• Pregnancy
• airway
• Trauma
• crowding
• burns
• Fall
• adults
• Paediatrics
• Ultrasound

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In putting together April’s Primary Survey, it struck me how wonderfully wide-ranging emergency medicine practice is. This month’s offerings include studies regarding pregnancy, trauma, airway management, and cardiac arrest; studies regarding older and paediatric patients, as well the benefits of technology. A microcosm of our professional lives.

This month’s Editor’s Choice by Srajer et al examines how gender of the treating doctor may play a role in the way in which pregnancy loss is handled in the emergency department (ED). This multicentre retrospective study from Canada determined the frequency with which emergency physicians obtained ob-gyn consults for pregnant women with vaginal bleeding and potential (or completed) miscarriage. The authors found that women emergency medicine physicians were more likely to consult, and as a result, their patients underwent more procedures at the time of the ED visit, although ultimately the proportion of women who underwent procedures was similar for patients treated by male and female doctors. Potential reasons for this difference in management are explored by the authors. The accompanying commentary by Dr Meg Autry and Nelly Ghazaryan, obstetrician/gynaecologists from California, details some important limitations of this study, but also the importance of examining potential bias so that women with pregnancy loss can be treated “equitably in a safe and expeditious manner.”

The news has been filled with articles about the long waits for care and for admission in our EDs. (The paper by Jones et al on deaths attributable to waiting published last year in EMJ has been cited in many of these stories).¹ Prior studies have suggested that those hardest hit by these delays are our older patients. In this month’s Reader’s Choice, Maynou et al explore the factors that contribute to the long ED stays of older patients. Age, arriving out of hours and prior ED attendance were associated with longer waits, admission and reattendance; however, these factors were less prominent among those arriving by ambulance. The study also identified two hospitals which had better performance on all these outcomes for older patients suggesting that the impact of these factors can be modified by the system’s response.

We’ve written before about the changing face of trauma as our patients age. With low falls now exceeding road traffic collisions as the mechanism for injuries in many areas of the world, what is the role of trauma centres? Tonkins et al used TARN data to compare outcomes of older patients with falls treated at major trauma centres (MTC) and trauma units (TU) in England. Including only patients who were treated at the original site they were brought to (be it MTC or TU), outcomes were similar. However, if one includes patients transferred to an MTC, outcomes at the MTC are better. As an observational study it’s possible that only those with better prognoses requiring advanced care were transferred. However, the bottom line is that MTC likely benefit a proportion of our older patients with falls, but many can do as well in TUs, perhaps closer to home.

Airway management in patients with trauma is complicated by concern for creating or worsening spinal cord injury if the c-spine is unstable. Alternative devices (eg, video or ILMA) are thought to provide less movement than standard direct laryngoscopy but is there good data to show this? In their systematic review and detailed meta-analysis, Correa and colleagues found less movement at the cervical upper levels but no difference for C5 or lower. However, the authors considered the evidence to recommend these devices to minimise movement to be low or very low. Additionally, not all studies used some form of c-spine immobilisation, and intubators were all anesthesiologists.

Positioning of the patient for intubation used to be sacrosanct. Patient supine on the trolley, trolley at waist height, head in sniffing position on one folded towel. However, with changes in intubation equipment and patient body habitus, and theoretical suggestions of improved visualisation, inclined positioning has gained a following. A systematic review by Turner and colleagues compares data on these two intubation positions and ultimately concludes there is no clear benefit of one over the other, although the quality of the evidence is low.

As these two systematic reviews show, there is a need for better research in emergency medicine. Hirst et al report on EM research priorities set by UK EM trainees, who, quite rightly, argue that they may have a different perspective than consultants. This work may complement the ongoing priority setting for EM with the James Lind Alliance. Rounding out these perspectives, Ramage and colleagues from the PHOTON network report on a Delphi study to determine research priorities in prehospital critical care.

Two intriguing papers describe novel methods of patient assessment. Colson and colleagues validate EasyTBSA, a free app that allows more accurate estimates of total burn size, pitting it against other burn size estimation methods. The paper by Ling et al investigates the optimal measurement of the optic nerve sheath using ultrasound to predict prognosis after cardiac arrest.

Underlining that the scope of our care includes all age groups to care for patients of any age (and that children are not just little adults), we include a study describing development of an airway checklist for children. At the other end of the spectrum, Kkita et al retrospectively report on the long term outcomes of ECPR in refractory cardiac arrest patients older than 75, a group that has been largely excluded from prospective studies of this therapy. Finally, our Journal Top five covers articles from a variety of non-EM journals, reinforcing just how many different disciplines our work encompasses.

No one can say our days are boring.