851 e-Letters

  • 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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  • Prehospital rapid sequence intubation is not uncommon in unconscious stroke

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

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

    Ultimately we agree with...

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

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

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

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

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

    Disclaimer: JG an...

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