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  1. Geoff Hughes, Editor

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    This month we introduce a new series on critical appraisal. As the accompanying commentary highlights, critical appraisal is now an important component of training and assessment for ED trainees. We trust that readers of all ages and backgrounds will learn something from these articles (see pages 189 and 219).


    Do emergency departments have any role in public health screening? A team from Southampton decided to have a look at screening for hypertension in their ambulatory patients. Their conclusions may provide some solace for those who argue that screening programmes have no place in modern emergency departments. Others may, perhaps cynically, argue that the differences between some ED work and primary care are getting smaller with a blurring of the boundaries between them, and such screening will be more commonplace in the future (see page 196).


    It is one of those facts of life that practices and skills once seen as being owned by one discrete group of people gradually become owned by a wider group of people. In our own world two examples include tracheal intubation and thrombolysis, once only seen in the domain of anaesthetists and cardiologists. Richard Bolton and Anthony Bleetman offer us a literature review of non-invasive positive pressure ventilation (NIV) and continuous positive airway pressure ventilation (CPAP) and their roles in contemporary practice, skill sets once only seen in ICU, respiratory units or CCU. They also give us an evidence-based flow chart that we are sure many people will find helpful (see page 190).


    Toxinology, a specialty that deals with both the biology and the clinical consequences of animal and plant toxins, does not have a high profile in northern Europe, for obvious reasons. In many areas of our planet, toxinology is an important and vibrant discipline, dealing with injuries due to snake and spider bites as well as those from marine envenomation, and is a routine part of clinical practice. A team of authors from southern India report their own experiences, in particular using polyvalent snake antivenom (see page 200).


    Travelling from southern Asia to the Middle East, we have a report from Raiter and colleagues on the response to a mass casualty incident in Tel Aviv in 2006. They draw some lessons for us all to consider on management, primary triage, evacuation priorities and the rate of arrival of casualties to nearby hospitals (see page 225).


    Moving across the Atlantic to the United States, we have a fascinating paper that looks at the role of morphine in the management of heart failure. Peacock and colleagues argue that when used in this context it actually increases the number of adverse events, including longer length of stay and increased numbers of ICU admissions (see page 205).


    Please forgive this aside, but at the time of writing this the latest UK data have been released (although we are not publishing them in the EMJ) regarding ambulance response times in the NHS. Evidence of patient stacking is revealed in official “turnaround time” data from seven of England’s 11 regional ambulance services. Figures relating to the past 15 months show that a total of at least 44 000 delays were reported by the seven ambulance services. In London, there were 14 700 occasions last year when an ambulance took at least an hour from its arrival at one of the capital’s 35 hospitals to hand over a patient and be ready to respond to the next emergency. This figure includes 332 that took more than 2 hours. A spokesman is quoted as saying “The problem is that A&E units [sic] aren’t admitting patients who are in the back of ambulances if at all possible if it’s going to compromise the four-hour target that they are set by the government to treat all patients in A&E. They are deliberately keeping patients outside waiting in ambulances.”

    If Joseph Heller were still alive we have to ask if he would be tempted to write a sequel to his wonderful satire Catch-22; in resurrecting his fine hero Yossarian and to catch the flavour of the absurd statement above, would he be tempted to call it Catch-999?


    Finally we offer our usual mix of case reports, a set of questions (with answers) for you to challenge yourself with, some BETs focusing on how we splint and support some of the everyday minor orthopaedic problems we see in our work (see pages 222 ARTICLE ARTICLE ARTICLE224) and also some correspondence referring to a previously published paper on the topic of B-type naturetic peptide (see page 246).

    We hope you will all find something to enjoy this month.

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