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Primary survey: highlights from this issue
  1. Richard Body, Deputy Editor1,2
  1. 1 Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
  2. 2 Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
  1. Correspondence to Professor Richard Body, Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK; richard.body{at}

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Welcome to the June 2024 issue of the Emergency Medicine Journal. As we head into another heady summer in the northern hemisphere (though that’s wishful thinking for those of us in the UK), we once again have a superb array of papers on topics as diverse as acute headache, fascia iliaca block and patient predictions of their own mortality. We hope that you may enjoy digesting this wonderful offering on a light and sunny evening. For those who want a quick and handy summary on the go, make sure you check out our podcast. Backed by a superb team at the BMJ Group, Sarah Edwards and I very much enjoy covering many of the hot issues from the journal each month.

Do patients know if they’re going to die?

During the COVID-19 pandemic, I remember feeling particularly moved when, during a podcast, a public representative shared his thoughts about the anxiety of being admitted to hospital with COVID-19 during a global pandemic and the fear it may cause for one’s own mortality. In this issue, Mols et al ask whether acutely unwell patients can predict their outcomes. The results may surprise you. My own impression was that patients may overestimate the chance that they will die in hospital. In fact, that was not the case, but there are important nuances to the data. The authors cite previous research showing that injured patients tended to overestimate the severity of their injuries, while only a minority of patients in an intensive care unit predicted that they would die at the time of admission.

Do patients with acute headache and no ‘red flags’ need investigation?

I was personally privileged to be involved with the Headache in Emergency Departments (HEAD) study, led by Anne-Marie Kelly from Melbourne. In a very large cross-sectional epidemiological study that combined data from the 10-country HEAD study with an equivalent study in Colombia, we explored the predictive value of 10 ‘red flags’ for further investigation in acute headache. The absence of any red flags did not necessarily mean that we could rest easy: there was still a 6.5% probability of a serious diagnosis, which is still a considerable probability. There were more interesting findings: a sudden onset and precipitation by sexual activity or physical exertion were not statistically significant predictors of serious diagnoses after adjustment for confounders. Interestingly, however, the presence of a fever was quite strongly predictive of a serious diagnosis. Refer to the full paper for all the details!

How good are we at managing pain?

It has been reported that the majority of patients who attend EDs are in pain. Managing this should of course be our ‘bread and butter’: something so routine that we ought to be extremely good at it. However, managing pain in the complex and often crowded environments in which we work is challenging. In this issue, Wilson et al present the findings of a secondary analysis of data from Royal College of Emergency Medicine national audit data. They looked at the data from two audits: the management of pain in children and the management of patients with fractured neck of femur. You may or may not be surprised to learn that EDs did not perform very well against the standards: <1% of EDs achieved the standards for more than half of the patients with fractured neck of femur, and only 15% achieved the standards for more than half of children in pain. Reassuringly, there were improvements over time. However, the findings should serve as a reminder to all of us about how vigilant and careful we have to be to ensure adequate pain management for the patients in our care.

Are ambulance arrivals with chest pain sicker than walk-ins?

It may seem like a question that doesn’t need to be asked. Of course, we would expect that patients with chest pain who arrive in the ED by ambulance are more likely to have a myocardial infarction (MI) than patients who walk in. Patients and telephone triage systems must surely be effective at determining the need for conveyance by emergency ambulance. You may be surprised that, when Murray et al asked this question and ran a retrospective analysis of patient data from Aberdeen Royal Infirmary, they did not find this, at least after adjustment for confounding factors. Without any statistical adjustment, patients arriving by ambulance were slightly more likely to have MI than those who walked in. However, this association disappeared following adjustment for confounders. What does this mean? I think the findings may have significance for triage: many EDs in the UK now triage low-risk patients to adjacent same day emergency care (SDEC) units. Given the perceived higher risk status of patients arriving by ambulance, some people may be reluctant to triage those patients to SDEC units. These findings perhaps suggest that such concern is unwarranted, while the fact that a patient has walked in should not be taken as reassurance that MI is unlikely.

A checklist for fascia iliaca block

Inserting a fascia iliaca block, particularly for patients with fractured neck of femur, has become a core competency for emergency physicians. In this issue, Guyader et al present a very interesting method to develop and validate a checklist for assessment of this procedure. Their final 30-point scale covered all the vital steps from patient positioning to anatomical and ultrasound identification to assessing for signs of local anaesthetic toxicity. This should be a very useful tool for educators but also for practising emergency physicians, as a reminder of the important steps to go through.

There’s plenty more as well in this issue. We hope that you will enjoy reading!

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  • 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.