We use cookies to improve our service and to tailor our content and advertising to you.More infoYou can manage your cookie settings via your browser at any time. To learn more about how we use cookies, please see our cookies policy.
We read with great interest the paper by Chen et al [1]. However, we
believe there is a serious methodological error in the interpretation of
the results.
They did not apply Bonferroni correction when they made multiple
comparisons between two groups. The Bonferroni correction is a statistical
adjustment for the multiple comparisons [2,3]. The alpha level used in the
study was 0.05 and they m...
We read with great interest the paper by Chen et al [1]. However, we
believe there is a serious methodological error in the interpretation of
the results.
They did not apply Bonferroni correction when they made multiple
comparisons between two groups. The Bonferroni correction is a statistical
adjustment for the multiple comparisons [2,3]. The alpha level used in the
study was 0.05 and they made 13 comparisons. In order to ensure that the
overall chance of making a Type I error is still less than 0.05, only the
p value less than 0.0038 (0.05/13) will be considered statistically
significant. Instead of being interpreted as significantly different, the
proportions of mechanical ventilation, AAD, length of stay > 2 hours,
and upper abdomen sonography are not significantly different between two
groups if we apply Bonferroni correction.
Furthermore, they did not test the effect of adequate infection
control measure. We believe it is not appropriate to make the conclusion
that the impact of severe acute respiratory syndrome on quality of medical
care can be minimized when adequate infection control measures are
applied.
References
(1) Chen TA, Lai KH, Chang HT. Impact of a severe acute respiratory
syndrome outbreak in the emergency department: an experience in Taiwan.
Emerg Med J 2004;21:660¡V662.
(2) Guyatt G, Jaeschke R, Cook D, et al. Therapy and understanding the
results: hypothesis testing. In: Guyatt G, Rennie D, eds. Users¡¦ guides
to the medical literature. Chicago, IL: American Medical Association
2002:335-7.
(3) Pocock SJ, Geller NL, Tsiatis AA. The analysis of multiple
endpoints in clinical trials. Biometrics 1987;43:487-98.
The letter by Gilligan and colleagues suggests that SHO's in emergency
departments are getting slower, seeing far fewer patients in a standard
full shift rota than in previous years. Using 'before-after' comparisons
can be confounded by factors such as increased patient acuity, or
increased availability of slower tests. Decreased access to actually
seeing patients, because ED beds are 'blocked' by admi...
The letter by Gilligan and colleagues suggests that SHO's in emergency
departments are getting slower, seeing far fewer patients in a standard
full shift rota than in previous years. Using 'before-after' comparisons
can be confounded by factors such as increased patient acuity, or
increased availability of slower tests. Decreased access to actually
seeing patients, because ED beds are 'blocked' by admitted patients
waiting for hospital beds an also reduce the numbers of patients we are
able to see. Practice patterns and patient expectations may also have
changed.
I was most interested in their comparisons between SHO's of different
sex or different clinical interest, because further examination of these
could contribute to our understanding of what elements of practice could
be embraced to teach 'ideal' practice patterns for doctors who wish to
work in emergency.
The aspect of 'productivity' (defined for this letter as 'number of
patients seen per unit time'), of the variation in 'speed' between
emergency physicians is an uncomfortable one to address, and has been
neglected. In a one-year (01.07.01 to 30.06.02) audit of a group of 22
academic emergency physicians at a 70 000 visit/year emergency department,
we found that the number of patients seen per hour varied from 2.3 to 4.8
patients/hour. This variation was found to be consistent when times were
compared for high- and low-acuity patient areas [1].
These variations leaves us with many questions unanswered, including
whether ‘fast’ care is of an inferior quality to ‘slow’, whether ‘fast’
physicians teach trainees less effectively, or whether there is a
difference in clinical longevity between physicians performing at
different speeds?
Regardless of these answers, we need to recognise that the physician
is often the bottleneck in the system, and physician productivity is a
significant determinant of department overcrowding. Physician practice
patterns undoubtedly contribute to this, and safe strategies for managing
patient flow need further research [2]. Although rapid transit of patients
through the ED should not be achieved at the cost of good, appropriate
patient care, an ideal standard should be developed appropriate to patient
acuity, that can be used for training and quality management purposes.
References
(1) Campbell SG, Maxwell DM, Sinclair DE. Is individual Emergency Physician
efficiency a significant determinant of ED overcrowding. (Abstr) CJEM
2003;5:202.
(2) Campbell SG, Sinclair D. Strategies for managing a busy emergency
department. CJEM 2004;6(4):271-6.
