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Highlights from the issue
  1. Ellen J Weber, Editor in Chief

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I'm delighted to introduce this virtual, on-line only issue of EMJ. This additional issue of the journal provides free full-length access to all articles for the next three months. Why have we done this? To paraphrase the legendary motto of the New York Times, we have more news than we can fit in print! The articles in this issue have all been peer-reviewed and published on line and their authors have been patiently awaiting their re-birth in print. However, the interval is now too long, and valuable information and insights may not be reaching our readers in a timely fashion. This virtual issue may not totally suit those of you who prefer to cosy up to the fire to browse the month's articles, but we hope it will bring to your attention articles that you may have missed on-line, and at the same time, provide well-deserved exposure of these articles beyond our usual readership.

Of course we've created some additional work for you. You now have an additional 17 articles to read this month. But as you will see from the primary survey, there are some very interesting papers you won't want to miss!

If they don't say stroke, its probably not…

You are sitting in a dispatch centre taking emergency calls. Your next call, like your last one, is from a panicked bystander who has just witnessed an elderly man fall on the street. The patient is awake, breathing, and has a large cut on his scalp. The caller says he thinks the patient has had a stroke. You wonder –much can you rely on this bystander to tell you what is going on – and how quickly to despatch the ambulance? According to the findings of Leathley and colleagues in the Emergency Stroke Calls: Obtaining Rapid Telephone Triage Group, suspicions should be raised by the word stroke or the description of stroke symptoms. In 40% of stroke 473 cases, the word stroke was used, whereas it was used in only 3% of 277 non-stroke cases. Additionally, calls about stroke patients were more likely to come from someone other than the patient, and were generally about older people. Its not perfect, but it is reassuring to know that bystanders, at least in England, are unlikely to use the word stroke if its not.

Is there a magic bullet for managing pain?

Improving pain management in emergency departments is a high priority, and a quality measure in many countries. Sampson et al performed a systematic review of published articles on interventions to improve ED pain management. Readers hoping to discover the magic bullet will be disappointed, as the authors conclude that the study design's (largely before and after) and risk of bias makes it impossible to recommend any particular intervention. A particularly important point is making the diagnosis: that is, why is pain management not being achieved? The answer to that may be different in each department, and so individual EDs are encouraged to decide what is wrong, and what will be a patient-centered outcome, before adopting an off-the-shelf solution.

As a case in point...

McDermott et al report a case control study of pain management of cognitively impaired vs. unimpaired patients with fractured neck of femur. In the ambulance, cognitively impaired patients were much less likely to receive any pain medication, and in the ED cognitively impaired patients waited on average one hour longer and were given lower doses of pain medication.

Maybe this will help…

Chesters and Atkinson performed a systematic review of 14 articles published on fascia iliac block for fractured neck of femur. Two randomised studies suggest that the FIB provides good pain management compared with traditional analgesia, and several other non-randomized studies have supporting evidence for this method of analgesia.

Predicting admission in asthma

Asthma is a straightforward disease with clear algorithms for care. Yet, predicting who needs admission early in the visit is fraught with difficulty. Perhaps one more bronchodilator treatment will do it. Perhaps we should just a bit longer for the steroids to kick in. Older studies have suggested that if patients don't have a rapid improvement in PEFR within the first few hours of care, they will need admission. But that was before we used steroids routinely, and hospital beds were less precious. In this issue, Goodacre and colleagues analysed the ED course of 1084 patients in the multicentre 3Mg trial to determine what factors predicted the need for critical care or unanticipated care in the next 7 days. Peak flow, heart rate and other serious illnesses were independently associated with the outcome, but still had only modest predictive value. While helpful, this carefully analysed, multicentre study serves to demonstrate that while the treatment path is clear, the admission decision will not be so simple.

Where do I take this patient?

Most patients who call for an ambulance need to come to the ED. But in jurisdictions that can provide alternative sites for acute care, paramedics will need guidance about who can be diverted from the ED. In this interesting study of “paramedic pathfinders”, paramedics were asked to use a triage tool to assign patients to either ED care or an alternative Urgent Care site. Patients were those arriving at the ED by ambulance conveyance, so no change in disposition actually occurred. Using the tool, the paramedics had an 80% agreement with the gold standard, a panel of three ED senior clinicians. They also found that using this tool, 23% of patients would have been deflected to another site. However, caution is necessary because the study excluded patients with s, cardiac chest pain, obstetric and gynaecological presentations, and positive Face Arm Speech Test. And the patients were seen on arrival in the ED, when potentially their chief complaint and condition were clearer than they were at the scene.

Foam rising

What would an on-line issue be without a study about the rise of on-line education and commentary in emergency medicine and critical care? Cadogan et al report that Between 2002 and 2013, the landscape changed from two blogs to 141 blogs and 42 podcasts identified on 183 EMCC websites. Wait, its September 2014? That number has surely already grown!