I am curious whether you are able to provide comparable data from
before the introduction of the Standard Operating Procedure (SOP)
discussed here. Does the data gathered demonstrate an improvement in
complication rates during pre-hospital anaesthesia compared with data from
before the introduction of the SOP? In addition, did you analyse data
regarding complications apart...
I am curious whether you are able to provide comparable data from
before the introduction of the Standard Operating Procedure (SOP)
discussed here. Does the data gathered demonstrate an improvement in
complication rates during pre-hospital anaesthesia compared with data from
before the introduction of the SOP? In addition, did you analyse data
regarding complications apart from failure to intubate?
You also indicate that intubations were undertaken by registrars,
consultants and general practitioners. I am curious whether all
intubations were undertaken by the physician member of the team or if any
were carried out by the flight paramedic? Does your SOP preclude
paramedic performed intubation in cases of prehospital anaesthesia?
First, we would like to emphasize the importance of the study
published in the EMJ1 and similar studies based in emergency departments,
since they provide valuable information on prevalence, trends, and
emergence of new drugs of abuse, which produces epidemiological data to
support public policies. However, we believe there are some additional
considerations regarding the work by Horyniak and colleagues that should
be m...
First, we would like to emphasize the importance of the study
published in the EMJ1 and similar studies based in emergency departments,
since they provide valuable information on prevalence, trends, and
emergence of new drugs of abuse, which produces epidemiological data to
support public policies. However, we believe there are some additional
considerations regarding the work by Horyniak and colleagues that should
be mentioned.
Our main concern regards the use of methods to identify and
unequivocally confirm the compounds that were used by patients. Trust only
on the results of questionnaires is questionable, since sometimes the user
unknown which drugs he consumed. Several emergency departments worldwide
use analytical separation methods (e.g., chromatography or capillary
electrophoresis) coupled to a mass spectrometer to analyze their patient
samples for drugs and poisons. In this way, the results provide
qualitative and quantitative information on the compounds in several
biological matrices (e.g., urine, plasma or serum). The piperazines and
their analogues represent a class of drugs of abuse with strong similarity
of effects to ecstasy2, therefore reinforcing the importance of
unambiguous confirmation of the drug.
Recently, a group of so called "rape drugs" has been a target for
police. Date rape drugs often have sedative, hypnotic, and/or amnesiac
effects, which can be potentiated when combined with alcohol, and they can
be added to food or drink, without the victim's knowledge, to assist in
the execution of sexual assault crimes. Among the major drugs used for
this are: mephedrone, GHB, ketamine, and benzodiazepines3. We also
emphasize that, of the poisoning cases forwarded to the hospital in this
study, female patients were significantly younger than male patients.
Finally, we suggested that the comparison between rape drugs and
amphetamine compounds would be done differently, since the first aims to
produce depressant effects and the second, stimulants effects.
Daniel Polesel, Sergio Tufik and Monica Andersen
References
1) Horyniak D, Degenhardt L, Smit DV, Munir V, Johnston J, Fry C,
Dietze P. Pattern and characteristics of ecstasy and related drug (ERD)
presentations at two hospital emergency departments, Melbourne, Australia,
2008-2010. Emerg Med J doi:10.1136/emermed-2012-202174
2) Tancer M, Johanson CE. The subjective effects of MDMA and mCPP in
moderate MDMA users. Drug Alcohol Dependence 2001;65:97-101.
3) Ness A, Payne J. Patterns of mephedrone, GHB, Ketamine and
Rohypnol use among police detainees: Findings from the DUMA program,
Australian Institute of Criminology, Research in Practice: DUMA Quarterly
Report 2011;16:1-6. Available at:
<http://www.aic.gov.au/documents/0/6/0/%7B0605DBE8-C4C4-46C6-807E-
042F849D1826%7Drip16_003.pdf>.
Thank you for sharing your method for remembering the Sepsis Six.
Being terrible at remembering anything, I developed a method which
required me to only remember three things. As long as I remember that for
each thing you put "in" to the patient, you take something "out".
So, for each thing I put in, something related comes out; Fluids in
(Urine out), Antibiotics in (Cultures out) & Oxygen in (ABG o...
