I thank Dr DaCruz for his interest in my article and I agree it is
generally safe to apply standard (short chain) superglues to ones fingers
without any significant ill effects. However I think Dr DaCruz is mistaken
if he believes that when used to repair wounds, even if properly applied,
these adhesives do not come into contact to some extent with broken skin.
There is good scientific evidence, referenced i...
I thank Dr DaCruz for his interest in my article and I agree it is
generally safe to apply standard (short chain) superglues to ones fingers
without any significant ill effects. However I think Dr DaCruz is mistaken
if he believes that when used to repair wounds, even if properly applied,
these adhesives do not come into contact to some extent with broken skin.
There is good scientific evidence, referenced in my article which
demonstrates quite convincingly that the short chain cyanoacrylates are
significantly more histotoxic than their longer chain and more expensive
counterparts. It is good fun to suggest that it is all just a big drug
company rip-off however these newer cyanoacrylates are proven to be safe
when in contact with most 'wet tissues' and are used, as also stated in my
article not just for wound repair but also as wound dressings and for
vascular embolisation; they have a very low level of histotoxicity. Anyone
who has seen superglue in a wound will know that it is histotoxic. To use
cheap glues when the risks are proven and safer alternatives exist is
almost certainly medico-legally indefensible in the UK and I believe
supporting this practice is ill advised and potentially dangerous.
Luke Cascarini MBChB FDSRCS MRCS
Sir, we found Nicholl et al’s findings on distance to hospital and
patient mortality in emergencies both interesting and highly topical.
Although the authors justify the use of straight-line ambulance distance
opposed to journey times, in urban/inner city areas time to hospital may
be a more relevant factor. For instance in Sutton and Merton PCT all
general practices have one accident and emergency department within 5km,...
Sir, we found Nicholl et al’s findings on distance to hospital and
patient mortality in emergencies both interesting and highly topical.
Although the authors justify the use of straight-line ambulance distance
opposed to journey times, in urban/inner city areas time to hospital may
be a more relevant factor. For instance in Sutton and Merton PCT all
general practices have one accident and emergency department within 5km,
64% have two emergency departments within 5km and all practices have at
least two emergency departments within 10km. However, due to road systems
and heavy congestion within urban and city locations, journey times can
still be considerable. For this reason distances may not be representative
in determining rapid access. In many cases the closest hospital in terms
of distance may not be the most quickly reached in an emergency. As a
consequence the average time to reach an accident and emergency unit
should be seen as an important factor in London and other densely
populated urban areas, particularly at busy times of the day, when there
are high levels of congestion.
Thanks for your concern and opinion about our article.
To determine the influence of underlying diseases on the BNP values, this
survey was performed the non-CHF patients only. Therefore, the patients
who had myocardical dysfunction caused by sepsis was excluded in this
survey. In discussion, it was described that BNP values were increased in
the patients of hypertension more than non-hypertension patients due to
increas...
Thanks for your concern and opinion about our article.
To determine the influence of underlying diseases on the BNP values, this
survey was performed the non-CHF patients only. Therefore, the patients
who had myocardical dysfunction caused by sepsis was excluded in this
survey. In discussion, it was described that BNP values were increased in
the patients of hypertension more than non-hypertension patients due to
increasement of lt-ventricle mass index. Therefore we agree with your
opinion. Underlying diseases (COPD, HTN, et al) were diagnosed at the time
of discharge, and so we hardly miss. This study was conducted on dyspnea
patients not healthy people. We think the target of study was different
from your opinion. Nevertheless, it will be better if further study is
done with large population of patients.
In the article titled 'Can risk stratification of transient ischaemic
attacks improve patient care in the emergency department?'I want to make
two comments
(1)Table 2 shows that number of patients above 60 are more than the total
number of included subjects.
(2)the results of the study does not validate ABCD scoring system for
TIA(as is proposed in the conclusion) because it does not show how many of
the admitted or discha...
In the article titled 'Can risk stratification of transient ischaemic
attacks improve patient care in the emergency department?'I want to make
two comments
(1)Table 2 shows that number of patients above 60 are more than the total
number of included subjects.
(2)the results of the study does not validate ABCD scoring system for
TIA(as is proposed in the conclusion) because it does not show how many of
the admitted or discharged patient developed cerbrovascular accidents
within some follow up period.Better conclusion for this study should have
been that education of the ED doctors prevents hospital admissions.
