We have read the original contribution by Sutcu Cicek et al. [1] with
high interest regarding the effect of nail polish and henna on pulse
oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is
interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not pro...
We have read the original contribution by Sutcu Cicek et al. [1] with
high interest regarding the effect of nail polish and henna on pulse
oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is
interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven that nail polish
effects the accuracy of pulse oximeters [1]. However, several randomized,
controlled trials with both healthy persons and critically ill patients
report on the effect of nail polish on oxygen saturation measured by pulse
oximetry [2, 3, 4]. Interestingly, some of these studies have been cited
by the authors themselves.
Sample size calculation prior to beginning of a trial is obligate to
determine the significance of results. Unfortunately, in this trial an
adequate mathematical sample size calculation was obviously waived.
Therefore, results of the present study cannot be interpreted regarding
both the statistical significance and the clinical relevance.
To determine pulse oximetry accuracy, intermittent arterial blood gas
analyses (ABGA) are essential [3]. However, accuracy in the present study
was only determined by consecutive pulse oximeter measurements over a
specific duration, which may alter pulse oximetry readings. A major
limitation of the present study is that accuracy is not analyzed in the
present study although it is most important in patients who have nail
polish applied, e.g. to identify hypoxia. The authors only report on mean
values (given in percent) but omit to verify their measurements, e.g. with
ABGA. Additionally, the presented results also lack standard deviation
(SD). Independently, one may assume that the presented differences (max.
1,25%) are not clinically relevant, which is in congruency to other
publications [2, 3, 4].
In the present trial one may therefore speculate the differences
identified might be due to slightly alternating oxygen saturation values
in spontaneously breathing persons.
In conclusion, the present study does not add significant new data for
nail polish to the present knowledge.
References:
[1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E,
Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen
saturation determined by pulse oximetry in healthy young adult females.
Emerg Med J. 2010 Oct 5. [Epub ahead of print]
[2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail
polish on pulse oximetry. Anesth Analg 1988;67:683
[3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail
polish on oxygen saturation determined by pulse oximetry in critically ill
patients. Resuscitation. 2007 Jan;72(1):82-91
[4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish
affect pulse oximeter readings? Intensive Crit Care Nurs. 2007
Feb;23(1):51-5.
I read, with considerable interest, your case history of a 21 year
old man who was stabbed in his buttock and went on to suffer a
hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting
transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes
of physiology to your Emergency Department his outcome wo...
I read, with considerable interest, your case history of a 21 year
old man who was stabbed in his buttock and went on to suffer a
hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting
transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes
of physiology to your Emergency Department his outcome would have been
worthy of a case report. However, it appears that he presented with no
more than cryptogenic shock (Hb 7.1) at worst (though there is no mention
of a FAST and IVC assessment being carried out) and one might argue that
prompt and aggressive damage control resuscitation with urgent surgery
would have avoided a cardiac arrest, rhabdomyolysis, ionotropic support,
hospital acquired pneumonia and a prolonged ITU stay.
Quite why the patient was moved to the emergency unit ward is not
clear but you do document that after two hours whilst still awaiting
transfusion he arrested and promptly went on to receive a hypothermia
inducing 4 litres of gelofusin to compound his already dysfunctional
clotting mechanism.
His age and physiological reserve saved his life - this phenomenon is
nothing new.
I am stunned that in these days of centralisation of trauma services
post the damning NCEPOD and NAO reports1 2 as well as the emphasis being
placed placed on trauma care nationally, cases such as these still occur
in our Emergency Departments. More concerning is that 'our' journal sees
fit to publish such horrors that would constitute a SUI in many
establishments.
The case highlights that the human body does have the ability to
survive critical physiological insult - it does not mean we should allow
our patients to reach these limits if there is no requirement to do so.
Major HJ Pynn RAMC
ST5 Emergency Medicine
1 Trauma. Who Cares? National Confidential Enquiry into Patient
Outcome and Death 2007.