We must accept that our original analysis, which assumed statistical
independence between observations obtained from staff within the same
hospital, might not be justified. To explore this possibility we have
computed Intra Cluster Correlation Coefficients (ICCs) using estimated
components of variance obtained from an analysis of variance in which
hospitals were treated as random effects within a nest...
We must accept that our original analysis, which assumed statistical
independence between observations obtained from staff within the same
hospital, might not be justified. To explore this possibility we have
computed Intra Cluster Correlation Coefficients (ICCs) using estimated
components of variance obtained from an analysis of variance in which
hospitals were treated as random effects within a nested sampling design.
With regards the total score at sixty seconds the between hospital
component of variance was negative and hence the estimated ICC was set to
zero. The ICCs and variance inflation factors (VIFs, assuming an average
cluster size of 15) for all four outcome measures are presented below:
Outcome
Original p-values
ICC
VIF
Adjusted p-values
Score @ 60
seconds
0.034
0.000
1.00
0.048
Total score
overall
0.067
0.011
1.15
0.095
Proportion
with max score at 60 seconds
0.054
0.002
1.03
0.077
Proportion
with max score overall
0.100
0.016
1.22
0.123
As pointed out, the consequences of positive ICCs is that the
reported p- values, which ignored the clustering effect, will tend to be
biased downwards. A subsequent analysis, which adjusts for clustering
within the study, produced elevated p-values for all outcomes with that
for the score at 60 seconds remaining significant at the 5% level.
We did however, state in the paper that the results were at best of
marginal significance, statistically. The ceiling of a maximum of 8
correct causes may have reduced the ability to demonstrate a significant
effect, if one exists. Despite these p value discussions, the paper
remains of importance for two reasons. Firstly, it points out that despite
the best of intentions, the use of a device to augment recall may
potentially lead to adverse effects; 78% house officers could recall
hypothermia, which in UK an uncommon cause with a long treatment
wheelbase, whilst only 35% remembered hypoxia, a more common cause with
rapid treatment. Secondly, such devices may be subject to study of their
effectiveness, albeit with difficulty.
We thank Dr Menon for his thoughtful understanding of our solution to
the development of EM in our country. We find it interesting that he
believes that the system we developed out of necessity is potentially
applicable to the UK and other countries with similar models.
We would like to thank Dr Gaber for his insightful questions, and
will attempt to answer them one by one.
We thank Dr Menon for his thoughtful understanding of our solution to
the development of EM in our country. We find it interesting that he
believes that the system we developed out of necessity is potentially
applicable to the UK and other countries with similar models.
We would like to thank Dr Gaber for his insightful questions, and
will attempt to answer them one by one.
First we would provide a clarification. The "grandfather clause"
does not pertain to residency training. Rather, it was the way to
recognize the status of physicians who had been working for prolonged
periods of time in the ED and were still active in the ED at the time of
specialty recognition. Thus, they were formally declared to be the
teachers for the young incoming generation. We fully realize that this
formal recognition did not turn them overnight into the "true" emergency
physicians we are trying to educate in the new specialty.
The residents in EM in Israel chose to train in EM for two main
reasons: most of them wanted to work in the ED because they had the
opportunity to become true professionals in the broad aspects of EM. A
few others, on the other hand, came because they had heard that the new
specialty made jobs available. Most EM residents are not particularly
young and do have families. They had trained in their first specialty,
usually spent 3 years in the armed forces, and are mature and actually
well-trained physicians by the time they start their training in the ED.
The acceptance of EM as a new specialty is still partial and slow to
come by. There is still a lot of resistance from the established
specialties. The new generation of Emergency physicians is changing the
old way of interacting with the specialties. They do this assuming more
and more of the patient care previously done by the various traditional
specialties.
EM is not, unfortunately, well paid, it is not particularly
glamorous, yet the residents currently in training mostly chose to train
in EM, due their personal preference for the specialty. They are allowed
to supplement their income by working in their private clinics after
hours, and in fact most could not have survived financially without this
extra income. This work has the added benefit of maintaining the skills
they had gained in their first specialty, which are also useful in their
work in the ED. Clinical hours in the ED are mostly usually approximately
30/week.
In response to the letter from Dr Raveenthiran, I feel that there are a
number of issues to be addressed.
Firstly, many BETs are written not to reflect and reinforce current
practice in emergency departments. Often, as in this case, this is a
response to advice recieved upon referring to the appropriate specialty.
