Inconsistent practice and incidentalomas: time to ban the pan scan in trauma?

In this issue of the Emergency Medicine Journal we have two papers relating to the use of whole body computed tomography (WBCT) scanning in trauma. First, Sammy et al report on the extent of variation in practice across the United Kingdom. Even among Major Trauma Centres and after adjustment for potential confounders, there was a 13-fold difference in the proportion of patients undergoing WBCT. This important work should clearly lead us to ask why there is such variation, and to determine which approach is optimal for patient outcomes.

On the same topic of WBCT in trauma, Croczek et al report on the proportion of patients that have incidental findings. All emergency physicians who care for patients with suspected major trauma must be familiar with this issue: the WBCT is intended to detect serious injuries but ultimately reveals an incidental finding that may require further investigation. Indeed, this work demonstrates that the phenomenon is very common. Three quarters of all patients undergoing WBCT had at least one incidental finding. While we may consider that such findings are likely to have dubious clinical importance, this work also suggests that many of the incidental findings are highly clinically significant and require urgent attention. Almost one tenth of patients undergoing WBCT had incidental findings that required urgent attention.

Extreme emergency medicine

In this issue, we also take a detour from the ‘routine’ of day to day practice within the confines of an Emergency Department (ED). Laskowski-Jones et al provide a structured overview of the considerations for providing healthcare at extreme events in remote settings. Such events, which are gaining in popularity, include ‘obstacle’, ‘adventure’ and ‘endurance’ competitions with examples ranging from mountain biking to immersion in icy water and ultra-endurance foot races for up to 100 miles over 7 days. It is totally clear that providing healthcare for such events will require specific skills, and the excellent overview provided by Lawowski-Jones et al will clearly help to prepare emergency physicians who have an interest in this area.

In addition, we are proud to publish the results of a fascinating randomised controlled trial evaluating the impact of non-steroidal anti-inflammatory drugs (NSAIDs) on the incidence of acute kidney injury (AKI) in ultra-endurance runners. The findings reported by Lipman et al are intriguing for several reasons. First, the overall incidence of AKI in ultra-endurance runners was found to be incredibly high in this study, at 44%. Second, and importantly, the use of NSAIDs was found to significantly increase the incidence of AKI with a number needed to harm of just 5.5. The paper is clearly a must read for anyone with an interest in this area.

Sex, race and serious cardiopulmonary diagnoses

Proving that it’s never too late to publish good data, Pines et al report a secondary analysis from a cohort of over 4000 patients with chest pain recruited between 1999 and 2008. They evaluated the differential value of individual symptoms for predicting serious cardiopulmonary diagnoses. There were some important differences. While in white men, the ‘typical’ symptoms for an acute coronary syndrome were predictive (pressure/tightness, substernal location and pain radiation to the left arm), there were no predictive symptoms in white women and only diaphoresis predicted serious cardiopulmonary diagnoses in black men. These findings suggest that sex and race do have an impact on a patient’s symptoms in this context, supporting the notion that women and black patients are more likely to present with ‘atypical’ symptoms.

How to make co-location of primary care a success

The Royal College of Emergency Medicine and the Patients Association both support the co-location of primary care services with EDs. In doing so, those patients who present to the ED with a complaint that could most appropriately be cared for in a primary care environment can be immediately re-directed to the co-located service, rather than adding to the problem of ED crowding. In this issue, Ablard et al use qualitative methodology to explore the factors that may help to make such initiatives a success, based on experience in the Yorkshire and Humber region of the United Kingdom. This is therefore important reading for anyone involved in service configuration.