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Highlights from the issue
  1. Ellen J Weber, Editor

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Editor's choice: what happens when the Manchester triage system comes to the Netherlands?

Storm-Versloot et al conducted this before and after study at university hospital in the Netherlands to evaluate whether waiting time, treatment time and length of stay improved after the Manchester triage system replaced a less formal triage system in their emergency department. Time to physician went up, but treatment time was shorter, and total length of stay stayed the same. Patients were less satisfied with the information they received and ability to communicate their concerns, but more satisfied with how their problem had been sorted. Is this an improvement? We will leave that opinion to you.

Question: can getting sick on a weekend be hazardous to your health?

Answer: no, so long as the weekend isn't attached to a bank holiday

It has been thoroughly reported that mortality for emergency admissions increases on weekends and public holidays. Isles et al conducted a retrospective study in a Scottish hospital where senior medical consultants are present for at least 6 h a day, every day and found this not to be the case—or at least not entirely. Patients admitted through the emergency department on ordinary (2-day) weekends had the same mortality as those admitted on weekdays, but those admitted on public holidays (the weekend plus at least one weekday) had a higher mortality.

Time for a rethink on Pre-hospital trauma life support?

ATLS guidelines recommend classification of hypovolaemic shock into four categories, based on systolic blood pressure, pulse and Glasgow coma scale, but concerns have recently been raised about whether it can actually work. PHTLS uses an algorithm only slightly different from that of ATLS. In this retrospective study of over 46 000 patients in Germany, Mutschler et al found that the PHTLS scale was only able to classify 26% of trauma patients by matching all three of these variables and only 12% of head injury patients.

Elderly patients affect length of stay for everyone

It is not news that elderly patients have more complex illnesses, subtle symptoms and generally require a very thorough and evaluation. However, what is the effect of this time intensive care on the rest of the ED? In this novel analysis done in an ED in Japan, Kiwano et al found that the length of stay for patients overall and for discharged patients was higher on days when the mean patient age was higher; length of stay for admitted patients was not correlated. This study demonstrates that ED resources are limited, and as the intensity of care increases for some patients, even those with less complicated illness will be affected.

Are doctors creating avoidable ED visits?

ED visits are rising, and its possible that the medical profession is contributing to the problem. This prospective study by Ahern et al at Cork University Hospital in Ireland reviewed admissions to the hospital from the ED for four weeks. A panel of experts concluded that an adverse drug reaction (ADR) was related to 8.8% of admissions. Wih ADRs were taking a mean 7.5 medications. Drugs most commonly involved were cardiac and CNS agents, and the elderly were more likely to be affected. While perhaps not surprising to anyone working in an ED, medication side-effects should be considered in the differential diagnosis of patients presenting to the ED, as well as in our prescribing practices.

Another health risk from obesity

A retrospective look at all traffic fatalities in the US between 1996 and 2008 has identified that obesity conveys a higher risk of death in motor vehicle accidents. Rice and Zhu report that among over 3000 fatal collisions (over 6000 drivers), obese patients with body mass index (BMI) >35 had greater mortality, and those >40 had nearly two times the risk of death, after accounting for seat belt use, type of collision and vehicle.

Coping strategies in pre-hospital care

Pre-hospital personnel face traumatic situations on a daily basis and must make urgent life-saving decisions. Finding ways to cope is important to prevent depression, anxiety, post-traumatic stress disorder (PTSD) and burnout. In this qualitative study, Wild and Shepherd determined that ambulance workers who were able to make more positive appraisals of the situation coped better than those who had negative appraisals. The authors suggest that training in cognitive re-appraisal may be useful for these professionals.

Introducing…The view from here

This month we inaugurate a new feature, The view from here, a column about what its like to practice and teach emergency medicine, particularly in challenging circumstances. Dr. Teri Reynolds, our new global health editor, has spent the last three years in Dar Es Salaam, as the program director of the first emergency medicine residency in Tanzania. She describes a bit of what it feels like bringing our concept of emergency care to a country where there is no EMS system and the 1000 bed referral hospital has seven ventilators.