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  1. Simon Smith, Quality Improvement Editor
  1. Emergency Department, Oxford University Hospitals NHS Trust, Oxford, 0xfordshire, UK
  1. Correspondence to Dr Simon Smith, Emergency Department, Oxford University Hospitals NHS Trust, Oxford, 0xfordshire, UK; Simon.Smith{at}ouh.nhs.uk

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Welcome to the June issue of the EMJ, and we hope that you are keeping well. As the current pandemic continues to affect our working and personal lives, this Primary Survey has identified two COVID-19 related articles of interest. We also have some interesting articles on paediatric trauma, head injuries, sepsis and some thought provoking reads about the state of Emergency Medicine Research.

COVID in this issue

Editor’s Choice: Drs Jiang and Flores eloquently describe working in the pandemic at the (very) sharp end, in an Emergency Department in New York. They also describe the effects on them personally, such as the anxieties we are all feeling, and also the realisation of positive aspects that can protect our mental wellbeing at this time. We would recommend this short ‘View from here’; I have reflected on the points it raises myself; especially with regards to the support we should be receiving at this time.

On a practical level, Chou et al describe the use of intra-departmental telemedicine during the crisis to protect both healthcare workers and patients by reducing unnecessary exposure. Telemedicine was initially devised to overcome the issue of distance between patients and clinicians, and this paper notes how it is now being used to (conversely) create a protective barrier.

Lastly, a letter from Shovlin and Vizcaychipi discusses COVID-19 specific triage in the United Kingdom, and the possible effect on patients admitted to ICU. This is an area that has received significant media interest in the UK; this paper is another stimulus for reflection upon the many ethical dilemmas we currently face.

Lastly, a letter from Shovlin and Vizcaychipi discusses COVID-19 specific triage in the United Kingdom, and the possible effect on patients admitted to ICU. This is an area that has received significant media interest in the UK; this paper is another stimulus for reflection upon the many ethical dilemmas we currently face.

Head injury management

The presence of post-concussion symptoms in seemingly mild head injury will be familiar to most Emergency Physicians, and is often under-appreciated. In their paper on symptoms following mild traumatic brain injury in children, Gravel et al look at the association between delayed presentation to the Emergency Department, and risk of persistent symptoms (at 4 and 12 weeks). This association, and the increase in chance of persisting symptoms, is intriguing. This paper also highlights the high rate of persisting symptoms, and challenges Emergency Departments to address this.

Also on the subject of head injury, Drs Coats and Lecky provide a perspective on the recent controversy around guidelines in the light of CRASH3 results. Should all head injured patients get TXA pre-hospital? This Reader’s Choice gives a nuanced response to this question.

Issues in paediatric trauma

In their paper looking at minor tibial fractures in the under-5s age group, Ferrier et al have looked at the rate of immobilisation. This retrospective study found that confirmed and suspected fractures had a high immobilisation rate. Immobilised patients were much more likely to re-attend the ED (15.3% vs 6.6%) and had a complication rate related to immobilisation of about 20%. This paper adds further ‘fuel to the fire’ to the increasing trend for more conservative management of paediatric fractures.

Hepburn et al describe an initiative to standardise care and documentation of paediatric burns patients. This is a ‘before and after’ study of the introduction of a standardised documentation template. Many Quality Improvement projects concentrate on reducing variability and increasing standardisation using checklists and proforma. This paper provides evidence of the effectiveness of these interventions. In this paper, the ‘process measures’ improved, however ‘outcome measures’ (screening for non-accidental injury) also demonstrated improvement.

Prognosis in sepsis

Two papers look at outcome prediction in sepsis. First, Jang et al investigate the association of hyperphosphatemia with increased mortality in adults with sepsis and suggest that it is an independent prognostic variable. As ever further studies are awaited. Meanwhile, Sinto et al compare the prognostic value of SOFA, qSOFA, qSOFA-lactate, and SIRS tools in the specific setting of a resource limited Emergency Department. Interestingly, the performance of these scores differed from data published in settings in high income countries.

The current state of emergency medicine research

Patterns in Emergency Medicine research are investigated in the paper by Jesse Smith et al. Published research in Emergency Medicine journals are assessed for geographical origin, specific reported article (eg, author contribution) items and methodological indicators (eg, blinding, sampling). The work suggests some interesting trends; those working in the United Kingdom will be concerned by reading of the decrease in research from there. This is discussed in two, related, commentaries by Jason Smith and Richard Body, and will hopefully spark debate. However it is pleasing to note the improvement in methodological and reporting rigour and the increase in Emergency Medicine research publications worldwide, although it would be interesting to compare these changes to other, newer medical specialties.

Other articles of interest

A systematic review by Avery et al considers transfusion in major trauma; asking if there is a superiority of whole blood transfusion compared with component therapy. The authors suggest no evidence to support or reject whole blood use, although they conclude the evidence is limited and poor-quality.

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Footnotes

  • Contributors N/A.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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