The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are...
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are you going to orchestrate daily life during lockdown? Although drug dealers are not exempt from social isolation, they are unlikely to have their usual presence on the street and drug-seeking may be more difficult. With international travel currently limited there is likely to have been adaptations to the mechanisms via which drugs are acquired and sold. Smaller drug packages are likely to be on offer to maintain transactions, especially to those who have lost usual sources of income. To address shortages of supply there may be more ‘cutting’ of active substance with other substances, potentially with toxic side-effects. These factors are likely to end up being the most detrimental to a vulnerable end-user.
Perhaps the paucity of supply of the usual drug abused by an individual forces them towards different, more easily available substances to which they go on to become addicted to. For those who have become addicted to prescribed medication, the cost of obtaining such drugs is likely to have sky rocketed.
Conversely, this scenario of desperation may not be replicated in those whom partake only in occasional recreational drug use. Staying at home may cause a decrease in social drug use from lack of opportunities to see friends, bans on festivals and parties, closure of nightclubs or because an individual is at home with their family. The rising use of video-based social gatherings could, however, trigger increasing drug use.
This complete disruption to normal life, however, could prove an opportunity for periods of abstinence and detox. There is an increased presence of information upon social media platforms reaching out to patients who may be suffering with drug addiction during this time. Many habitual drug users who are previously homeless have been accommodated in hotels, paid for by local councils, to protect them during COVID-19 pandemic (2). This has given many a well-needed source of stability with the opportunity to recuperate and achieve positive lifestyle changes. Community drug project workers have had an active presence in such hotels providing socially-distanced needle-exchange programmes, opiate substitute therapy, community naloxone provision and nursing staff to monitor those symptomatic of COVID.
This change in social circumstance may also have contributed to 56.6% fewer attendances to Emergency Departments (ED) in April 2020 compared to the same month in 2019 (3). High Intensity Users (HIUs), those whom attend ED more than five times per year, make up a significant proportion of this case load (4). Drug-related HIU attendances are likely are likely to have fallen in line with other non-COVID presenting complaints.
If analysis of current statistics proves a reduction in ED attendances related to drug use, including overdose, withdrawal, changes to mental health and death from drug toxicity, then there could be more evidence to increase funding and provision of services to this cohort of the population. And if that is the case, at least there is one small positive found at the end of the NHS rainbow.
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Traditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released from fire, had their glycemia levels determined in a prehospital setting, an issue which we consider can really be improved. For all these reasons, we have recently proposed that the determination of glycemia in poisoned patients should be routine, being included in the panel of indicators of healthcare quality of these patients(9), which reinforces the conclusion of Vihonen et al.
References
1. Vihonen H, Lääperi M, Kuisma M, Pirneskoski J, Nurmi J. Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study. Emerg Med J. 2020; 37:286-92.
2. Kievlan DR, Martin-Gill C, Kahn JM, Callaway CW, Yealy DM, Angus DC, et al. External validation of a prehospital risk score for critical illness. Crit Care. 2016; 20:255-61.
3. Lane DJ, Wunsch H, Saskin R, et al. Assessing Severity of Illness in Patients Transported to Hospital by Paramedics: External Validation of 3 Prognostic Scores. Prehosp Emerg Care. 2020; 24:273‐81.
4. Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018; 132:101-11.
5. Amrein K, Kachel N, Fries H, Hovorka R, Pieber TR, Plank J, et al. Glucose control in intensive care: usability, efficacy and safety of SpaceGlucose Control in two medical European intensive care units. BMC Endocr Disord. 2014; 14: 62.
6. Erickson TB, Thompson TM, Lu JL. The approach to the patient with an unknown overdose. Emerg Med Clin N Am. 2007; 25: 249-81.
7. Moon JM, Chun BJ, Cho YS. Hyperglycemia at presentation is associated with in hospital mortality in non-diabetic patient with organophosphate poisoning. Clin Toxicol. 2016; 54:252‐8.
8. Sharma A, Balasubramanian P, Gill KD, Bhalla A. Prognostic Significance of Blood Glucose Levels and Alterations Among Patients with Aluminium Phosphide Poisoning. Sultan Qaboos Univ Med J. 2018; 18: e299‐e303.
