eLetters

41 e-Letters

published between 2017 and 2020

  • Triage portals in to A&E departments

    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...

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  • Public and Political Influence on Frontline Practice

    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...

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  • Erratum in Article Citations Noted on July 13, 2020

    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.).

  • Glucose as an additional parameter to National Early Warning Score (NEWS) in prehospital setting enhances identification of patients at risk of death: an observational cohort study.

    Dear 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)
    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...

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  • Behind the scenes of COVID-19- Thoughts about illicit drug use during a pandemic

    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...

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  • Sustainable models of rostering for COVID19 crisis

    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.

  • NEWS used without clinical judgement is of limited value

    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...

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  • Overdiagnosis and typicality of symptoms in suspected myocardial infarction

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

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  • Drowning is neither near nor far, it just is

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

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

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  • Improving Major Incident Preparedness

    Dear Editor,

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

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

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

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

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