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This first Primary Survey of 2022 marks the two-year anniversary of our awareness of SARS COVI-2 as a worldwide threat and one year since we began vaccinations. In this relatively short time frame, we have learnt a great deal about how COVID-19 is transmitted, treatments that do and don’t work, and tragically, how lethal it can be. Despite what can only be described as a medical marvel – the development and delivery of highly effective vaccines, COVID-19 continues to be a dominant factor in our work, our lives, and our thoughts. For emergency medicine, efforts revolve around separating those with and without COVID-19 to prevent nosocomial spread, and those with COVID-19, determining the need for hospitalisation. Among the things we have learnt is the COVID-19 can be asymptomatic and thus, despite ED efforts to cohort individuals according to symptoms (and previously, travel), we remain in need of rapid tests to diagnose these individuals at the front door. In this issue, we present a Practice Review of rapid tests for COVID-19 by Reynard et al, describing current options and those on the horizon, and importantly how these can be used and interpreted in practice. With regard to determining the need for hospitalisation, a multicentre observational study from Italy demonstrates that an initial albumin level of ≤3.5 g/dL was predictive of a severe course or death within 30 days.
Our Editor’s Choice this month is a randomised controlled trial of prehospital continuous positive airway pressure (CPAP) for acute respiratory distress. While there is considerable evidence for the use of CPAP in the ED and ICU, the literature around CPAP in the prehospital setting is sparse and contradictory. This RCT demonstrated that, for a variety of etiologies of respiratory distress, CPAP improved dyspnoea and tachypnea, although it did not affect hospital length of stay among those admitted. Still, outcomes that affect patient comfort are important. The authors are to be congratulated for meeting the multiple challenges of conducting a randomised controlled trial in the prehospital setting.
And speaking of challenges in prehospital care, we point you to the runner-up for Reader’s Choice this month, a truly eye-opening qualitative study on the incidence and impact of incivility in paramedicine. This is a valuable read, not only for our prehospital providers, but for those of us working in the ED, as the study demonstrates that the incivility paramedics experience is not exclusively, or even primarily, from patients, and its impact on paramedic performance and well-being is substantial.
This month’s Reader’s Choice is a systematic review on the use of POCUS to detect skull fractures in children. The review includes seven papers, which the authors rated as having low risk of bias, and finds a pooled sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97% for this imaging method in detecting skull fractures. Can this information be used to inform existing – or revised- decision rules for head trauma?
Perhaps our most provocative articles this month are related to frequent use of the ED. While we know that the bulk of ED crowding is due to the exit block of our admitted patients, the emergency medicine literature is packed with papers about frequent users. The articles usually centre on identifying who they are and why they come, so that we can figure out how to find them alternative services that are less busy and less costly, and which, we hope, will provide longer term solutions. We also know that the majority of frequent users don’t remain frequent users for more than a few years, and yet, there are always frequent users in our departments. In this issue, Burton and colleagues demonstrate that the pattern of frequent ED use is the hallmark of a “complex system”. This study takes advantage of the increasing availability of large data sets with linked data that can show us the bigger picture, essentially how parts interact to produce a noticeable phenomenon. In essence, the study shows what many of us have gathered informally, which is that frequent use of the ED is a result of a whole system, not the characteristics or behaviour of an individual frequent attender. However, as Than and colleagues write in their related commentary: “the study is not saying—‘don’t bother, you can’t do anything about the frequent attenders’, rather, it is helping us see that while we may impact the individual by providing resources needed to avoid ED use, we will only make meaningful volume change through changes in the system itself.” And they caution us to remember, even at our most exhausted moments, that “frequent users are ‘caught up’ in a complex system effect”.
We also have our monthly Top five update on recent articles relevant to EM that you may have missed. This month’s educational article on bedside ultrasound provides an expert guide to management of hip fracture pain using ultrasound-guided fascia iliaca block.
I would like take this opportunity to wish all of our readers a happy, healthy and fulfilling 2022, and to thank you, and our editors, reviewers, staff and authors for your contributions to the Emergency Medicine Journal and to the patients that rely on emergency care providers to be there when they need us.
Patient consent for publication
This study does not involve human participants.
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.
Provenance and peer review Not commissioned; internally peer reviewed.