9. Ferrés-Padró V, Amigó-Tadín M, Puiguriguer-Ferrando J, Nogué-Xarau S. Proposal for a new quality indicator for care of patients with acute poisoning. JHQR. 2020. (In press) JHQR-D-19-00203R1.
This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli infection. Clinical staff reacted to the change with a mixture of concern and mistrust, referencing the ever-changing advice from government sources and the differences in practices across trusts.
This pandemic has led to an unprecedented change to the dissemination of scientific information. In usual times, it is expected that evidence-based medicine (EBM) forms the pillar from which clinical practice is developed. The channels in which this information is delivered are well-established and validated through peer-review, as the authors note. The vast public interest and vested political interest in the outcomes and development of the pandemic has led to more scientific information being shared on public platforms.
With this in mind, I propose to the authors an addition to their fourth solution: “design studies for deployment in future pandemics and place them in a ‘hibernated state’ such that the future research infrastructure is in place prior to requirement”1. I suggest the implementation of internal trust structures for the dissemination of up-to-date EBM and resulting changes to clinical practices and policies. This may be in the format of daily or weekly briefings, perhaps through trust intranet services or via a specified research guardian dedicated to the communication of EBM to staff.
The authors have proposed detailed suggestions as to how EBM should be upheld during the COVID-19, and future, pandemics. I caution the need to maintain and uphold channels for communicating such evidence, particularly when social media, news outlets and politicians proliferate information at a speed greater than traditional avenues for the dissemination of research.
References
1. Carley S, Horner D, Body R, et al Evidence-based medicine and COVID-19: what to believe and when to change. Emergency Medicine Journal Published Online First: 10 July 2020. doi: 10.1136/emermed-2020-210098
2. Rome BN, Avorn J. Drug evaluation during the Covid-19 pandemic. N Engl J Med 2020;382:2282 doi:10.1056/NEJMp2009457 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32289216
3. COVID-19 personal protective equipment (PPE) [Internet]. GOV.UK. 2020 [cited 6 August 2020]. Available from: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infec...
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
What this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
.
I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial decisions on decisions to pick up patients from homes or to leave them to be attended by 'hospital at home' services (including mental health crisis / street triage).
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an already extremely busy system, if those patients require acute attention it is important that they are appropriately referred. Similarly, there may be a number of patients with NEWS<5 who were unnecessarily referred to hospital; without outcomes data, conclusions about appropriateness of referrals cannot be drawn. In addition, in the West of England, where NEWS is used by GPs, admissions did not increase at any greater rate than elsewhere (3).
It is also suggested in the paper that a NEWS cut off of <5 could be used to reduce ‘low acuity admissions’; however, it is often appropriate to admit a patient irrespective of NEWS, for example someone with a stroke or crushing central chest pain. The Royal College of Physicians is clear that ‘NEWS should be used as an aid to clinical assessment- it is not a substitute for competent clinical judgement’ (4). Using NEWS promotes a full assessment of the patient and, if used at referral, is also a useful communication tool which helps the receiving hospital to recognise the patients that are deteriorating in the time frame between referral and arrival.
GPs have to make important and challenging decisions in a short time frame and formal actions should not be ascribed to NEWS in the community but instead there should be increased awareness that the higher the NEWS the more likely the patient is to be sick. Before NEWS, GPs would admit a patient and highlight the most extreme observations; perhaps the learning from this analysis could be that simply measuring observations is of limited value in identifying who needs admission and the aggregate nature of NEWS is better suited to identifying potential deterioration than high scores for a single vital sign(5).
1. Scott LJ, Redmond NM, Garrett J, et al. Distributions of the National Early Warning Score (NEWS) across a healthcare system following a large-scale roll-out. Emergency Medicine Journal 2019; 36:287-292.
2. Scott LJ, Redmond NM, Tavaré A, et al. National Early Warning Scores in primary care are associated with clinical outcomes. BJGP 2020, In press.
