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Welcome to the February 2023 issue of the Emergency Medicine Journal. This issue is brimming with collections of complimentary articles that promise to enrich your daily clinical practice.
The psychological impact of COVID-19 on our workforce
The early stages of the COVID-19 pandemic were scary for all of us. We had the unprecedented national lockdowns, the fear of an unknown and lethal infection and (for those of us working in Emergency Departments) the challenge of treating so many seriously unwell patients amid so much uncertainty about how to do it.
In this issue, we have three papers exploring the psychological impact of the pandemic on emergency physicians. We have two qualitative analyses of semi-structured interview data: one from Canada and one from the United States. The Canadian piece reports on the psychological impact between March and September 2020, a time when prevalence was still low in Canada but there was of course a growing global pandemic in progress. The US piece focused on the experiences of residents between November 2020 and February 2021. Both analyses pull out important themes that should inform future pandemic responses. These including the stress of having inadequate personal protective equipment (PPE); the impact of changing guidelines and information bombardment; feeling unsafe or useless; the need for structured leadership support; fear of missed educational opportunities; and, interestingly, an apparent report of ‘imposter syndrome’ - not feeling that they deserved the ‘hero’ label that was given to healthcare workers by the general public.
A third paper explored factors that affected the comfort (or discomfort) of physicians when intubating patients who had COVID-19. In a survey of 329 physicians at 55 hospitals, physicians reported feeling more comfortable with the procedure when they had more experience, adequate PPE, an intubation team to support them and when their specialty background was Emergency Medicine.
Debunking ‘MONA’ in acute myocardial infarction
In recent years we’ve seen compelling evidence to demonstrate no benefit with oxygen in acute myocardial infarction. In this issue, we publish two articles evaluating the impact of opiates (the ‘M’ in MONA, standing for ‘morphine’) and nitrates in acute coronary syndromes (ACS). Fernando et al report a large retrospective evaluation of prehospital opioid use in patients with ACS, finding no association with major adverse cardiac events, though patients who received opioids were more likely to have critically obstructed coronary flow prior to coronary intervention.
Separately, Wilkinson-Stokes et al report a systematic review to examine the assertion that nitrates should not be used in patients with right ventricular myocardial infarction, due to the risk of precipitating hypotension. Interestingly, the evidence did not support the avoidance of nitrates in this context, which challenges current international guidance.
What’s the role of ultrasound in suspected testicular torsion?
We also have two papers covering the diagnostic accuracy of ultrasound for testicular torsion. First, we have a systematic review evaluating the accuracy of point of care ultrasound. The sensitivity appears good, at 98.4%, though the 95% CI extends down to 88.5%. So will you rule out torsion based on your point of care ultrasound? Not so fast! Our second paper covers a 10 year review of practice at a single centre, including 555 patients. In that analysis, the absence of blood flow on Doppler ultrasound had a sensitivity of only 58.3% with 81.3% negative predictive value. The need for orchiectomy was associated with longer time from symptom onset and a longer wait for ultrasound scan. How do we put the two together? Well, if you have the skills then a point of care ultrasound might help you to confirm torsion, but the message seems to be: don’t rule out and don’t delay surgical exploration because of your scan.
In other news…
Elsewhere, we have a survey of 496 emergency clinicians showing that screening for domestic and family violence is unsual in the ED but most staff support it and appreciate its importance. We have a systematic review capturing the many benefits of ED pharmacists including associations with significantly fewer drug errors, more complete and accurate histories, more appropriate prescribing and (importantly) quicker initiation of time critical medications. We also have piece exploring the benefits of prehospital video consultations for patients with mental health emergencies, which were found to lead to better patient engagement, high satisfaction, lower costs and fewer ambulance transfers than voice consultations. There’s a comprehensive and topical practcie review of TASER injuries. And finally, there’s a poignant letter about the ‘broken’ National Health Service in the United Kingdom: something I’m sure we’ve all unfortunately felt the brunt of this winter. Spring is around the corner. Let’s hope for a little respite.
Patient consent for publication
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.