Many techniques require questioning whether they are acccepted practice or
otherwise. As...
In response to the letter from Dr Raveenthiran, I feel that there are a
number of issues to be addressed.
Firstly, many BETs are written not to reflect and reinforce current
practice in emergency departments. Often, as in this case, this is a
response to advice recieved upon referring to the appropriate specialty.
Many techniques require questioning whether they are acccepted practice or
otherwise. As such the bestBETs procedure, looks at available evidence on
a practice, appraises and shows that evidence and derives a clinical
bottom line.
Secondly, in an attempt to cast as sensitive a net as possible for
that evidence, some BETs authors choose to include accepted spellings from
different countries (eg tumour or tumor) and also the more common mis-
spellings. The efficacy of this method was shown as the second paper
(published in the Annals of the Royal College of Surgeons of England)
quoted used the incorrect spelling "paraphymosis" in the title and
throughout.
Thirdly, there is some difficulty in changing the bottom line as
suggested. Evidence has been found, and although this evidence appears
poor with no control group and may be confounded by inadvertant pressure
to the glans (particularly in the pins group). As with all BETs, the
available evidence is presented in which reader's can draw their own
conclusions. Based on the evidence provided, the clinical bottom line we
reached was one we felt most appropriate to that evidence available, it
cannot simply be dismissed as it disagreed with our belief when we
approached the subject.
I would like to thank Drs Glazebrook and Probst for pointing out a
potential source of confusion. I also considered gastric lavage
innapropriate management of overdose for multiple reasons, which gave me
cause to review the evidence. The fact it's use is still occasionally
suggested in clinical practice remains a personal concern.
At the time of the initial authorship of the BET concerned,
g...
I would like to thank Drs Glazebrook and Probst for pointing out a
potential source of confusion. I also considered gastric lavage
innapropriate management of overdose for multiple reasons, which gave me
cause to review the evidence. The fact it's use is still occasionally
suggested in clinical practice remains a personal concern.
At the time of the initial authorship of the BET concerned,
gastic lavage was being performed for a number of drug groups in
overdosage, in particular ions, NSAIDs and tricyclic antidepressants - for
which lavage was advocated due to the poor absorbtion of these drugs by
charcoal. BETs were performed on all these drug groups and the clinical
bottom line reflects a response to our initial clinical problem. In
response to the above letter all of the gastric lavage BETs on the website
will contain links to national poisons information service for up to date
advice. Clinical bottom lines are being updated to avoid the potential for
ambiguity.
We would like to thank Dr Oglesby and colleagues for their helpful
comments [1], and for highlighting their data on complication rates for ED RSI
[2] which were published subsequent to the submission of our paper [3].
We share entirely their reservations regarding propofol as an
induction agent in ED patients. It is our observation that it is
associated with a greater incidence of hypotens...
We would like to thank Dr Oglesby and colleagues for their helpful
comments [1], and for highlighting their data on complication rates for ED RSI
[2] which were published subsequent to the submission of our paper [3].
We share entirely their reservations regarding propofol as an
induction agent in ED patients. It is our observation that it is
associated with a greater incidence of hypotension than other agents in
inexperienced hands, and that junior anaesthetic staff consistently
demonstrate a remarkable predilection for its use. This is an example of
the inappropriateness of directly applying theatre-based anaesthesia
practice to the critical care setting, and we continue to hope that our
data might contribute to the development of more tailored anaesthesia
training for critical care and emergency physicians.
We note that the larger Scottish study demonstrated a greater
proportion of physiologically compromised ED patients than ours. However
this does not negate our observation of ‘relative cardiovascular stability
and normal respiratory function of ED patients’ compared with patients
intubated in the ward and ICU settings. This might also be the case in
Scotland if such a comparison between clinical areas were to be made. The
point has been made by Dr Oglesby and colleagues in their own paper that
‘the lack of internationally accepted definitions of complications of RSI
means that studies of emergency airway management...cannot be compared on
an equivalent basis’, and the complication of ‘critical desaturation’ was
not defined in their paper. Bearing these limitations and our stricter
definition of hypotension in mind, ED complication rates were not in fact
markedly dissimilar between our studies, whereas complication rates on the
ICU were three times higher than in the ED.
We applaud the approach of having a senior anaesthetist or intensive
care specialist present during ED RSI. Although this may well be
achievable in the teaching hospital setting, many district general
hospitals may not have an available anaesthetist, let alone a senior one.
