The human connection

When writing this primary survey under the cloud of COVID-19, it is encouraging to see so many excellent papers being submitted to EMJ knowing that many of these have been written and re written in a time of adversity and the greatest challenge our specialty has faced. This issue has papers that cover the wide range of emergency medicine all of which are informative and interesting, but, for me the most moving and poignant paper of all is ‘The View from Here’ written by Landry and Ouchi in Boston. They describe how one doctor used her phone to make a brief video which allowed an elderly dying patient to say a last few precious words of love to his family who could not be with him because of the virus. She then sent the video to his family. It was, in her own words ‘a desire to provide connection in a deeply difficult time and to preserve the patient’s final conscious moments, she didn’t want these intensely emotional moments and thoughts to belong only to her, she wanted to offer them to his loved ones as well’. This doctor’s empathy and deep compassion for this dying man and his family epitomises true humanity and the great privilege we have as clinicians sharing such moments in our patients’ lives. The silver lining of this cruel virus is that it has brought to the fore the very best in healthcare staff where there have been countless examples of extraordinary acts of human kindness that have helped lighten the burden and sadness that is COVID-19. Many of us have been touched personally by tragedy and sadness during this time and we have been encouraged and inspired by the compassion and fortitude demonstrated by our colleagues. We can be confident that our specialty irrespective of future challenges will be underpinned by kindness and the human connection. Do read this paper, it is humbling, but also reassuring in times of such anxiety and upheaval. Most of all, it is an important human account for posterity.

Under triaging the older patient

Under triage in the older patient is an ongoing concern, as major trauma in older patients is on the increase it is worrying that serious injury might not always be recognised in this group. Hoyle and colleagues in the UK undertook a retrospective review of the Trauma Audit& Research Network (TARN) data of a 3 month period from 2014 to investigate this concern. Their findings give some substance to these concerns as they found mortality higher in older patients despite a lower median ISS. Older patients were significantly less likely to have the attention of a consultant first attender or trauma team and similar trends were also seen on subgroup analysis by mechanism of injury or number of injured body areas. While more recent interventions and awareness focusing on the older patient in the ED may have improved initial assessment there is little room for complacency, older patients deserve the same urgency as younger patients. Do read this paper even if this has not been your experience the findings are a reminder of the need for equitable care.

Two other papers among the many worthy of mention in this issue relate to common presentations in the ED, Headache and Colles’fracture.

Editors’s choice

Headache, a common presentations in the ED can be a high risk consultation. Many physicians use an IV fluid bolus as part of a cocktail of treatments for patients presenting with headaches even though the benefit of this treatment is less than clear. Zitek and colleagues undertook a randomised single -blinded clinical trial on patients from the age of 10 years to 65 years who presented to a single ED in Nevada USA to determine if an IV fluid bolus would help reduce pain or improve other outcomes for those with a benign headache. All patients received Prochlorperazine and Diphenhydramine and they were randomised to receive either 20 mL/kg up to 1000 ML of normal saline (the fluid bolus group) or 5 mL (the control group). Perhaps, surprisingly, the patients that received the fluid bolus for their headache had similar improvement in their pain and other outcomes as those who did not. So it seems fluid is not the cure.

Fixing broken bones

In the UK, Colles’ fractures account for nearly one sixth of all fractures presenting to the ED. Learning how to manipulate a Colles’ fracture usually under a haematoma block is a rite of passage for most trainees but we rarely get to hear how these patients fare afterwards or how effective our management has been. It was interesting therefore to read a paper by Malik and colleagues in this issue. In response to a local audit that suggested a high proportion of these injuries often need surgical fixation, they conducted a multicentre observational study in 16 Emergency departments in February and March 2019 of all patients who underwent manipulation of a Colles’ fracture in the ED. Of the 328 patients who presented with a distal radius fracture during the study period, 83 underwent fracture manipulation and were eligible for the study. Of these 83 cases 41% required surgical fixation. Younger patients were more likely to have surgical fixation but the ED anaesthetic used did not affect the subsequent need for surgery in this sample. The authors suggest these findings merit further research particularly in terms of rationalising repeat procedures.