2 Major Trauma Care in England. National Audit Office. Feb 2010.
The principle of 'primum non nocere' stems from the ancient world of
Plato. In the 'real' world it is immpossible to act without doing harm. An
examination or treatment takes always some time and money from the
patient. Taking time and money is the minimum harm that is done. In many
cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first
sight a better and more realistic...
The principle of 'primum non nocere' stems from the ancient world of
Plato. In the 'real' world it is immpossible to act without doing harm. An
examination or treatment takes always some time and money from the
patient. Taking time and money is the minimum harm that is done. In many
cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first
sight a better and more realistic principle but unfortunately what is
'more good than harm' cannot be easily defined. Indeed, what is considered
as more good than harm differs from individual to individual, from time to
time, from society to society.
A diagnosis is not only a matter of knowing. The more that is known
the more correct diagnoses will be made, but for an individual diagnosis
it is ultimately a decision based on less or more firm knowledge, not on
certainty. Who has the right (or the duty) to decide where uncertainty is
the rule? Perhaps it is (partly) dependent on the circumstances. For many
it will seem to be the first right of the well informed patient since
he/she will suffer from the potential harms or profit from the potential
benefits of the treatment. But even if this principle should be generally
accepted there is often lack of time in urgent situations to inform the
patient or the patient is not in the possibility to understand the
information. Moreover the government and/or insurance companies too will
influence the decision by less or more or no reimbursement for
examinations and treatments.
Since it can be assumed that diagnoses are more often accurate with
increasing knowledge it can perhaps be stated that doing more good than
harm can be defined by the duty of making efforts by the individual as
well as by the society to increase knowlegde.
Woollard et al reiterate the view that many of us have for some time,
there is no evidence that an 8 minute response target is worthwhile in
itself, that it should be replaced with more clinically orientated
priorities and that it has had unfortunate consequences. It is interesting
to reflect that most other health organisations (whether primary or
secondary care) have significantly increased both the breadth and depth of...
Woollard et al reiterate the view that many of us have for some time,
there is no evidence that an 8 minute response target is worthwhile in
itself, that it should be replaced with more clinically orientated
priorities and that it has had unfortunate consequences. It is interesting
to reflect that most other health organisations (whether primary or
secondary care) have significantly increased both the breadth and depth of
the skill mix of clinical staff over recent years and that ambulance trust
policies of employing large numbers of emergency care practitioners with
three weeks clinical training runs counter to the approach of other parts
of the health economy and most importantly makes little or no sense. By
design such personnel are not in a position to be able to make an overall
clinical assessment and take responsibility for decisions with the
consequence that patients in virtually all cases are transported to a
hospital emergency department. At a time when the NHS is struggling to
meet demand and contain financial pressures and where the solution is to
guide patients (where appropriate) to more suitable and cost effective
community health services (including general practice), ambulance trusts
need to be concentrating on increasing significantly the breadth and depth
of clinical decision making (likely to include nursing and medical
disciplines) rather than employing personnel with limited training and
rushing to "stop the clock".
As many colleagues have said to me (once they have understood the
level of training of an emergency care assistant), if they became unwell,
they would prefer to be seen by a health professional who had undergone
significant training and who could undertake relevant treatments at 8
minutes and one second than an individual with a very limited skill mix at
7 minutes 59 seconds! Probably just as important is that those who develop
policy, is to consider the effects upon the overall health economy as
there are large interdependencies between organisations with the risk that
there are unexpected and often expensive clinical and financial
consequences.
Conflict of Interest:
NHS Worcestershire is involved with commissioning ambulance services in the West Midlands. The author responds in a voluntary capacity for West Midlands Ambulance Service
I thank the authors for an interesting article.
The article states that none of the other 13 GP co-ops are located on
hospital grounds close to an ED. This is factually incorrect. The North
East Doctor on call service has 2 co-located sites on hospital grounds,
Cavan and Navan. In the case of the Cavan centre the GPs are located in
the hospital building. In Navan, the site is on the hospital grounds. In
both cases, unlik...
I thank the authors for an interesting article.
