• emergency care systems

Scoping reviews are, as you might imagine, a scouting of the literature to see what’s been published on a specific topic with the goal of determining the evidence base that does or does not exist in an area. As these reviews are generally not designed to provide specific answers to their clinical questions (as systematic reviews are), EMJ does not publish these. Although, in fact, we have. Because the scoping review in this issue, the Editor’s Choice, looks at what has been studied on retention of emergency physicians in their careers, and goes a bit beyond telling us just what is missing. You’ll note that, although Darbyshire et al submitted the paper just after the first surge, COVID-19 is not mentioned as a rationale for this work. And that is appropriate, because even before COVID-19, the stresses on emergency physicians were omnipresent and intensifying. The authors found “Multiple factors were identified as linked with retention including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work-life balance and anti-social working patterns.” Worrying, they found little in the literature about interventions. Sunil Dasan’s companion commentary “Easy come, easy go?” speaks to the need to change our approach to staff retention.

One of the more stressful aspects of emergency medicine practice is making the decision to discharge or admit a patient when the diagnosis or the likely course of the disease is unclear. Decision rules have proved helpful in this aspect. But they do need external validation. In this issue we present multi-centre validation study of the Canadian Syncope Risk Score (CSRS) among 345 patients from six hospitals in Northern Italy. Solbiati et al found that while clinical judgement and theCSRS had similar AUROC, there were adverse events among 6.7% of the patients the CSRS rated low risk, compared with 2% of those considered low risk by clinical judgement. The authors caution that further evaluation of the CSRS is needed.

We’ve seen several studies asking if, given their extensive experience, nurses can predict at triage whether a patient is going to need admission. The premise is that early prediction of admission could lead to earlier requests for beds and faster flow through the ED. In this issue, Afnan et al present a systematic review and meta-analysis of 10 studies determining how well nurse judgement predicts admission or discharge. Bottom line: While certainly better than chance, nurse prediction isn’t sufficiently accurate to rely on this method.

I doubt I am the only one who has asked patients to wait hours after a joint aspiration for the cell count in order to determine if I need to request a consultation by orthopaedics or hospital admission? The study by Knapper et al evaluates colorometric leucocyte esterase detection using a standard urinalysis dipstick for testing of joint fluid in a query-septic joint patient. Can a decision to give antibiotics, do a washout or send the patient home be made sooner with this point of care test? In another study on test strategy in this month’s issue, Coggins et al compared the utility of venous and arterial blood gases in determining shock in trauma patients.Shock was defined using pH ≤7.2, base deficit (BD) ≤−6, bicarbonate <21 and lactate ≥4. VBG’s had “false negatives” for 20 of the 176 patients tested, but the authors note that in only 2 cases would the results of the ABG change management. Finally, Cattermole and Manirafasha performed a comprehensive prospective study to assess the accuracy of various weight estimation methods for both adults and children, finding that parents/guardians or patients are the most accurate, age-based formulas are least accurate, and overall, as weight increases, the likelihood of under-estimation of weight increases.

We include under our “COVID-19” section this month a study in which Dbouk and colleagues created 3-D models and simulations to predict the direction of exhaled infectious aerosols during CPR. Although not specific to COVID-19 transmission, the paper provides valuable instructions for how a rescuer can position themselves during CPR to reduce exposure to potential infectious material. This is particularly relevant to the article from Taiwan by Yu et al on out of hospital cardiac arrest which found that during 2020 bystander CPR and use of AED’s actually increased compared with 2019, but EMS response time was significantly longer.

Now onto education: yours. This month’s Reader’s Choice is a practice review, written by well-established experts in the care of the elderly, on the management of patients with frailty in the ED. This month’s ED ultrasound education article illustrates how to diagnose and safely drain a peri-tonsillar abscess under ultrasound guidance. You’ll also notice that our Top five has transformed to a more general journal update, including non-Covid research. Although COVID-19 (unfortunately) appears to be with us for a while, the originators of COVID-19 Top five have wisely decided to expand their search to keep our readers well-informed on other developments relevant to our specialty.

Finally, please do take just a few a moments to read this month’s In Perspective (“Regain Humane”) which reminds us of where we need to focus in caring for our patients in their time of crisis.

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