The challenges of Hospital at Night and European Working Time compliant
rostering may further deplete this supply, and only by the development of
joint protocols as recommended by Dr Oglesby can this vital patient need
be met. In our current practice setting we have pursued a similar course
with a joint anaesthesia / emergency medicine Standard Operating Procedure
for Rapid Sequence Intubation which we would be happy to share with anyone
hoping to develop their ED RSI program.
References
(1) Rapid response: The who, where, and what of rapid sequence
intubation
Angela J Oglesby, Mark J D Dunn, Alasdair J Gray, Diana Beard, Dermot W
McKeown, Colin A Graham (10 August 2004)
(2) Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation
in Scottish urban emergency departments. Emerg Med J 2003;20:3-5
(3) Reid C, Chan L, Tweeddale M. The who, where, and what of rapid
sequence intubation: prospective observational study of emergency RSI
outside the operating theatre. Emerg Med J 2004;21:296-301
I read, with interest, the article by Jones and Teece [1]. The
authors have attempted to find the best out of three procedures, which
more or less resemble home remedy. They should not be offered in a modern
scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis
[2].
In paraphimosis, as soon as the constricting ring of prepuce gets
stuck...
I read, with interest, the article by Jones and Teece [1]. The
authors have attempted to find the best out of three procedures, which
more or less resemble home remedy. They should not be offered in a modern
scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis
[2].
In paraphimosis, as soon as the constricting ring of prepuce gets
stuck to the coronal sulcus, vascular spaces of the glands are engorged due
to venous impedance. This tumescence of glands is the real hindrance for
reduction. Therefore, manual squeezing of the glands or needle aspiration
of the vascular spaces is essential for reducing the stuck foreskin. (2)
If left untreated, lymphatic blockage causes delayed onset of oedematous
swelling of inner preputial layer. Thus, oedema is the result and not the
cause of irreducibility. Very often this cause-effect relationship is
misunderstood. Many authors, who erroneously incriminated preputial oedema,
attempted to dissipate it by a variety of techniques such as multiple
puncture of swollen foreskin, injection of hyaluronidase, application of
hygroscopic agents such as granulated sugar and use of ice packs. All of
them are either useless or unnecessary. Application of ice is probably
dangerous as it carries the risk of spasm of penile end-artery and
gangrene. If some hygroscopic agent has to be applied I wonder if it is
the sweetness of sugar that made it preferable over salt!
The spelling PARAPHYMOSIS used by the authors for Medline search is
nonexistent. PARAPHIMOSIS is derived from the Greek word ‘PHIMOS’ meaning
muzzle (Verb). The Greek word ‘PHYMA’, which means a tumor, has no
relevance to the restraining foreskin.
The clinical bottom line of the paper needs to be modified as, “Ice, pins
and sugar have been claimed to aid reduction of paraphimosis, but there is
no evidence to show any of them really works.” Unless these primitive
methods are discouraged, one would not be surprised to read in Emergency
Medical Journal, after sometime, an article entitled “Dipping in honey
aids reduction of paraphimosis” - for honey is also hyperosmolar and
hygroscopic as sugar!
References
(1) Jones KM, Teece S. Ice, pins and sugar to reduce paraphimosis. Emerg
Med J 2004; 21: 77-78.
(2) Raveenthiran V. Reduction of paraphimosis: a technique based on
patho-physiology. Br J Surg 1996; 83: 1247.
The letter by C D Okereke [1] “Head injury transfers: arm of greatest
delay” confirms that considerable delays persist in the transfer of
patients with traumatic brain injury from district general hospitals to
regional neurosurgical units. Our own data indicates that emergency
craniotomy for traumatic brain injury was achieved in only 1 out of 24
patients [2] within the recommended four hour target [...
The letter by C D Okereke [1] “Head injury transfers: arm of greatest
delay” confirms that considerable delays persist in the transfer of
patients with traumatic brain injury from district general hospitals to
regional neurosurgical units. Our own data indicates that emergency
craniotomy for traumatic brain injury was achieved in only 1 out of 24
patients [2] within the recommended four hour target [3] and we are currently
investigating how transfer strategies can be refined to meet this target.
Mr Okereke poses two questions:
Why see the scans images before sanctioning a transfer? Are there concerns
relating to the radiologists interpretation of the scans?