A 62-year-old gentleman presented with a 10-day history of right sided pleuritic chest pain and shortness of breath. Chest X-ray (CXR) on admission (left) confirmed a primary spon...
A 62-year-old gentleman presented with a 10-day history of right sided pleuritic chest pain and shortness of breath. Chest X-ray (CXR) on admission (left) confirmed a primary spontaneous pneumothorax of the right lung. This was treated with simple needle aspiration. CXR immediately after the procedure (middle) showed re-expansion of the right lung with unilateral pulmonary oedema. Subsequent CXR (right) demonstrated complete resolution of both the pneumothorax and re-expansion pulmonary oedema (REPO).
REPO is an extremely uncommon but recognised complication of re-expansion of the lung following evacuation of either air or fluid from the pleural space. REPO has an overall incidence of 1% and its occurrence after simple needle aspiration of pneumothorax is exceptionally rare. Despite treatment which involves resuscitation with intravenous fluid and oxygen therapy, REPO is potentially fatal with mortality as high as 20%.
What’s important is to know what we mean by ‘common practical
procedures’. If it means starting an IV line or intubation or putting a
naso gastric tube, then yes, all doctors should know these basic life
saving procedures.
I think all medical procedures that can help save a life should be taught
to all medical students. All ‘doctors’ should be expert in resuscitation.
Everyone should know ABC of resuscitation. No life sh...
What’s important is to know what we mean by ‘common practical
procedures’. If it means starting an IV line or intubation or putting a
naso gastric tube, then yes, all doctors should know these basic life
saving procedures.
I think all medical procedures that can help save a life should be taught
to all medical students. All ‘doctors’ should be expert in resuscitation.
Everyone should know ABC of resuscitation. No life should be lost because
of ignorance, or the junior doctor not knowing how to intubate a patient.
In today’s medical practice scenario, where private practice is becoming
more and more integral part of hospitals and achieving target financial
goals determine a doctors continuing to work or getting fired, neither the
senior, nor the patient want any complications. So the senior does not
want his patient to become guinea pig and subject him to a procedure with
errors and complications at the hands of an inexperienced junior doctor.
In fact anyone would want the best person to perform the procedure on
themselves than an ‘inexperienced’ junior doctor performing it on them.
Partly it is because of the strict litigation procedures. Patients
file case against their doctor more frequently today compared to the good
old times when there was just pure‘bed side medicine’.
Also the patients want the senior to perform the procedure and to make
sure of this they prefer to be their private patient so that only the
senior doctor sees n examines them.
Today’s junior doctor’s vision is exam oriented. So if someone is
interested in doing a specialization in gynecology, he won’t be interested
in learning how to perform a lumbar puncture. There is increased work
load, more paper work to finish. Pressure to finish the thesis on time.
So the senior does not want to teach and the junior does not want to
‘waste’ time learning a procedure which he won’t be performing after he
joins a MD or MS post graduation course.
Now a day’s modern medicine and evidence based medicine is backed by more
sophisticated bed side investigations. Eg in a patient with suspected
liver abscess, no one would perform a liver abscess aspiration based on
just a positive hepatic punch. Routinely an ultrasound would be ordered or
better a CT Scan abdomen, followed by aspiration by an interventional
radiologist or a surgeon or a gastroenterlogist. So the junior doctor does
not get to learn these procedures. There are so many super specialists
wanting to do the same procedure and wanting to increase their income.
I have read with interest the replies to Lee and Porter’s article on
suspension trauma. As a mountain rescue doctor I have been involved in the
care of an individual with suspected suspension trauma. The patient fell
10 metres vertically onto a 40 degree scree slope, with feet facing down
the slope and reluctant to place the pelvis on the ground as it caused an
increase in pain in both legs. Paramedi...
I have read with interest the replies to Lee and Porter’s article on
suspension trauma. As a mountain rescue doctor I have been involved in the
care of an individual with suspected suspension trauma. The patient fell
10 metres vertically onto a 40 degree scree slope, with feet facing down
the slope and reluctant to place the pelvis on the ground as it caused an
increase in pain in both legs. Paramedics immobilised in a vacuum mattress
with legs outstretched – still facing downhill, (Morphine Sulphate being
used to relieve pain). The team attended to assist in extraction, the
patient had been immobile in excess of two hours.
