Advanced airway management

This month we have two complementary papers on advanced airway management.

The first, from Jonathan Benger in Bristol, reports the results of a survey into drug assisted intubation in emergency departments during a 2-week period in 2008 (see page 217). The results may not be a surprise to seasoned readers but they are still something to be noted and are summarised in the paper's abstract—namely that ‘the 0.12% incidence of ED RSI is consistent with previous studies, as is the finding that only 20% are performed by emergency physicians. The relative infrequency of ED RSI and increasing pool of staff has important implications for training and skills maintenance. Despite the acknowledged difficulty of this technique nearly half of all ED RSIs are done by unsupervised trainees’.

The second paper, from Tim Harris and David Lockey in London, reports on the skills of doctors who perform prehospital intubation (see page 225). This is an important piece of work because, as the authors mention, there is still a considerable debate in the UK about who is best at and who should perform this procedure; doctors (be they anaesthetists, emergency physicians or intensivists) or paramedics.

We welcome readers' opinions on these important (and at times very emotive) topics, whether they be in the context of the emergency department, the prehospital world or both.

Emergency care pathways

I was planning to abbreviate this topic to EPCs, but quickly realised that the acronym maybe confused with Emergency Care Practitioners (see page 203). Under the neat heading of ‘action research’ a team from Plymouth comment, wisely, that the original aims of a research project may change as the parameters that give context to the research change; they describe the problems they met and then discuss them in the broader context of health reform. It is a fascinating paper which contains several nuggets of discrete wisdom and insight; it is recommended to any reader who is interested in, or is responsible for, system reform.

TARN in Switzerland

This is not a reference to mountain lakes in the Alps but to a paper from Bern describing the use of the UK-based Trauma and Research Network (TARN). It was found to be the most suitable register for a level one Swiss trauma centre (see page 221). The authors tell us that Bern University hospital, situated in the heart of Europe, surrounded by different trauma systems, faced difficulty in choosing a proper registry suitable for the Swiss Medical System. TARN hit the spot.

Imaging the renal tract

New technology is appealing to practitioners for many reasons, even trite ones, but be careful; a new piece of equipment that is bright and shiny when it comes out of its box and has loads of functions attached to it (described with hyperventilatory zeal by the relevant sales teams) may come with unintended consequences.

Michael Quirke and his Dublin colleagues report that compared to intravenous pyelograms, helical CT impacted negatively on patient processing times in their ED and for patients presenting after midnight, it led to a twofold longer length of stay from the time of scan request to referral or discharge (see page 197). This leads to prolonged patient stays in ED and contributes to overcrowding.

Cannulae and fluids

We have a study from Dundee that will be of interest to ‘resuscitationologists’ (see page 201). In summary, when rapid fluid resuscitation is needed, a peripheral cannula of size 18G or greater is preferable to a central line. If a central line is the only obtainable access, a pressure bag makes a greater difference to flow rate than it would with a peripheral cannula.

Primary percutaneous coronary intervention, inhospital and prehospital thrombolysis in STEMI

This paper, from Edinburgh, is of great merits a concentrated read by those responsible for managing cardiac pathways in their area or hospital (see page 230). The authors state that optimal reperfusion treatment, including a combination of those mentioned above, is feasible in the UK although the balance between the use of different treatments will differ between urban and rural areas.

Portable treatment technologies

This paper explores ‘the portable technology requirements needed to support new professional roles that are designed to deliver urgent care in the community, defining a three level technology system for personal kit, assessment packages and a clinical workspace’ (see page 192). Don't be fooled into thinking ‘this is not for me’.

It is a paper with a very practical aim, namely to describe a process and methodology to help define the equipment needed to set up a new ‘model of care’ that is urgent care in the community.

It is an excellent paper.

Alcohol screening

Lucy Jones from Sheffield offers us a systematic review of alcohol screening tools in ED. The title says it all (see page 182).

Finally…

As always, we have many other splendid original papers as well as our usual regular features this month; we hope you will enjoy them.