3. Pullyblank A, Tavaré A, Little H, et al System Wide Implementation of the National Early Warning Score Reduces Mortality in Patients with Suspicion of Sepsis. BJGP 2020, In press.
4. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. London: RCP, 2017.
5. Jarvis S, Kovacs C, Briggs J, et al. Aggregate National Early Warning Score (NEWS) values are more important than high scores for a single vital signs parameter for discriminating the risk of adverse outcomes. Resuscitation 2015, Volume 87, 75 – 80.
The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
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...
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 Best Practice on drowning was written by members of the International Drowning Researchers' Alliance, and includes a review of nomenclature. Additionally, readers are invited to visit https://bit.ly/2PgUgD2, which includes an evidence-based post regarding the frequent use of the out-dated term "dry drowning" in the media.
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...
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 dilatation, pericardial effusion or tamponade, and aortic valve regurgitation, warranting urgent definitive aortic imaging or transfer to expert centres(9). In particular, in the latter study "integration of[focused TTE] with D-dimer provided an exceptionally safe and fairly efficient rule-out criterion for AAS(acute aortic syndrome"(9).
I have no funding and no conflict of interest
References
(1) Greenslade JH., Sieben N., Parsonage WA
Factors influencing physicians' estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
EMJ 2020;37:2-7
(2) Swan D., Hitchen S., Klok FA., Thachill J
The problem of underdiagnosis and overdiagnosis of pulmonary embolism
Thrombosis Research 2019;177:122-129
(3) Gimenez MR., Reiter M., Twerenbold R et al
Sex-specific chest pain characteristics in early diagnosis of acute myocardial infarction
JAMA Internal Medicine 2014;174:241-249
(4) Kukla P., Diugopolski R., Krupa E et al
How often pulmonary embolism mimics acute coronary syndrome?
Kardiologia Polska 2011;69:235-240
(5) Sandoval Y., Thgesen K
Myocardial infarction Type 2 and myocardial injury
Clinical Chemistry 2017;63:101-107
(6) Villablanca PA., Vlismas PP., Aleksandrovich T et al
Case report and systematic review of pulmonary embolism mimicking ST segment elevation myocardial infarction
Vascular 2019;27:90-97
(7) Amjad A., Ali A., Bashir A et al
Chest pain with raised troponin, ECG changes bu normal coronary arteries
BMJ case Reports 2014;doi:10.1136/bcr-2013-201975
(8) Yen K-H., Chang H-C
Massive pulmonary embolism with anterolateral ST segment elevation: electrocardiogram limitations and role of echocardiogram
Am J Emerg Med 2008;26:632.e1-632.e3
(9)Nazerian P., Mueller C., Vanni S et al
Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes
Eur Heart J 2019;40:1952-1960
PS please ignore my previous Rapid Response. This one is the definitive version
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...
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 protocol as well as intranet based guidance; and a series of handover presentations.
From baseline to final collection, more staff in the ED were able to correctly define a major incident (58% to 94%); understand the role of major incident protocol (58% to 100%) as well as correctly locate the protocol quickly (63% to 100%). These interventions demonstrate how simple QI initiatives can significantly improve awareness, knowledge and understanding, for negligible cost.
As part of additional data we collected, we surveyed staff attitudes towards the importance of understanding major incident protocol as well as the number who had received formal training in major incidents. Only 67% had received formal training, and the format of this was variable. Some training was delivered at trust induction, some had attended simulation and disaster management courses.
We strongly endorse your recommendations to improve knowledge of major incident protocol, especially through the use of simulation and induction action cards as well as using virtual reality and other technology. Our cost effective interventions, and targeting of all stakeholders in the department would help to improve basic understanding of the need for and the role of the MIP, and would encourage staff to improve major incident protocol knowledge and event preparedness.
Reference: Mawhinney JA, Roscoe HW, Stannard GAJ, et al Preparation for the next major incident: are we ready? A 12-year update. Emergency Medicine Journal Published Online First: 12 August 2019
The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.
The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).
One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.
If your first thought upon waking is how you are going to obtain your next fix, then how are...