The article states that none of the other 13 GP co-ops are located on
hospital grounds close to an ED. This is factually incorrect. The North
East Doctor on call service has 2 co-located sites on hospital grounds,
Cavan and Navan. In the case of the Cavan centre the GPs are located in
the hospital building. In Navan, the site is on the hospital grounds. In
both cases, unlike DubDoc, the service extends from 6pm to 8am and both
day and night at weekends and public holidays.
Moratalla describes a case of posterior reversible encephalopathy
syndrome (PRES) in a female patient after delivery.1 We feel concerned
about the accuracy of his diagnosis.
PRES (also termed reversible posterior leukoencephalopathy syndrome)
represents a clinical and radiological disease entity characterized by
reversible vasogenic oedema in the brain, which primarily results from
autoregulation failure and endothelial...
Moratalla describes a case of posterior reversible encephalopathy
syndrome (PRES) in a female patient after delivery.1 We feel concerned
about the accuracy of his diagnosis.
PRES (also termed reversible posterior leukoencephalopathy syndrome)
represents a clinical and radiological disease entity characterized by
reversible vasogenic oedema in the brain, which primarily results from
autoregulation failure and endothelial dysfunction.2 The reversibility of
vasogenic oedema, as most specifically and sensitively detected by
diffusion-weighted imaging (DWI), especially ADC map, preferably involving
posterior white matter can unambiguously differentiate typical PRES from
differential diagnoses including metabolic encephalopathy, inflammatory
demyelinating diseases, etc. Although atypical cases are not uncommon,2
they should be diagnosed with caution, after prudential exclusion of other
confounding disorders. However, reversibility, not only clinical but
radiological, and vasogenic oedema, as revealed by DWI ADC map, as well as
well-acknowledged risk factors that may predispose to hypertension, such
as phaeochromocytoma, glomerulonephritis, eclampsia and with cytotoxic and
immunosuppressant drugs,2 were not confirmed by clinical and neuroimaging
findings to categorize this case into a typical PRES.
In summary, PRES represents a clinicoradiological syndrome, the diagnosis
of which relies on typical clinical manifestations and neuroimaging
findings.
References
1. Moratalla MB. Posterior reversible encephalopathy syndrome. Emerg Med J
2010;27:547.
2. Sharma M, Kupferman JC, Brosgol Y, et al. The effects of hypertension
on the paediatric brain: a justifiable concern. Lancet Neurol
DOI:10.1016/S1474-4422(10)70167-8
The case Dr. Alzetta describes is similar to the ones I described.
Although these cases are rare in any one location and undocumented
especially after death I believe that taken nationally they are of
significant numbers. The evidence lies in a paper written to discover the
cause of the dramatic increase in asthma deaths in the sixties by Speizer,
Doll et al. They studied all the deaths in England and Wales for six
cons...
The case Dr. Alzetta describes is similar to the ones I described.
Although these cases are rare in any one location and undocumented
especially after death I believe that taken nationally they are of
significant numbers. The evidence lies in a paper written to discover the
cause of the dramatic increase in asthma deaths in the sixties by Speizer,
Doll et al. They studied all the deaths in England and Wales for six
consecutive months using Death Certificates from the Registrar General
from 1st Oct. 1966-31st March 1967 in which asthma was the underlying
cause. They wrote to the doctors and hospitals concerned for full details
of the cases. Most of the cases surprisingly occurred in persons with mild
asthma only
59% had ever been admitted to hospital. Death was sudden and unexpected in
80% of cases. In 25% death occurred in less than one hour and only 29%
survived more than 24 hrs. That death was commonly sudden is confirmed by
the fact that 59% of deaths (109 out of 184) were certified by coroners.
In 39% of cases (67 out of 171) the practitioner had not regarded the
patient as suffering from severe asthma in the terminal episode. This
paper is very important as :
1) it demonstrates the only way that one can collect and study
these cases in any number.
