upon as a young specialty run by young single (i.e. no family commitment) doctors or has that view changed like in the US and UK? Was EM portrayed to them as a 'glamorous' specialty or do EM physicians have a better salary than other specialists? Did they choose to train or were they formally asked to join an EM training program? Are these physicians still allowed to run private clinics after being trained in EM and what are their working hours like?
Enlighten me Dr. Halpern. Thank you.
Jelly on the Belly
I read with interest Brooks audit of FAST in a 100 Blunt Abdominal Trauma and 10 penetrating abdominal injuries done by 3 non-radiologists members of of the emergency department. Ultrasound imaging as a diagnostic modality is unique for us in A&E as it requires skills in both image acquisition and interpretation where we have traditionally had only to deal with the latter for plain films or CT/MRI. The sensitivity of ultrasound in picking up even small volumes of free fluid especially in Morrison's pouch is without doubt and confirmed by this audit. It also raises the point that contemporaneous CT scanning may not pick the fluid up even if its used as the gold standard. DPL provided its done well may resolve the issue but then again may not if its a small bleed with equivocal results.
To me a well acquired and interpreted negative initial FAST scan is very reassuring that the blood is probably not coming from the belly and positive FAST with clinical signs of abdominal injury and hemodynamic compromise is a reason to go straight to the operating theatre. The added pre-test high index clinical suspicion of an experienced "hand" on the belly before the jelly with the ability to serially repeat the ultrasound should enhance the pick-up rates although most studies/audits don't look at this aspect of the workup. Otherwise, it can inadvertently start generating large numbers of true negatives as there was really no serious pre-test concerns of abdominal injury.
Fast food medicine for thought
The paper by Terris  on reducing waiting times in the ED using consultant/Senior Nurse triage and subsequent papers by Subash on team triage and Mitchell on Senior House Officer time-motion study in this month's EMJ is giving me serious concerns we have missed the woods for the trees. Our core activity of giving high quality emergency care to those who truly need it is being diluted by the increasing demands of functioning as a safety net for resource limited access to primary/community care.The emergency department is now becoming an access path of least resistance for one and all who choose to attend it as there is no waiting list for appointments. Our efforts to improve the efficient processing of patients who really need to attend as an emergency using yardsticks like 4 hour processing is increasingly having a knock on effect in the general public taking advantage of this efficiency.
Anecdotally I am certainly seeing patients who are using us as a one stop convenient point of access for minor injuries/illness simply because we are providing a far more efficient service than their primary care providers. I don't personally have a problem with who I see but lets not pretend we are only an emergency department if we are masquerading as an easy access primary care centre. Lets also not rush around like headless chickens processing patients quickly here and there with so called consultant/senior nurse led input/triage trying to keep these 4 hour targets if we are indeed functioning as a glorified primary care centre. Lets also not deny junior doctors the opportunity to undertake varied clinical activity just so they can process patients quicker. There is a teaching and training function that is integral to the future of the NHS as a whole and the papers seem to suggest this is not happening as well as it should.
If a patient has to wait because
a) a medical student has to be trained to take a good history, examination, Inx or
b) a junior doctor gains confidence in making decisions, deliberating on those decisions, discussing and learning lessons from those decisions or
c) because a distressed wife of a cardiac arrest victim needed the empathetic ear and care of a senior experienced senior nurse that needs to be part and parcel of the service agreement.
I think its time we put a brake on this fast food restaurant mentality in clinical emergency medicine. For one thing, it's not sustainable without a massive influx in the workforce at middle grade/ senior level in all departments and there aren't the bodies out there for it. I think the job now is to make the practice of emergency medicine and workplace clinically stimulating, challenging and fun for all practitioners medical, nursing and allied staff and the rest will take care of itself. I hope!.
(1) Terris J, Leman P, O’Connor N, Wood R. Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage.Emerg. Med. J., Sep 2004; 21: 537 - 541.
(2) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency
Emerg. Med. J., Sep 2004; 21: 542 - 544.
(3) Mitchell J, Hayhurst C, Robinson SM. Can a senior house officer’s time be used more effectively?
Emerg. Med. J., Sep 2004; 21: 545 - 547.
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