From a neurosurgical perspective, I agree with Mr Okereke that it is
not always necessary to see the CT scan images before transfer. There is a
population of patients who need urgent transfer to the neuro-surgical unit
irrespective of the interpretation of the CT scan by the neurosurgical
unit. For example, patients with deteriorating levels of consciousness and
a space occupying haematoma should be accepted at the time of referral not
at the time of review of the CT scan. There are exceptions to this rule,
however, notably patients who are hypotensive with ongoing blood loss who
may require urgent extra-cranial surgery and patients in whom the
prognosis is deemed hopeless from the onset. In these patients it is
essential to see the scan to determine the suitability and timing of
transfer. Mr Okereke eludes to taxi transfer of images which inevitably
leads to delays. It is of paramount importance that district general
hospitals have an electronic image link with the regional neurosurgical
unit.
Should it be a matter of policy that all isolated severe head
injuries (GCS <_8 be="be" taken="taken" directly="directly" to="to" the="the" neurosurgical="neurosurgical" centres="centres" p="p"/> Whilst this concept would reduce delay in the definitive management
of patients with severe head injuries there are a number of concerns in
implementing such a policy at the present time. Firstly, two of the major
factors in determining outcome are the presence of hypoxia and hypotension
as secondary insults. Comatose patients therefore require urgent placement
of a definitive airway (cuffed tube in the trachea)[4] and fluid
resuscitation. This is likely to be achieved more rapidly by transferring
patients short distances to district general hospitals than by longer
primary transfers to neurosurgical units unless patients can be intubated
at the scene which requires both the expertise to place the endotracheal
tube and to administer sedating and paralysing drugs. Such expertise is
not yet universally available. Secondly, it is often difficult in the
field to distinguish between patients who are comatose with an isolated
head injury from those who are harbouring other injuries, for example,
thoracic, abdominal or pelvic haemorrhage. The priority in these patients
is to treat shock with urgent extra-cranial surgery. Thirdly, it is not
currently logistically appropriate that all patients with isolated head
injuries are transferred to regional neurosurgical units. There is a
population of patients who present with an isolated head injury who may
not require neuro-critical care, for example those with a seizure and
normal CT scan. There is also a population of patients with devastating
injuries with no chance of survival in whom transfer is clearly
inappropriate.
In summary, I agree with Mr Okereke that the concept of transferring
all patients with isolated severe head injuries directly to neurosurgical
centres is attractive but at present would produce significant problems.
However, given the evidence that specialised neuro-critical care has the
potential to improve outcome in patients with diffuse injury as well as
those with mass lesions [5-7] we should be ensuring that all patients likely
to benefit should be transferred. Direct transfer to neurosurgical units
may become possible in the future but would require widespread
implementation of personnel with the ability to intubate patients in the
field which requires expertise in the use of sedation and paralysis, rapid
transport systems from the field to the regional neurosurgical unit
(distances in some regions in excess of 100 miles), capability for extra-
cranial surgery in all regional neurosurgical units and an expansion in
the number of neuro-critical care beds.
PJ Hutchinson
Academic Department of Neurosurgery, University of Cambridge,
Addenbrooke’s Hospital, UK
Address for correspondence:
Mr PJ Hutchinson
University of Cambridge Department of Neurosurgery
Box 167
Addenbrooke’s Hospital
Cambridge
CB2 2QQ
UK
Telephone +44 1223 336949
Fax +44 1223 216926
E-mail pjah2@cam.ac.uk
References
(1) Okereke CD. Head injury transfers: arm of greatest delay. Emerg
Med J 2004;21:397.
(2) Sergides IG, Howarth S, Whiting G, Hutchinson PJ. Is the
recommended four hour target from injury to emergency craniotomy for head
injury achievable? Br J Neurosurg 2004;abstract in press.
(3) Royal College of Surgeons of England. Report of the working party
on the management of patients with head injuries. London: RCS, 1999.
(4) American College of Surgeons Committee on Trauma. Advanced Trauma
Life Support for Doctors. Chicago: American College of Surgeons, 1997.
(5) Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick
PJ. Specialist neurocritical care and outcome from head injury. Intensive
Care Med 2002;28:547-53.
(6) Polderman KH, Tjong Tjin Joe R, Peerdeman SM, Vantertop WP,
Girbes AR. Effects of therapeutic hypothermia on intracranial pressure and
outcome in patients with severe head injury. Intensive Care Med
2002;28:1563-73.
(7) Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury
improved by an organised secondary insult program and standardised
neurointensive care. Crit Care Med 2002;30:2129-34.
While I normally find the Best BETs both informative and useful, I was
surprised at the publishing of one concerning gastric lavage in drug overdose
[1].
Gastric lavage is both dangerous and without benefit in all but a few
overdoses. The 1997 Joint Position Statement made by the American Academy
of Clinical Toxicology, and the European Association of Poisons Centres
stated that gastric lavage s...
