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Back to the future
Emergency Physicians are diagnosticians all of the time and (short-term) therapists some of the time. It is interesting to consider how, then, information about longer-term outcomes can be of value to them. Two papers in this month's journal explore how information about prognosis that is available (or potentially available) in the Emergency Department can be of utilised. Thomas Guidez and colleagues, from Lille, France, (see page 274) consider the role of B-type natriuretic peptide as an adjunct to the GRACE score in predicting acute myocardial infarction or death in patients with acute coronary syndrome. They show that the GRACE score together with BNP is better than the GRACE score alone at predicting the outcomes at 6 months. Perhaps more importantly from an Emergency Physicians' viewpoint, the addition of BNP refines the allocation of individual patients to risk groups at presentation, and may therefore alter initial treatment decisions. In a separate paper Hermans and coworkers, from Maastricht, the Netherlands, compare the performance of the Mortality in Emergency Department Sepsis (MEDS) score with CRP and lactate at predicting 28-day mortality. Of the three, the MEDS performs the best (though the number of lactate measurements was small and further work is needed there). In the highest risk group defined by MEDS (score over 15 points) 28 day mortality was 77.8%. The question for us all is how we use such information (and whether we should). Consider, for example, that the highest single score in MEDS is ‘terminal disease’ (at 6 points). Bearing that in mind do the author's findings mean that we should always try the hardest with the patients with the highest scores, or does it mean that we should sometimes declare futility in that group and move on? (see page 295) and decide for yourselves.
Rhythm and blues
In a neat little cohort study Camilla Fundarò and others, from Milano, Italy report on the 7th day heart rhythm of patients who had attended the Emergency Department in atrial fibrillation. Two groups were identified—those who were cardioverted on the day of attendance and those who were managed with pharmacological rate control. How many of each group do you think were in sinus rhythm at follow-up? (see page 284) to find out.
The elephant is no longer in the room
In a well designed randomised cross-over trial 74 volunteers attending a conference in New Zealand did their best to deliver good chest compressions (as assessed by measures of rate and depth) while listening to achey breaky heart, disco science or nothing at all. It would be wrong to give away the ending to such an exciting plot here, and you will have to (see page 290) to finish the story for yourselves. Suffice it to say at this stage that Malcolm Woollard and co-conspirators give assurances that no volunteers were permanently harmed by repetitive musical exposure, athough it is reasonable to imagine that further studies into longer term psychological sequelae might be needed.
Glowing in the dark
Ryan Lee and co-investigators from Hong Kong, China have undertaken an interesting study into the knowledge of clinicians about the radiation doses of commonly performed radiological investigations. While radiologists (particularly young ones) performed best, no clinicians performed well. If it is a surprise to you that a hip x-ray requires the radiation exposure of 20 chest x-rays or that a CT abdomen equates to 500 chest x-rays then you could do well to look at table 1 in this paper. (see page 306) to be better informed.
Mike Brooke and colleagues from the North West of England report on the ability of Advanced (Master's level) Paramedics to acquire and interpret emergency lung ultrasound images. All the paramedics attended a 2-day course and were examined by and compared to expert emergency ultrasound practitioners. They preformed well in this simulated environment. As the authors state in their conclusion more research is needed to look at whether this technical ability, and the potential it generates, can be translated into real patient benefit in the pre-hospital setting (see page 322).
Minh Le Cong and others from the Royal Flying Doctor Service in Cairns, Australia have provided a short report on their experience of using ketamine to sedate acutely agitated patients during aeromedical transport. In a small case series of 18 patients (19 retrievals) they found no adverse reactions or consequences and they therefore argue that this is an effective and safe strategy. (see page 335) to see if you agree with them.
Nirmal Panesar and Colin Graham from Hong Kong, China report on their study into comparative death rates in Hong Kong during the lunar ghost month (when the ghosts of those who died hungry are said to escape through the open gates of hell to haunt the living). Their results are interesting (see page 319) and they seek to explain them in terms of the behaviours of the living rather than the actions of the dead. Go and critically appraise the article for yourself and see whether you believe more in ghosts, chance (type 1) or neither.
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