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A FADING MEMORY?
It is increasingly common for sedation to be given in the emergency department, and in recent years emergency department physicians have started to use a much greater range of drugs than the slug of 10 mg midazolam that I remember from my early days in the speciality (well they were sedated!). We never considered awareness back then, but it clearly is an important issue for many patients who undergo a painful procedure. Swann et al have specifically looked at the incidence of awareness in patients undergoing emergency department sedation and found a relatively low rate of 7.4% immediate recall and 4.5% delayed recall of events. Many patients remember dreaming, though the nature of the dream is sadly not reported. Overall a high level of satisfaction was reported, which again strengthens the argument for procedural sedation in the emergency department. See page 322
GONE BUT NOT FORGOTTEN
One of the more challenging aspects of being an emergency physician is dealing with bereaved relatives. For most of us this will be a transient meeting to inform the next of kin, friends or family of a patient’s death in the emergency department. Such conversations are often brief and there is good evidence to suggest that patients remember little of what is said. In South Manchester the emergency department has invited the bereaved back to the department at a later date to answer any questions they may have. Parris et al, report their assessment of the bereavement service where 14% of bereaved relatives take up the opportunity to discuss what happened. This service is not offered everywhere, but after reading this you may well decide that it is a worthwhile effort. See page 339
There are few things in life that excite me more than a ROC curve. This month we have a lovely curve from Korea looking at BNP levels in the diagnosis of congestive heart failure. The authors have found that the optimal cut-off level is 296.5 pg/ml, a remarkably accurate value you might say. However, for those of you about to take the FCEM exam, and for all of us who use diagnostic tests, I challenge you to read the paper and pick two other values that might be more use in practice. See page 343
Do you admit patients following electrical shocks if they are well? Well some places still do if they are deemed to have had a high risk injury. Canada seems to be the place to go as a report on 115 patients over a 4-year period demonstrated that no patient developed a potentially life threatening dysrthymia after admission. However, a small number developed problems in the subsequent year, which did require investigation. See page 348
CONFUSED HEAD INJURIES
You would think that that there would be consistency in the advice given to patients attending the emergency department with head injuries, but this seems to not be the case in Scotland (and I suspect elsewhere as well), where Kerr et al have shown a great deal of variability with respect to immediate and late complications. They did not look at the utility of the cards in helping patients, but some consistency and help with explaining post-concussion symptoms would seem to be a good idea. After all, there is no point in confusing them anymore (NB: confusion was only mentioned on 67% of cards). See page 330
A STORMING NECK INJURY
You must be having a bad day if you manage to spear yourself in the neck, through the thyroid thereby releasing enough thyroxine to precipitate an endocrine emergency, yet this is what happened to a 32-year-old spearfisherman in Greece. There is no mention of how it actually happened, but hopefully his rehab program will include lessons on which end of the spear is pointy. See page 355
RESCUE THEN RESUSCITATE
Everyone loves National Standards…well maybe not, but Lee and Porter give a convincing argument for consistency in the life support skills taught to the fire service. The fire service is often the first on scene and has a real opportunity to do more than just rescue patients, but also to intervene with life saving procedures. The list of suggested procedures will no doubt be controversial, but if you don’t agree then get in touch through our rapid responses. See page 353