2) It is the only record we have of the numbers of deaths due to asthma
in that era and the dramatic increase at that time. The reason being that
asthma deaths were included with all other types of respiratory diseases
until several years late.
It is very important that this work is repeated today to discover the
prevelance today.
The paper by Harris and Sharma [1] confirms what many emergency
physicians think they know : no beds means no admissions. An automatic
plea for more beds needs to be regarded sceptically.
The authors rightly conclude that "the availability of fully staffed
beds is a major determinant of ED overcrowding".
It is crucial for clinicians as well as planners to realise that
availability does not equate simpl...
The paper by Harris and Sharma [1] confirms what many emergency
physicians think they know : no beds means no admissions. An automatic
plea for more beds needs to be regarded sceptically.
The authors rightly conclude that "the availability of fully staffed
beds is a major determinant of ED overcrowding".
It is crucial for clinicians as well as planners to realise that
availability does not equate simply with numbers. Less could mean more in
terms of effect!
Effective bed capacity is a function of length of patient stay as
well as crude bed numbers.
In turn, length of stay can be a function of three major factors, two
active at strategic and the third at operational level.
At strategic level, the configuration of resources in community
settings has an arguable impact on their capacity to 'pull' patients out
of in-patient wards. Funders' and planners'distribution of resources and
attention , towards elective versus emergency 'activity', is a second strategic
factor.
The operational factor relates to the intensity with which resources
downstream from the ED are actually utilised. The 5 day/40 hour pattern
of diagnostic sessions, theatre sessions and consultant ward rounds,
characteristic of historical UK practice has fitted ill with the 7 day/168 hour pattern of illness.
The authors' message may be that fewer in-patient beds, more
intensively used, could release resources for more effective deployment :
in our own Emergency Departments if nowhere else.
Nicholas Harrop,
Consultant in Emergency Medicine,
Victoria Hospital,
Blackpool, UK.
Reference
1 Harris A, Sharma A. "Access Block and Overcrowding in emergency
departments: an empirical analysis". Emerg Med J 2010;27:508-511
Editor, I read the recent publication by Mann et al. with a great
interest. Mann et al. concluded that " There is a significant risk of harm
with false-positive diagnoses and potential delays in appropriate
treatment [1]." I agree that there are several problem in diagnosis of
swine flu. Several problems can lead to the failure of using any scoring
system or algorithm for diagnosis [2-3]. On the other hands, although
sev...
Editor, I read the recent publication by Mann et al. with a great
interest. Mann et al. concluded that " There is a significant risk of harm
with false-positive diagnoses and potential delays in appropriate
treatment [1]." I agree that there are several problem in diagnosis of
swine flu. Several problems can lead to the failure of using any scoring
system or algorithm for diagnosis [2-3]. On the other hands, although
several new diagnostic tools can be availble, the problem of false
positive can be seen. How to manage and weight for risk and benefit on
using simple method with possible false negative and new modern tools with
possible high cost and false positive should be the topic to be discussed.
References
1. Mann C, Wood D, Davies P. An evaluation of the UK National
Pandemic Flu Service swine flu algorithm in hospitalised children, and
comparison with the UK National Institute for Health and Clinical
Excellence fever guideline. Emerg Med J. 2010 Sep 3. [Epub ahead of print]
2. Wiwanitkit V. Scoring system for diagnosis of swine flu. Heart Lung.
2010 Jul-Aug;39(4):345-6.
The correct answer to question 2a in the EMQs on magnesium is false,
at least with regard to adults. For children it is probably true. The
evidence cited to support the answer provided is ten years old [1]. Avid
EMJ readers will know that a more recent meta-analysis [2] showed that in
adults there was only weak evidence that intravenous magnesium sulphate
had an effect upon respiratory function (standardised mean differe...