Show MoreDear Editor,
We have read with great interest the article by Vihonen et al, ‘Glucose as an additional parameter to National Early Warning Score in prehospital setting enhances identification of patients at risk of death: an observational cohort study’, recently published in your journal.(1)
Show MoreTraditionally, the scores published to assess the risk of mortality in patients attended in a prehospital setting, the predictive value of which had been questioned until recent studies, did not include the quantification of glycemia among the parameters analysed in the initial assessment of the patient.(2-4)
Overlooking its systematic determination in the initial care of any critically ill patient represents an easily avoidable risk, due to its accessibility and to the ease in interpreting results in any setting. This shortcoming is especially relevant in the initial care of patients with acute poisoning, due to the limitations of the anamnesis and the need to establish a rapid and reliable differential diagnosis in patients with often complex and plural clinical symptoms.(5,6) In this regard, the prognostic value of glycemia as a biomarker in some acute, highly lethal levels of poisoning must also be taken into account.(7,8)
In Catalonia, two studies undertaken by the Prehospital Medical Emergency Service in recent years have shown that only 30.1% of those poisoned by caustic products or 15.2% of the 1,930 people poisoned by carbon monoxide or smoke released f...
This article draws its evidence from two citations, one by Madsen et al., and the other from a systematic review, which has been mis-cited as a duplicate of the Madsen reference. The correct citation to the systematic review is not Madsen et al., but Tarnutzer et al., PubMed ID 28356464 (Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017;88(15):1468-1477. doi:10.1212/WNL.0000000000003814.).
Dear Editor,
I read with interest the recent article by Carley et al., “Evidence-based medicine and COVID-19: what to believe and when to change”1. The authors pay homage to the challenges of keeping pace with a pandemic growing at unprecedented speeds, forcing the hand of clinicians to make therapeutic decisions on the basis of weak, often unvalidated evidence. They also note the influence of political opinion, referencing Donald Trump’s infamous declaration on the efficacy of hydroxychloroquine as a treatment for COVID-192. In their concluding statements, the authors eloquently present the need to follow science rather than emotions or politics.
Having worked in a large critical care unit over the pandemic, I question how easy this is in practice. Clinicians, nurses and Allied Health Professionals do not exist in a vacuum, but rather their opinions and knowledge are inevitably shaped by social and cultural rhetoric. I use the example of Personal Protective Equipment (PPE), an acronym once reserved to select professions yet now colloquially used by the lay person. Information regarding the appropriate PPE to be worn was disseminated in multiple formats, from news broadcasts to social media platforms such as Twitter. As knowledge developed about how the SARS-COV-2 virus was transmitted, recommendations on PPE changed accordingly. As of July 23rd, it was recommended that double gloving was not necessary3, and in fact increased the risk of transmitting e-coli...
Show MoreWhat this proposed reset does not describe is a reorganisation of 'at the door' triage based on the type of presentation.
The need for effective patient throughput (patient flow); the major problem in contemporary A&E (at least pre Covid19) has not been addressed.
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I propose triaging 'at the door' carried out by nurse practitioners (assisted by paramedic crews bringing patients in) and admin staff to access medical information rapidly (for example via the Great North Care Record). These insights were gained from camp Bastion in Afghanistan.
There should be 4 key portals and pathways thereafter.
a) The seriously ill (Major Trauma, Sepsis, Stroke, Cardiac Infarcts, Acute Abdomens etc.)
b) Cases of frailty (mainly elderly people, including delirium / dementia, minor trauma)
c) mental Health presentations (of all ages, including learning disability)
d) overspill from General Practice
These pathways would be staffed by specialist nurse practitioners, pharmacists and speciality doctors, working on prearranged algorithms with electronic prescribing and discharge / handover templates (ideally in a SBAR format) to assist patient flow. cross referral (called scaffolding in mental health) should be possible on occasion. Overall, a duty matron should keep overall control of activity through an electronic dashboard. Paramedic / ambulance crews should have access to this matron remotely to make crucial d...
Show MoreFinnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.
The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.
Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.
The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...
Show MoreThe courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.
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...
Show MoreBoth 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...
Show MoreDear 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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