Not just a minor injury

The term minor in the vernacular of emergency medicine is relative, often a misnomer can serve to downplay and underestimate the complexity of some injuries and the potential adverse ramifications and outcomes for patients with some minor injuries. Rightly, the primary focus for emergency medicine is saving lives; nonetheless, I was delighted to see two papers in this issue on very common non-life threatening presentations to the ED, ankle injuries and scaphoid injuries. Excluding fractures is a priority but it’s often more difficult to exclude soft tissue ruptures in a very swollen ankle, these injuries classed as “minor” can have negative long term effects for the patient including recurrent injury and attendances unless appropriately managed. They can also significantly impact lifestyle including the ability to work and partake in sport. So, it was refreshing to read a study by Deutekom and colleagues in the Netherlands who undertook a systematic review to investigate the accuracy of ultrasound in diagnosing ankle injuries other than fractures. They found ultrasound to be a reliable method for diagnosing foot and ankle injuries but a higher grade of evidence is needed. Given the volume of ankle injuries to any ED, timely access to ultrasound would be a helpful adjunct to plain xrays for severe sprains. Ultrasound may help guide treatment decisions. Sadly, in the real world of most EDs, ultrasound is more likely a bit of a luxury, so for now we must rely on the signs and symptoms and our clinical skills to manage these patients but pursue more research in this area of practice. For those ED clinicians with a special interest in muscular skeletal injuries, this paper is an eye-opener and well worth a read as is the accompanying commentary “Revisiting the humble ankle sprain” by Metcalfe and colleagues.

Similarly, fractures of the scaphoid bone can be subtle and are not always evident on initial imaging even with the enhanced visualisation and functionality of PACS. MRI is the gold standard test but this is a limited resource and not usually available in the ED. Missed fractures or delayed immobilisation can result in adverse outcomes for the patient. Therefore, identifying the most reliable clinical features of a scaphoid fracture is important, so it was good to read the systematic review by Coventry and colleagues in the UK. They aimed to identify the prevalence of scaphoid fractures in patients with a normal initial x-ray but with a clinical suspicion of a fracture, and second, to determine whether clinical examination can be used to identify patients that could be safely discharged without immobilisation and further imaging. They found that no single feature excludes an occult scaphoid fracture. They suggest further research and perhaps a combination of symptoms in conjunction with injury characteristics such as mechanism of injury alongside a normal x-ray. So, for now we must continue to immobilise suspected scaphoid fractures.

Community pharmacist in Childrens’ Emergency Department (CED)

Re-directing adult patients from triage is not an easy option, re-directing children from triage to a community pharmacist tends to be a non-starter and is often met with resistance. However if the pharmacist is within the department, children and their carers may be more inclined to accept this redirection. Educating our patients about where to access urgent care is key to reducing crowding in the ED so readers may be interested to read this paper by Patel and colleagues from Leicester. They investigated whether a pharmacist in the Children’s ED (CED) could safely discharge eligible patients. Unsurprisingly they found that pharmacists can safely manage selected CED patients, furthermore, they can educate families about using the community pharmacist for conditions that do not require an CED attendance. Cost savings for this study were not determined but as the cost of a pharmacist in hours in the ED for both adults and children is unlikely to exceed the costs of countless patients being unnecessarily assessed in the ED, this seems like a good trade-off and one we should consider.

Who to escalate during a pandemic

While the intensity of the pandemic is fading, the findings of research undertaken during the pandemic is important and continues to have relevance to many aspects of current practice. Decisions on which patients are escalated to critical care where there are limited resources can be a source of moral distress for doctors making these decisions. This moral dilemma was thrown into sharp focus during the pandemic when there was a significant shortfall of ICU beds in the many countries badly impacted by the pandemic. How these decisions were made at the time caused a degree of disquiet especially in relation to age. So with the benefit of hindsight it is very useful to read the retrospective analysis conducted by Beresford and colleagues in the UK. They looked at optimal decision making with respect to who to admit to critical care during two surges of the pandemic. They compared age, clinical frailty scale (CFS) 4C mortality score, and hospital mortality based on the escalation decision. They found patients deemed suitable for ICU were significantly younger with lower CFS and 4C scores compared with patients who were not deemed to benefit from ICU. Mortality in those not escalated in the first surge was 61.7% and 47.4% in the second surge. While the pandemic presented unique and unprecedented challenges and the need for rapid decision making especially for respiratory support, such escalation decisions have not gone away and will frequently resurface as a dilemma in ED practice. The authors’ findings that decision support tools and mortality scores can provide additional information when decision-making is difficult and fraught with uncertainty is just as relevant post pandemic.