Thank you for sharing your method for remembering the Sepsis Six.
Being terrible at remembering anything, I developed a method which
required me to only remember three things. As long as I remember that for
each thing you put "in" to the patient, you take something "out".
So, for each thing I put in, something related comes out; Fluids in
(Urine out), Antibiotics in (Cultures out) & Oxygen in (ABG out).
There is no doubt that emailing has revolutionised communication in
the past 10-15 years and the number of messages received daily (both
during working and non-working hours) will be seen as a nightmare by most
NHS workers.
We need to urgently adopt a pragmatic change in the way we deal with
the vast amount emails we get inundated with.
With the rise of smart phones, work emails can often be checked o...
There is no doubt that emailing has revolutionised communication in
the past 10-15 years and the number of messages received daily (both
during working and non-working hours) will be seen as a nightmare by most
NHS workers.
We need to urgently adopt a pragmatic change in the way we deal with
the vast amount emails we get inundated with.
With the rise of smart phones, work emails can often be checked on
the move (on the train, in the street, on the corridor) and non-important
or irrelevant emails can be dealt with immediately.
Social media undoubtedly will have a key role in knowledge
dissemination in the next few years. Links, meetings can be posted easily
on a closed Twitter account and accessed by those who have an interest in
it rather than bombarding everyone with emails that are often outside of
our area of practice or interest.
Skype phone conferences often can replace the often difficult to
arrange face-to-face meetings.
The above obviously beg the questions of confidentiality and data
protection but this is another debate...
There is almost a natural resistance from medical professionals to
embrace modern technologies but the internet (and emails) is here to stay!
We need to deal with it before the apocalyptic vision set in the
Terminator films (where the machines dominate the humans) becomes a
reality!
Conflict of Interest:
Janos P Baombe is a Consultant in EM with a special interest in social media and education
We read with interest the article by Bruijns et al. comparing the
relationship between heart rate (HR) and systolic blood pressure (SBP) in
non-haemorrhagic, minimally injured patients with that of a non-injured
control group.1 There was a statistically significant difference between
the groups for both HR and SBP (p<0.001), demonstrating that as far as
mild to moderate injury is concerned, HR tends to be higher than...
We read with interest the article by Bruijns et al. comparing the
relationship between heart rate (HR) and systolic blood pressure (SBP) in
non-haemorrhagic, minimally injured patients with that of a non-injured
control group.1 There was a statistically significant difference between
the groups for both HR and SBP (p<0.001), demonstrating that as far as
mild to moderate injury is concerned, HR tends to be higher than that
expected in an uninjured person, mainly due to the white coat effect
(WCE). We totally agree with the authors when they stated that changes
seen in the vital signs of patients with injuries have complex mechanisms
and include haemorrhage, injury, fear and pain. However, changes in vital
signs such as HR and SBP can be analysed not only independently, but also
calculated together in the Shock Index (SI). SI (calculated as HR/ SBP;
normal range, 0.5-0.7) may be useful to evaluate acute critical illness in
the emergency department. In a cohort of 275 consecutive adults who
presented for urgent medical care, Rady et al found that with apparently
stable vital signs, an abnormal elevation of the SI to > 0.9 was
associated with an illness that was treated immediately, admission to the
hospital, and intensive therapy on admission.2 Compared with HR or SBP
alone, SI has been suggested to be a better measure of hemodynamic
stability.3 Finally, other studies have confirmed the usefulness of the SI
as an indicator of clinical instability.4
To conclude, we wonder if, the changes observed in the vital signs in
patients with a non-haemorrhagic injury lead to significant changes in SI
and if the authors could precise their opinion regarding the potential
relationship between SI changes and the WCE.
1. Bruijns SR, Guly HR, Bouamra O, Lecky F, et al. Heart rate and
systolic blood pressure in patients with minor to moderate, non-
haemorrhagic injury versus normal controls. Emerg Med J 2012;0:1-5. [Epub
ahead of print]
2. Rady MY, Smithline H, Blake H, et al. A comparison of the shock
index and conventional vital signs to identify acute critical illness in
the emergency ?department. Ann Emerg Med 1994;24:685-90.
3. Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying risk for
massive transfusion in the relatively normotensive patient: utility of the
prehospital shock index. J Trauma 2011;70:384-8.
4. Birkhahn RH, Gaeta TJ, Terry D, et al. Shock index in diagnosing
early acute hypovolemia. Am J Emerg Med 2005;23:323-6.
I am glad to see Eye
Know How featured in the Emergency Medicine Journal. As someone who has worked in accident and
emergency and now a starter in the ophthalmology world, this book has proved
invaluable. I feel the need to reiterate
the symptom led approach highlighted in this b...
I am glad to see Eye
Know How featured in the Emergency Medicine Journal. As someone who has worked in accident and
emergency and now a starter in the ophthalmology world, this book has proved
invaluable. I feel the need to reiterate
the symptom led approach highlighted in this book review, as it underpins its great
practicality and close correlation to real life practice in the emergency
department. Two books (ref. below) take
a similar approach and I feel they would be of use to the A+E trainee.
The Handbook of
Ophthalmic Emergencies.G Jayamanne (2005). UK: Firstcourse-Medical LLP. ISBN: 0-9544365-1-2
Fast
Facts: Ophthalmology.A Pane, P Simcock (2006). UK: Health Press Ltd. ISBN: 1-903734-64-9
There is no excuse, even for the busy A+E doctor, to not
find the time to read these two little books. Both books illustrate almost
every diagnosis with colour photos in contrast to Eye Know How. Unfortunately the poor photo quality in The Handbook of Ophthalmic Emergencies underappreciates
finer pathologies such as dendritic ulcers. Fast Facts: Ophthalmology is
more intuitively structured with stricter organisation by symptoms per chapter. This book usefully addresses the need for
urgent referral with simple checklists throughout its content. Jayamanne's differential
diagnoses section in the introductory chapter is a very useful no frills reference
which can be read quickly during a busy A+E shift.
Both books, similar to Eye Know How, seem to be based on the authors experience with no reference
to evidence. Jayamanne does not address ophthalmic history
taking and his section on ocular examination could benefit from more detail
such as how to test for a RAPD.
These two books are inexpensive and practical because of
their symptom orientated approach. They
are certainly not comprehensive, with Eye
Know How being bigger than both of them. This makes Fast Facts:
Ophthalmology and The Handbook of Ophthalmic
Emergencies useful in the early stages of A+E training when there is a
competing need to learn the relevant topics of other specialities in a short
time. Out of the two shorter texts I
would recommend Fast Facts: Ophthalmology
because of its more structured layout. This should be the only text needed amongst those trainees rotating
through A+E for a short while.
I am a specialty registrar in Emergency Medicine presently working at
CrossHouse Hospital, Kilmarnock, Scotland.
I have prepared a mnemonic to help remember the sepsis six bundle
which I thought, I might share it with you.
"Give 3, Take 2 and Monitor 1"
Give 3 ( Oxygen + IV fluids + Antibiotics)
Take 2 ( Blood Cultures + Hb/Lactate)
Monitor 1 ( urine output)
I have found the use of this mnemonic extreemly useful when I am
teaching my junior colleagues about the Sepsis Six Bundle and this seems
to retain in their minds when managing patients
We would like to thank Brooks Walsh for his comments and agree that
it is important to understand the rich and mostly ignored perspectives of
prehospital clinicians and their patients.
Whilst it is true that patients were drawing upon a singular concrete
experience they usually reported this in the context of their broader
experiences and expectations of interactions with health services.
Similarly, although cl...
We would like to thank Brooks Walsh for his comments and agree that
it is important to understand the rich and mostly ignored perspectives of
prehospital clinicians and their patients.
Whilst it is true that patients were drawing upon a singular concrete
experience they usually reported this in the context of their broader
experiences and expectations of interactions with health services.
Similarly, although clinicians were drawing upon a range of experiences
during the interview process, they often related this to individual
experiences of care. The difference in patient and clinicians experience
is inevitable, i.e. patients (usually) access prehospital services on rare
occasions whereas for prehospital clinicians this is the 'bread-and-
butter' of their work.
We wanted to provide detailed descriptions of their personalised
individual recollections and views, but we also wanted to draw on
clinicians' wider experiences of care which they had provided to many
patients over a period of time.