The correct answer to question 2a in the EMQs on magnesium is false,
at least with regard to adults. For children it is probably true. The
evidence cited to support the answer provided is ten years old [1]. Avid
EMJ readers will know that a more recent meta-analysis [2] showed that in
adults there was only weak evidence that intravenous magnesium sulphate
had an effect upon respiratory function (standardised mean difference
0.25, 95% confidence interval (CI) -0.01 to 0.51; p=0.05) and no
significant evidence of an effect on hospital admission (relative risk
0.87, 95% CI 0.70 to 1.08; p=0.22). However, even this latest meta-
analysis is effectively out of date. The 3Mg Trial [3] has so far
recruited over 400 patients and is now the largest trial of magnesium
sulphate in acute asthma. When the 3Mg trial is completed and the results
analysed we will have a definitive answer to this tricky EMQ.
Steve Goodacre
1. Rowe BH, Bretzlaff J, Bourdon C, et al. Magnesium sulphate for
treating exacerbations of acute asthma in the emergency department.
Cochrane Database Syst Rev 2000;(1):CD001490.
doi:10.1002/14651858.CD001490.
2. Mohammed S & Goodacre S. Intravenous and nebulised magnesium
sulphate for acute asthma: systematic review and meta-analysis. Emerg Med
J 2007;24:823-830.
3. The 3Mg Trial, ISRCTN 04417063, http://www.hta.ac.uk/project/1619.asp
To the Editor!
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed. To our surprise, the authors state, it is not pro...
Dear Sirs
I read, with considerable interest, your case history of a 21 year old man who was stabbed in his buttock and went on to suffer a hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes of physiology to your Emergency Department his outcome wo...
The principle of 'primum non nocere' stems from the ancient world of Plato. In the 'real' world it is immpossible to act without doing harm. An examination or treatment takes always some time and money from the patient. Taking time and money is the minimum harm that is done. In many cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first sight a better and more realistic...
Woollard et al reiterate the view that many of us have for some time, there is no evidence that an 8 minute response target is worthwhile in itself, that it should be replaced with more clinically orientated priorities and that it has had unfortunate consequences. It is interesting to reflect that most other health organisations (whether primary or secondary care) have significantly increased both the breadth and depth of...
I thank the authors for an interesting article. The article states that none of the other 13 GP co-ops are located on hospital grounds close to an ED. This is factually incorrect. The North East Doctor on call service has 2 co-located sites on hospital grounds, Cavan and Navan. In the case of the Cavan centre the GPs are located in the hospital building. In Navan, the site is on the hospital grounds. In both cases, unlik...
Moratalla describes a case of posterior reversible encephalopathy syndrome (PRES) in a female patient after delivery.1 We feel concerned about the accuracy of his diagnosis. PRES (also termed reversible posterior leukoencephalopathy syndrome) represents a clinical and radiological disease entity characterized by reversible vasogenic oedema in the brain, which primarily results from autoregulation failure and endothelial...
The case Dr. Alzetta describes is similar to the ones I described. Although these cases are rare in any one location and undocumented especially after death I believe that taken nationally they are of significant numbers. The evidence lies in a paper written to discover the cause of the dramatic increase in asthma deaths in the sixties by Speizer, Doll et al. They studied all the deaths in England and Wales for six cons...
The paper by Harris and Sharma [1] confirms what many emergency physicians think they know : no beds means no admissions. An automatic plea for more beds needs to be regarded sceptically.
The authors rightly conclude that "the availability of fully staffed beds is a major determinant of ED overcrowding".
It is crucial for clinicians as well as planners to realise that availability does not equate simpl...
Editor, I read the recent publication by Mann et al. with a great interest. Mann et al. concluded that " There is a significant risk of harm with false-positive diagnoses and potential delays in appropriate treatment [1]." I agree that there are several problem in diagnosis of swine flu. Several problems can lead to the failure of using any scoring system or algorithm for diagnosis [2-3]. On the other hands, although sev...
The correct answer to question 2a in the EMQs on magnesium is false, at least with regard to adults. For children it is probably true. The evidence cited to support the answer provided is ten years old [1]. Avid EMJ readers will know that a more recent meta-analysis [2] showed that in adults there was only weak evidence that intravenous magnesium sulphate had an effect upon respiratory function (standardised mean differe...
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