eLetters

837 e-Letters

  • Overdiagnosis and typicality of symptoms in suspected myocardial infarction

    Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...

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  • Drowning is neither near nor far, it just is

    I was happy to see the inclusion of two systematic reviews regarding the proper treatment and evaluation of drowning patients in the same issue; this one, pertaining to CT head investigation, and an additional one pertaining to cervical spine immobilization. While the information included is up to date and pertinent, unfortunately the nomenclature used is over 15 years out of date and no longer accepted by all major health organizations dealing with the prevention and treatment of drowning. In 2002, the World Conference on Drowning developed the uniform definition for drowning, which is "The process of experiencing respiratory impairment due to submersion or immersion in a liquid." With this work also came the recommendations to discontinue the use of modifiers such as "near", "wet", "dry", and "secondary" to describe a drowning, as these terms are inconsistent and do not fit within the wording of the uniform definition. Since its development, the medical and research communities as a whole have been fairly slow to adopt, but much progress has been made with the hard work of many drowning researchers and educators around the world.

    We encourage authors, reviewers, and editors and educate themselves on the current, accepted drowning nomenclature so that we may all present a uniform front in our efforts to decrease this prominent cause of morbidity and mortality around the world. The most recent version of the BMJ Bes...

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  • Improving Major Incident Preparedness

    Dear Editor,

    We were pleased to read the short report entitled: ‘Preparation for the next major incident: are we ready? A 12-year update’ by Mawhinney et al. (1). We were particularly interested to read the recommendations of the authors for improving knowledge of major incident protocol, as we have recently completed a Quality Improvement (QI) initiative at a central London hospital Emergency Department (ED), aiming to improve knowledge and awareness of major incident protocols.

    We note that in your paper you assessed only doctors at registrar level. While we recognise the value of this approach, we adopted a slightly different methodology, by evaluating a single department but across staff groups; the importance of nurses, porters and security staff would be vital in transitioning to a major incident state.

    We reviewed a trust Emergency Preparedness, Resilience and Response (EPRR) report that demonstrated, although the trust was broadly compliant with major incident guidelines, there was a suggestion training and awareness amongst staff could be improved.

    We conducted a driver analysis to determine possible factors causing low levels of awareness of major incidents and methods of protocol access. This allowed us to optimise our understanding and target our interventions. Following this analysis we conducted baseline data collection and implemented two interventions: a poster campaign directing staff to both hard copies of the major incident...

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  • Prehospital rapid sequence intubation is not uncommon in unconscious stroke

    We thank Drs Gibson, Jones and Watkins for their interest in our paper and for pointing out that our statement that RSI is commonly used by paramedics may be incorrectly interpreted by readers. We agree that whilst RSI for traumatic and non-traumatic causes of coma are common in paramedic practice, it cannot be inferred that paramedic RSI is common in stroke. It would have been more accurate to say that paramedic RSI is not uncommon in stroke patients that are unconscious. In our dataset of 38,352 strokes 3,374 had an initial Glasgow Coma Scale of less than nine, of which 627 (18.6%) received RSI by our paramedics, but this was not reported in our paper. In our opinion, 18.6 % paramedic RSI in unconscious patients would qualify as common use of RSI.

    Alternatively, we could have stated that the emergency use of intubation techniques such as RSI in the stroke patient is common. In our recent systematic review and meta-analysis it was demonstrated that emergency department and prehospital intubation via methods such as RSI is commonplace in strokes.1 This review shows that emergency endotracheal intubation was used in 79% of haemorrhagic, and 6% of ischemic strokes. In a sensitivity analysis, the removal of a large influential study raised the prevalence of intubation in ischaemic strokes to 25%. We argue that most of these intubations were RSI, and we can therefore conclude that RSI in the emergency setting for strokes is frequent.

    Ultimately we agree with...

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  • Are Care Quality Commission inspections fostering a vicious cycle of (quality) improvement?

    To the editor,
    I read with interest the recent article by Allen et al, “Measurement and improvement of emergency department performance through inspection and rating: an observational study of emergency departments in acute hospitals in England”1.
    National Health Service (NHS) performance indicators are cited throughout Care Quality Commission (CQC) reports when rating emergency departments4-8. Given use of these data as justification for achieving a specific rating, it is reasonable for the authors and the wider acute medicine and healthcare communities to assume a relationship exists between improved ratings and improved performance. Allen et al found no such relationship on any of the 6 emergency department NHS performance indicators prior to CQC inspection and on the subsequent rating score. This finding expands the void of evidence to support the suggestion of improved emergency department performance after inspection and published ratings2.
    Performance indicators such as those implemented by Allen et al and the CQC have evolved over the
    last 2 decades as we attempt to “cross the quality chasm”. Time and presentation-based data points
    such as time to assessment and treatment, time in department, unplanned re-presentations, left
    before being seen etc. are easily measurable since the advent on electronic health records and patient
    management systems. Their reflections in the tenets of the Institute of Medicine’s ideals of safety...

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  • Rapid sequence intubation (RSI) is uncommon in prehospital stroke care

    As researchers with an interest in pre-hospital stroke care, we read this paper with interest, but also with some surprise at the authors’ assertion that ‘RSI is commonly used by paramedics in stroke’. On examining the cited studies and the authors’ own findings more closely, this statement is hard to justify. Although Meyer et al did indeed report that 55% of out-of-hospital haemorrhagic strokes received RSI, this actually refers to a retrospective chart review of 20 children, all of whom with a Glasgow Coma Scale ≤ 8 following acute haemorrhagic stroke from a cerebral arteriovenous malformation rupture. This small, selective paediatric sample cannot be held to be representative of all stroke patients who are conveyed to hospital by emergency medical services. The other study cited as evidence found that people with acute stroke form a substantial proportion (36.6%) of RSIs undertaken by paramedics (Fouche et al., 2017). Whilst stroke may be a common reason for paramedic RSI, it cannot therefore be inferred that paramedic RSI is common in stroke. The authors’ own findings bear this out: of their sample of nearly 44,000 stroke patients conveyed by the emergency medical services, only 2% had received paramedic RSI.

    Whilst we congratulate the authors on their comprehensive analysis of this large dataset, it is important that readers do not gain the impression that paramedic RSI is frequently indicated and performed in pre-hospital stroke care.

    Disclaimer: JG an...

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  • Reply

    Dear Dr J Benger,

    Thank you for highlighting the need for correction in the article. The option D was meant to be spelt as Abductor pollicis longus (APL) instead of Adductor pollicis longus.  Your elaboration on the anatomy of APL muscle will help readers understand our article better.

  • Thumbs down for anatomical accuracy

    Smith and Bongale correctly emphasise the importance of anatomical accuracy when examining the hand.[1] However their article requires correction. The muscle adductor pollicis longus (answer D in their question) does not exist. The abbreviation APL usually denotes abductor pollicis longus, a muscle of the forearm which contributes to abduction and extension of the thumb, and which runs alongside extensor pollicis brevis as it crosses the anterior (radial) border of the anatomical snuffbox. Adductor pollicis (shown in Figure 2 of the article) is an intrinsic muscle of the hand, and is not involved in thumb extension.

    Hand injuries are common in Emergency Departments. Anatomical accuracy is essential when examining and describing these important presentations.

    1. Smith E, Bongale S. Thumbs down: testing anatomy in the ED. Emerg Med J 2019;36:224-238.

  • Emergency Department Setting: an opportunity to detect the patient with heart failure who may benefit from palliative care.

    Dear Editor,
    We have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
    In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
    In conclusi...

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  • missed diagnosis of infective endocarditis-related stroke in the emergency department

    Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
    For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...

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