The quotation on page 2 of the article is indicative that
practitioners reflected on actual past experience rather than simply
offering generalised beliefs or opinions:
If you get somebody who's had like, like a massive stroke I
think the care, obviously you're giving them the oxygen and
things like that and sometimes I think my lack of care would
have been, really you're rushing so much, you don't have the
time, you're under pressure to deliver so to speak so you do
sometimes forget about the other person or forget about the
patient who can still hear you and understand even though they
might not be able to communicate and sometimes you don't
really talk enough to the patient you don't tell them what
you're going to do. You just literally pick them up, grab them,
put them in the chair, oxygen, done, gone. (C1) 1
Fiona Togher, Zowie Davy, A Niroshan Siriwardena
References
1. Togher FJ, Davy Z, Siriwardena AN. Patients' and ambulance
service clinicians' experiences of prehospital care for acute myocardial
infarction and stroke: a qualitative study. Emerg Med J 2012.
As an Emergency Medicine Higher Speciality Trainee taking time out of
training to complete a research post I read the recent article by Allard
and colleagues (1) regarding interruptions on the ED shop floor with great
interest. During my ST4 post in Emergency Medicine at a large teaching
hospital in the United Kingdom I undertook my own self- observational
audit study similar to that performed by Allard. During a total o...
As an Emergency Medicine Higher Speciality Trainee taking time out of
training to complete a research post I read the recent article by Allard
and colleagues (1) regarding interruptions on the ED shop floor with great
interest. During my ST4 post in Emergency Medicine at a large teaching
hospital in the United Kingdom I undertook my own self- observational
audit study similar to that performed by Allard. During a total of 174
shifts (1740 hours) I was involved in 3184 cases. Over 40% of
interactions involved providing support or supervision to junior staff in
the department. Approximately 60% of requests for assistance involved
patient review compared to a third that were for simple opinions (e.g.
interpretation of x-rays). The mean number of requests for assistance
doubled from 6 per shift during daytime shifts to 12 per shift at night.
Most notably the mean number of requests for patient review that were not
completed due to other clinical commitments in the ED almost quadrupled on
night shifts (mean of 4 cases per shift).
Allard and colleagues correctly highlight that the Emergency Department is
particularly susceptible to error. The cognitive burden now associated
with practicing as a Higher Speciality Trainee in Emergency Medicine and
the added risk of error that it entails, should not be underestimated.
The annual caseload of 2000 patients recommended by the College of
Emergency Medicine (2) vastly underestimates the expected workload of
trainees when the added responsibilities of supporting junior staff in the
ED are taken into account.
Efforts should be made by individual departments and the College of
Emergency Medicine to identify working patterns for Higher Speciality
Trainees that are sustainable and minimise the risk of cognitive overload
to ensure that high quality trainees are attracted to Emergency Medicine
and remain practicing in the speciality.
References
1. Allard J, Wyatt J, Bleakley A, Graham B. "Do you really need to ask me
that now?": a self-audit of interruptions to the 'shop floor' practice of
a UK consultant emergency physician. Emerg Med J. 2012 Nov;29(11):872-6.
2. http://www.collemergencymed.ac.uk/Training-
Exams/Curriculum/Curriculum%20from%20August%202010/ (accessed 23/11/12)
The most recent letter(1) published in response to the article 'Short
answer question case series: diagnosis and management of glaucoma'(2)
highlighted important errors within the article. Some further points need
to be clarified.
Iopidine and brimonidine are primarily alpha-2-adrenoreceptor
agonists. Subsequently they have no pharmacodynamic effect on pupillary
action as sympathetic innervation to the pupillar...
The most recent letter(1) published in response to the article 'Short
answer question case series: diagnosis and management of glaucoma'(2)
highlighted important errors within the article. Some further points need
to be clarified.
Iopidine and brimonidine are primarily alpha-2-adrenoreceptor
agonists. Subsequently they have no pharmacodynamic effect on pupillary
action as sympathetic innervation to the pupillary dilator is via
noradrenaline action on alpha-1-adrenoreceptors. Alpha-2 agonists act as
vasoconstrictors reducing the production of aqueous humour. It is
important to be clear about sympathomimetic pharmacodynamics in eye
disease as prescribing alpha-1 agonists mistakenly can lead to the
dilation of an acute angle closure eye.
