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September is upon us. Summer is not quite gone, and yet, we have already welcomed our newest junior doctors on their first rota in the ED. Our junior doctors change work environments frequently, but perhaps no change is as dramatic as moving from medical school—or a relatively predictable ward—to work in the ED. The first few days (or weeks) in an ED can be, frankly, scary. Trainees often feel like they arrived late at the cinema and have not quite gotten the plot. So, it may help those of you in more senior roles to read the qualitative study by Goodall and colleagues where, through observation and interviews, the authors tried to determine what is important to new doctor socialisation. According to the trainees, the formal induction was ‘ok’ but what really affected the creation of a safe learning environment was the behaviour of consultants. The paper describes what trainees (and consultants) thought were both good and bad behaviours. Interestingly, trainees felt that the most helpful consultants were those who admitted their own uncertainty.

The ED population is ageing. Yet, most of our algorithms for triage, diagnosis and treatment do not directly consider the physiological differences and alternative goals that older patients may have. Assessing older patients for frailty may be useful here, as a score suggesting frailty may prompt clinicians to stop and think about whether the ‘usual approach’ should be applied for these patients. The NHS now recommends that the Clinical Frailty Score (CFS) be used in the ED. However, the feasibility and clinical utility of routine use of the CFS in the ED has not been firmly established, as most prior studies have used independent investigators to perform the scoring. Our Editor’s Choice this month is a multicentre study from Sweden where the CFS was made part of standard clinical care for patients over 65 years. As Ehrlington and colleagues report, during an 8-month period in 2021, 1840 patients were scored, and a third were found to be living with frailty (CFS score ≥5). These patients had longer ED stays, more admissions and longer hospital stays than those scoring lower, and 7-day, 30-day and 90-day mortality was also higher among those living with frailty. These prognostic data can be useful when discussing diagnostic and treatment options for patients living with frailty. Unfortunately, only half of the patients eligible for scoring received it, suggesting the difficulty of routinely incorporating the CFS into ED care.

Older patients are more susceptible to falls, and we know now that ‘silver trauma’ is rapidly changing the composition of our trauma units. Options for pain management in older patients are limited due to the higher potential for side effects from opiates in these individuals, while non-steroidal anti-inflammatory medications run the risk of gastrointestinal bleeding and renal impairment. Rib fractures in particular present a challenge due to the risk of pneumonia in patients who have poorer pain control. Thus, there is a need for alternative methods for pain relief. The Reader’s Choice this month is the feasibility trial by Carlton et al on the use of lidocaine patches for pain control in older patients with rib fractures. Their study met the feasibility endpoints, which supports a full-fledged randomised controlled trial on the topic. However, they may face some challenges in a future trial. Although current data suggests equipoise for this treatment, the feasibility trial encountered protocol violations because physicians sometimes ordered lidocaine patches for patients in the control group.

The WHO calls snake bites a neglected tropical disease, with approximately 100 000 people dying each year from venomous snake bites. Bites from poisonous snakes are a daily threat for people living in countries in tropical climates, many of which are also countires with low resources. Antivenom is both expensive and scarce and has a limited shelf-life. Soopairin and colleagues performed a systematic review of evidence regarding the stability of expired venom, finding that the quality and efficacy were similar to non-expired samples, but with limited real-world evidence. This study triggered a debate between our expert reviewers. Dr. Jean-Philippe Chippaux writes that, though tempting, the use of expired venoms is a ‘false good idea’, while Dr Julien Potet points out that expired venom has been used in prior shortages and the FDA in the USA has extended the expiry date of these products several times. He argues that manufacturers should assess the long-term stability of their products. Both agree that the antivenom market is fragile and complicated and prone to country-wide shortages, particularly in Africa. If readers in cooler climates think they are immune from this issue, it is worth noting that the risk of a snake bite increases by 6% for every degree Celsius in daily temperature, another side effect of climate change.1

This month’s practice review is essential reading for interpreting the evidence in clinical studies. ‘Missing data’ is an issue often overlooked, yet threatens the validity of results. In their review, Coates et al describe the various kinds of missing data, how each type affects the outcomes of a study and what researchers should do (and readers should look for) to avoid potential bias.

This is just a fraction of the interesting articles in this month’s issue. For further explanation and commentary on these and other papers, make sure to listen to our always entertaining Primary Survey Podcast.