While I normally find the Best BETs both informative and useful, I was
surprised at the publishing of one concerning gastric lavage in drug overdose
[1].
Gastric lavage is both dangerous and without benefit in all but a few
overdoses. The 1997 Joint Position Statement made by the American Academy
of Clinical Toxicology, and the European Association of Poisons Centres
stated that gastric lavage should never be routinely used [2].
A statement on the National Poisons Information Website (TOXBASE)
indicates that gastric lavage should only be considered in a case of a
potentially life-threatening overdose taken within the last hour of a
poison that is not adsorbed by charcoal.
To state that gastric lavage is no better than charcoal as a clinical
bottom line at reducing toxicity following aspirin or non-steroidal anti-
inflammatory drugs is at Best misleading.
References
(1) Teece S. Gastric lavage in aspirin and non-steroidal anti-
inflammatory drug overdose. Emerg Med J 2004;21:591-592.
(2) American Academy of Clinical Toxicology and European Association
of Poisons Centres. Gastric Lavage. J Clin Toxicol-Clin Toxicol
1997;35:711-719.
Dear Editor
We read with great interest the paper by Chen et al [1]. However, we believe there is a serious methodological error in the interpretation of the results.
They did not apply Bonferroni correction when they made multiple comparisons between two groups. The Bonferroni correction is a statistical adjustment for the multiple comparisons [2,3]. The alpha level used in the study was 0.05 and they m...
Dear Editor
The letter by Gilligan and colleagues suggests that SHO's in emergency departments are getting slower, seeing far fewer patients in a standard full shift rota than in previous years. Using 'before-after' comparisons can be confounded by factors such as increased patient acuity, or increased availability of slower tests. Decreased access to actually seeing patients, because ED beds are 'blocked' by admi...
Dear Editor
We must accept that our original analysis, which assumed statistical independence between observations obtained from staff within the same hospital, might not be justified. To explore this possibility we have computed Intra Cluster Correlation Coefficients (ICCs) using estimated components of variance obtained from an analysis of variance in which hospitals were treated as random effects within a nest...
Dear Editor
We thank Dr Menon for his thoughtful understanding of our solution to the development of EM in our country. We find it interesting that he believes that the system we developed out of necessity is potentially applicable to the UK and other countries with similar models.
We would like to thank Dr Gaber for his insightful questions, and will attempt to answer them one by one.
First we...
Dear Editor
In response to the letter from Dr Raveenthiran, I feel that there are a number of issues to be addressed. Firstly, many BETs are written not to reflect and reinforce current practice in emergency departments. Often, as in this case, this is a response to advice recieved upon referring to the appropriate specialty. Many techniques require questioning whether they are acccepted practice or otherwise. As...
Dear Editor
I would like to thank Drs Glazebrook and Probst for pointing out a potential source of confusion. I also considered gastric lavage innapropriate management of overdose for multiple reasons, which gave me cause to review the evidence. The fact it's use is still occasionally suggested in clinical practice remains a personal concern.
At the time of the initial authorship of the BET concerned, g...
Dear Editor
We would like to thank Dr Oglesby and colleagues for their helpful comments [1], and for highlighting their data on complication rates for ED RSI [2] which were published subsequent to the submission of our paper [3].
We share entirely their reservations regarding propofol as an induction agent in ED patients. It is our observation that it is associated with a greater incidence of hypotens...
Dear Editor,
I read, with interest, the article by Jones and Teece [1]. The authors have attempted to find the best out of three procedures, which more or less resemble home remedy. They should not be offered in a modern scientific emergency department because they are based on misunderstood pathophysiology of paraphimosis [2].
In paraphimosis, as soon as the constricting ring of prepuce gets stuck...
Dear Editor
The letter by C D Okereke [1] “Head injury transfers: arm of greatest delay” confirms that considerable delays persist in the transfer of patients with traumatic brain injury from district general hospitals to regional neurosurgical units. Our own data indicates that emergency craniotomy for traumatic brain injury was achieved in only 1 out of 24 patients [2] within the recommended four hour target [...
Dear Editor
While I normally find the Best BETs both informative and useful, I was surprised at the publishing of one concerning gastric lavage in drug overdose [1].
Gastric lavage is both dangerous and without benefit in all but a few overdoses. The 1997 Joint Position Statement made by the American Academy of Clinical Toxicology, and the European Association of Poisons Centres stated that gastric lavage s...
Pages