Feeling non-inferior? which gloves to use for suturing?

I always wonder whether we really need to use sterile gloves for suturing. I’ve seen evidence to suggest that tap water is as good as sterile water for cleaning simple wounds. How about the gloves? This month, we see the results of a large randomised controlled trial comparing sterile and non-sterile gloves for patients with traumatic wounds in three Dutch Emergency Departments.

The findings are very interesting. This was a non-inferiority trial and the authors note that they finished recruitment prior to obtaining their full sample size. However, you’ll see that they did actually demonstrate non-inferiority: non-sterile gloves were found to be no worse than sterile gloves. You can find an accompanying editorial led by David Metcalfe, which helps to make sense of the findings. It also provides a useful reminder about the nuances of non-inferiority trials.

Echocardiography and point of care tests for paramedics

I have a personal research interest in the prehospital diagnosis of acute coronary syndromes, and in the use of point of care toponin testing. That being so, I was very excited to read this paper from colleagues in Norway. They took a fascinating approach: six paramedics were trained in echocardiography and their vehicles were equipped with an ultrasound machine and a point of care testing device with troponin cartridges. In this feasibility study, the investigators managed to recruit 253 patients and they report on the findings. Eighteen of 22 non-ST elevation myocardial infarctions could be spotted using at least one of ECG, troponin testing or echocardiography. However, detecting a regional wall motion abnormality on echocardiography was very specific, with 96% positive predictive value. This must have been a very challenging study to complete. Reading the full paper will be well worth your time.

Probing shoulder dislocations and flexor tenosynovitis

Having to transfer patients with apparent shoulder dislocations to x-ray before reduction can seem inefficient, and it keeps patients who are in pain waiting longer. Wouldn’t it be great if we could use a simple ultrasound scan at the bedside instead? In this issue, we have a great diagnostic randomised controlled trial from Malta. The 1206 patients enrolled were randomised to either diagnosis using physical examination alone or two-point ultrasound prior to receiving a reference standard x-ray. Diagnostic accuracy was significantly higher in the ultrasound group. So can we cut out the x-rays? Read the full article before you make your mind up, but it would certainly be a game changer!

Elsewhere, we have a nice case study of a patient with purulent flexor tenosynovitis detected on ultrasound in the ED. Have a read to get some sonic tips.

Time, muscle, prenotification and gender

In ST elevation myocardial infarction (STEMI), time is muscle. It can also mean the difference between life and death. In this issue, we have an analysis of the impact of ambulance prenotification on STEMI care, from Melbourne. When paramedics prenotified the hospital, the time from first medical contact to balloon (angioplasty) was significantly shorter.

OK, so far, so unsurprising. What else? Well, that’s where things get interesting. Take a look at the factors that were associated with prenotification. Women were less likely to have prenotification. Why? Could it be unconscious bias, or did they have more complex cases that were more difficult to recognise? This certainly needs further investigation. Patients who had a lesion in the right coronary artery were also more likely to have prenotification, which may suggest that inferior STEMI is recognised more often than STEMI in other locations. That has some face validity, given the frequent challenge of differentiating anterior STEMI from other causes of anterior ST elevation.

What’s more important: abnormal physiology or serious presenting complaint?

We also have some great papers on triage this month. First, we have a retrospective, single centre study from a Dutch trauma centre, which compared the accuracy of a complaint-based triage scale (the Netherlands Triage System) with the modified early warning score (MEWS). This is an interesting question to ask: MEWS is of course agnostic to presenting complaint, so you may feel that it won’t recognise important conditions that present with normal physiology. It has, however, been extensively validated for predicting mortality. The authors found that MEWS was superior for predicting 30-day mortality. But does that mean that it’s superior for prioritising the order in which we see patients? Is 30-day mortality all we need to consider? Read the paper and make your own mind up!

Once again, I feel so much wiser for having read the Emergency Medicine Journal. I hope you enjoy it as much as I have, and I hope it helps to keep you on the top of your game.