The patient was not suspended vertically but was immobilised at a
significant angle for a period of time. This prevented leg movement and
recirculation of the pooled venous blood – alerting us to possible
suspension trauma and hence raising the casualty’s feet. The side effects
of morphine, (hypotension, nausea, dizziness, and bradycardia), are
similar to the effects of suspension trauma, except for the narrow pulse
pressure and dilated pupils present in this patient. It could be argued
that a significant sympathetic drive would occur from the pain and fear of
sliding, which prevented further onset. The absence of a tachycardia does
not support this. The non specific bilateral leg pain may indicate
suspension trauma associated paraesthesia, rather than mechanical injury.
No hypovolaemia, back, pelvic or lower limb injury were confirmed in
hospital and the patient denied further pain.
It must be noted that if a casualty becomes unconscious whilst in
suspension their airway will be become obstructed, either by neck flexion
or hyperextension, masking any signs of suspension trauma. In training
risk of suspension trauma is grouped as follows:
1. Full body harness with posterior attachment point - low risk.
2. Sit harness with anterior attachment – low risk. Casualty will
hang almost horizontal, but additional weight can alter their centre of
gravity changing the angle of suspension1. If still conscious they will
attempt to recommence climbing or be lowered by the second climber to a
better position.
3. Full body harness with chest and waist attachment points – high
risk. Used in caving and industrial rope access as it allows rapid ascent
and descent of the rope. The unconscious casualty will remain in a
vertical position; reducing the time to brain hypoxia secondary to reduced
cerebral perfusion pressure from venous pooling and concomitant reduction
in cardiac output. Consequently rope access technicians must be able to
rescue and descend to safety in less than ten minutes2.
4. Third party induced. This group are placed in suspension by
other individuals and are at high risk. This includes rescue personnel
immobilising casualties.
This case demonstrates that suspension trauma is not hypothetical and
may present with varying symptoms and under varying conditions. It has a
small incidence following changes in harness design and education of those
at risk, but must be considered during rescue and in hospital if a history
of prolonged suspension at any angle is mentioned.
Regards
Dr Patrick Morgan
Avon and Somerset Cliff Rescue Team
References
1. Hillebrandt, D. Suspension Trauma in UK Climbers? Emerg Med J, e-
letter. 2007, 12 June.
2. Guidance on rescue during work at height. Technical Guidance Note
5. The Work at Height Safety Association. www.wahsa.org.uk. 2006.
Thank you to Dr Weatherup and Dr Mardon for bringing attention to the
error in atropine dosing in over 11s and discrepancies with the BTS asthma
guidelines.
Further amendments have now been made to the calculator to address these
issues and to further improve the calculator.
The revised Livingston Paediatric Dose Calculator should now be available
on the EMJ website (http://emj.bmj.com/supplemental) under 3rd revision
(LP...
Thank you to Dr Weatherup and Dr Mardon for bringing attention to the
error in atropine dosing in over 11s and discrepancies with the BTS asthma
guidelines.
Further amendments have now been made to the calculator to address these
issues and to further improve the calculator.
The revised Livingston Paediatric Dose Calculator should now be available
on the EMJ website (http://emj.bmj.com/supplemental) under 3rd revision
(LPDC Version 8).
It is pleasing to hear that they have found the calculator useful in their
own department.
We thank Dr Reid for his comments regarding the above paper. The
case described related to a seventy-three year old gentleman who was found
sitting at the wheel of his car in a collapsed state with a left-sided
hemiplegia. The patient was found to regain full power of his left side
when laid flat. This postural alteration in his neurological symptoms was
the point o...
We thank Dr Reid for his comments regarding the above paper. The
case described related to a seventy-three year old gentleman who was found
sitting at the wheel of his car in a collapsed state with a left-sided
hemiplegia. The patient was found to regain full power of his left side
when laid flat. This postural alteration in his neurological symptoms was
the point of interest which we were seeking to elucidate, as this patient
was subsequently found at post mortem to have a ruptured abdominal aortic
aneurysm with no thoracic involvement. These neurological symptoms were
attributed to quiescent carotid artery disease (which was subsequently
revealed at post mortem). This carotid artery disease manifested with a
left sided hemiplegia in the context of severe postural hypotension which
had resulted from rupture of his abdominal aortic aneurysm. Dissection of
Thoracic Aortic Aneurysm frequently manifests in neurological signs not
dissimilar to the initial presentation of this patient. It was for this
reason that papers relating to DTAA were referenced. We hope this
clarifies the confusion expressed by Dr Reid.