Sympathomimetic drugs do not include beta blockers as suggested in
the article but are undoubtedly valuable in lowering a high IOP.
The statement 'This was diagnostic of increased intraocular pressure
(IOP) due to glaucoma'(2) is a misunderstanding of the pathological
process. High IOP is not caused by glaucoma. It is a risk factor for
developing a progressive optic neuropathy termed glaucoma. Glaucoma is
defined by changes in the optic nerve head and visual field but not IOP.
(1)Reid C. eLetter Response: Diagnosis and management of glaucoma.
Emerg Med J. 2012 Oct.
(2) Beck J, Jang TB. Short answer question case series: diagnosis and
management of glaucoma. Emerg Med J. 2012 Feb;29(2):169
Thank you for this interesting study.
I am curious whether you are able to provide comparable data from before the introduction of the Standard Operating Procedure (SOP) discussed here. Does the data gathered demonstrate an improvement in complication rates during pre-hospital anaesthesia compared with data from before the introduction of the SOP? In addition, did you analyse data regarding complications apart...
First, we would like to emphasize the importance of the study published in the EMJ1 and similar studies based in emergency departments, since they provide valuable information on prevalence, trends, and emergence of new drugs of abuse, which produces epidemiological data to support public policies. However, we believe there are some additional considerations regarding the work by Horyniak and colleagues that should be m...
Thank you for sharing your method for remembering the Sepsis Six.
Being terrible at remembering anything, I developed a method which required me to only remember three things. As long as I remember that for each thing you put "in" to the patient, you take something "out".
So, for each thing I put in, something related comes out; Fluids in (Urine out), Antibiotics in (Cultures out) & Oxygen in (ABG o...
There is no doubt that emailing has revolutionised communication in the past 10-15 years and the number of messages received daily (both during working and non-working hours) will be seen as a nightmare by most NHS workers.
We need to urgently adopt a pragmatic change in the way we deal with the vast amount emails we get inundated with.
With the rise of smart phones, work emails can often be checked o...
We read with interest the article by Bruijns et al. comparing the relationship between heart rate (HR) and systolic blood pressure (SBP) in non-haemorrhagic, minimally injured patients with that of a non-injured control group.1 There was a statistically significant difference between the groups for both HR and SBP (p<0.001), demonstrating that as far as mild to moderate injury is concerned, HR tends to be higher than...
I am glad to see Eye Know How featured in the Emergency Medicine Journal. As someone who has worked in accident and emergency and now a starter in the ophthalmology world, this book has proved invaluable. I feel the need to reiterate the symptom led approach highlighted in this b...
I am a specialty registrar in Emergency Medicine presently working at CrossHouse Hospital, Kilmarnock, Scotland.
I have prepared a mnemonic to help remember the sepsis six bundle which I thought, I might share it with you.
"Give 3, Take 2 and Monitor 1"
Give 3 ( Oxygen + IV fluids + Antibiotics) Take 2 ( Blood Cultures + Hb/Lactate) Monitor 1 ( urine output)
I have found the use of thi...
We would like to thank Brooks Walsh for his comments and agree that it is important to understand the rich and mostly ignored perspectives of prehospital clinicians and their patients.
Whilst it is true that patients were drawing upon a singular concrete experience they usually reported this in the context of their broader experiences and expectations of interactions with health services. Similarly, although cl...
As an Emergency Medicine Higher Speciality Trainee taking time out of training to complete a research post I read the recent article by Allard and colleagues (1) regarding interruptions on the ED shop floor with great interest. During my ST4 post in Emergency Medicine at a large teaching hospital in the United Kingdom I undertook my own self- observational audit study similar to that performed by Allard. During a total o...
The most recent letter(1) published in response to the article 'Short answer question case series: diagnosis and management of glaucoma'(2) highlighted important errors within the article. Some further points need to be clarified.
Iopidine and brimonidine are primarily alpha-2-adrenoreceptor agonists. Subsequently they have no pharmacodynamic effect on pupillary action as sympathetic innervation to the pupillar...
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