A little perspective

It’s a pleasure to open this issue of EMJ with a healthy dose of perspectiven our constant quest for more and more resources to deliver excellence in healthcare, it’s all too easy to lose sight of how privileged we are in the developed world. In ‘A view from here’ Dr Mir Ahmad describes a project run by Doctors Worldwide looking at high impact outcomes in resource deprived settings. He gives us a glimpse of the reality of emergency h ealthcare in the largest refugee camp in the world, the Rohingya camps in Bangladesh.

His description of emergency response training for Rohingya Community leaders and the development of emergency response kits as an approach to local disaster risk reduction and community resilience is inspiring and humbling at the same time. It demonstrates the pragmatism and adaptability that is a common characteristic in ED clinicians. It is also a hopeful piece and worth reading if you’re feeling anyway disenchanted with your developed systems.

Trauma teams that make a difference

The institution of major trauma centres has improved outcomes in terms of mortality and morbidity for patients sustaining major trauma. What is less clear to date is the value and patient benefit of pre hospital Enhanced Care Teams (ECT) that are staffed by doctors and critical care paramedics (CCP) So it is well worth reading a study in this issue by Smith et al in the UK who conducted a retrospective analysis comparing the mortality and morbidity of traumatically injured patients treated in the pre hospital setting by a doctor and critical care paramedic with those treated solely by a paramedic. Analysing TARN data from North East England over a 4 year period they found 3.22 more survivors per 100 severe trauma patients when treated by ECT. This is a statistically significant benefit in adjusted survival rates and the authors would encourage other ECT services to conduct similar research in their networks.

Paediatric triage

Different triage systems have evolved around the world over the last two decades and been tested for validity and reliability. Paediatric Triage may not have had the same level of scrutiny as adult triage so ED clinicians, particularly those specialising in paediatrics may be interested to read in this issue a systematic review on the reliability of triage systems for paediatric emergency care. Magalhaes-Barbosa and colleagues from Brazil found some evidence of reliability in the Ca

nadian paediatric triage (PedCTAS), the Manchester triage system (MTS) and the Emergency Severity Index (ESI v4) but those studies were limited to the countries where they were developed. They suggest there is a need to improve the quality of the studies and cross- cultural adaptation of these tools for countries with different professional qualifications and sociocultural contexts. The need to have more adaptable and reliable triage systems for paediatric emergency care globally is indisputable but this may be a challenge given the infinite diversity in paediatric populations particularly the socio-cultural context. Ironically it is often this diversity that attracts clinicians to the ED specialty in the first place.

Treating severe asthma in children

Severe childhood asthma is a worrying emergency. It is likely that some of the anxiety in dealing with this emergency emanates from the considerable uncertainty that exists as to the best intravenous agent to use for treating this emergency. So it was interesting to read the paper in this issue by Gray and colleagues from Adelaide Australia. They conducted a systematic review of randomised studies of IV bronchodilator therapy. They reviewed 35 published papers and four registered protocols. They found studies comparing intravenous treatment modalities for children with acute severe asthma to be greatly varied in the type, number and timing of outcome measures used. They reported no patient or family specific outcomes. They concluded there is a need for international consensus regarding treatment and I suspect few would argue with this.

Eye openers

Ophthalmology papers don’t often grace the pages of EMJ even though eye problems are common presentations is EDs around the world. This issue has two ophthalmology papers which are interesting and informative. In the first paper, Edmunds and colleagues from Wales conducted a survey of ED physicians to explore their experiences of Retrobulbar haemorrhage with orbital compartment syndrome(RBH)and their confidence in undertaking lateral canthotomy and cantholysis(LC/C).190 doctors completed the survey in 7 UK locations. Only 37.1% stated they would be happy to perform LC/C themselves rather than referring the patient to another specialty. 92.2% of respondents felt that ED physicians required more training in LC/C. This paper is important because, although RBH with orbital compartment syndrome is rare, delayed treatment is likely to result in permanent vision loss. As not all departments have easy access to specialist Ophthalmology, ED clinicians need to be able to respond effectively to sight threatening eye conditions such as acute retrobulbar haemorrhage (RBH). The authors highlighted the importance of adding the management of RBH and the vital sight saving skill of LC/C to the Royal College of Emergency Medicine training curriculum.

Testing the pupils

The second ophthalmology paper will no doubt kindle curiosity not just for its intriguing title, Unilateral mydriasis secondary to ‘Angel Trumpet’ exposure, but also its interesting content. This image challenge by Stevenson and colleagues in the UK describes a case presentation of a patient presenting with a 1 day history of a dilated left pupil and no other symptoms. This was found to be due to exposure to a plant known as Angel’s Trumpet which contains parasympatholytic alkaloids such as atropine, hyoscyamine, and scolopamine. The patients aniscoria resolved spontaneously over a few days but the case highlights the importance of a focused history in terms of chemical exposure in patients presenting with mydriasis. Read this paper you might also learn some interesting facts about plant life.