We agree that the diagnosis of septic arthritis in the operating room
is
vulnerable to subjective intrepretation. There was one patient in our
study
whose diagnosis of septic arthritis was made based on operative findings
alone
(i.e. without a positive arthrocentesis culture). The operative findings
were
described as "pus", and we believe that supports the diagnosis of septic
arthritis.
The patient had been on a c...
We agree that the diagnosis of septic arthritis in the operating room
is
vulnerable to subjective intrepretation. There was one patient in our
study
whose diagnosis of septic arthritis was made based on operative findings
alone
(i.e. without a positive arthrocentesis culture). The operative findings
were
described as "pus", and we believe that supports the diagnosis of septic
arthritis.
The patient had been on a course of antibiotics prior to presentation,
which may
explain the negative microbiologic studies.
Sir
I thank Dr DaCruz for his interest in my article and I agree it is generally safe to apply standard (short chain) superglues to ones fingers without any significant ill effects. However I think Dr DaCruz is mistaken if he believes that when used to repair wounds, even if properly applied, these adhesives do not come into contact to some extent with broken skin. There is good scientific evidence, referenced i...
Sir, we found Nicholl et al’s findings on distance to hospital and patient mortality in emergencies both interesting and highly topical. Although the authors justify the use of straight-line ambulance distance opposed to journey times, in urban/inner city areas time to hospital may be a more relevant factor. For instance in Sutton and Merton PCT all general practices have one accident and emergency department within 5km,...
Thanks for your concern and opinion about our article. To determine the influence of underlying diseases on the BNP values, this survey was performed the non-CHF patients only. Therefore, the patients who had myocardical dysfunction caused by sepsis was excluded in this survey. In discussion, it was described that BNP values were increased in the patients of hypertension more than non-hypertension patients due to increas...
In the article titled 'Can risk stratification of transient ischaemic attacks improve patient care in the emergency department?'I want to make two comments (1)Table 2 shows that number of patients above 60 are more than the total number of included subjects. (2)the results of the study does not validate ABCD scoring system for TIA(as is proposed in the conclusion) because it does not show how many of the admitted or discha...
A 62-year-old gentleman presented with a 10-day history of right sided pleuritic chest pain and shortness of breath. Chest X-ray (CXR) on admission (left) confirmed a primary spon...
What’s important is to know what we mean by ‘common practical procedures’. If it means starting an IV line or intubation or putting a naso gastric tube, then yes, all doctors should know these basic life saving procedures. I think all medical procedures that can help save a life should be taught to all medical students. All ‘doctors’ should be expert in resuscitation. Everyone should know ABC of resuscitation. No life sh...
Dear editor
I have read with interest the replies to Lee and Porter’s article on suspension trauma. As a mountain rescue doctor I have been involved in the care of an individual with suspected suspension trauma. The patient fell 10 metres vertically onto a 40 degree scree slope, with feet facing down the slope and reluctant to place the pelvis on the ground as it caused an increase in pain in both legs. Paramedi...
Thank you to Dr Weatherup and Dr Mardon for bringing attention to the error in atropine dosing in over 11s and discrepancies with the BTS asthma guidelines. Further amendments have now been made to the calculator to address these issues and to further improve the calculator. The revised Livingston Paediatric Dose Calculator should now be available on the EMJ website (http://emj.bmj.com/supplemental) under 3rd revision (LP...
Reply to confusion of Rupture and Dissection
We thank Dr Reid for his comments regarding the above paper. The case described related to a seventy-three year old gentleman who was found sitting at the wheel of his car in a collapsed state with a left-sided hemiplegia. The patient was found to regain full power of his left side when laid flat. This postural alteration in his neurological symptoms was the point o...
We agree that the diagnosis of septic arthritis in the operating room is vulnerable to subjective intrepretation. There was one patient in our study whose diagnosis of septic arthritis was made based on operative findings alone (i.e. without a positive arthrocentesis culture). The operative findings were described as "pus", and we believe that supports the diagnosis of septic arthritis. The patient had been on a c...
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