We were intrigued to read that procedural sedation by emergency
physicians is safe and effective whilst admitting that complications do
occur. To us this is a contradiction in terms. Following the NAP4 project
into airway complications we know that aspiration is still the commonest
cause of death (1,3). Furthermore, patients undergoing airway manoeveres
in the ED and ICU are generally more challenging, with a higher inci...
We were intrigued to read that procedural sedation by emergency
physicians is safe and effective whilst admitting that complications do
occur. To us this is a contradiction in terms. Following the NAP4 project
into airway complications we know that aspiration is still the commonest
cause of death (1,3). Furthermore, patients undergoing airway manoeveres
in the ED and ICU are generally more challenging, with a higher incidence
of airway complications than that in theatres (2,3). Jacques study,
despite recognising that verbal contact be maintained, found 30% of
patients were deeply sedated or unconscious. Consultants were responsible
for 28% of sedations but we do not know how many clinicians had the
recommended skill level for general anaesthesia.
Numerous aspects of this study were worrying. No protocol was
included in the publication, there was no mention of assessment (and one
would expect exclusion) of patients with potential difficult airway/high
aspiration risk, whether a difficult airway trolley was readily available,
nor vitally whether end tidal carbon dioxide monitioring was used.
Similarly, whilst we recognise that many procedures involved the use of
propofol (n=293), a larger number were still using arguably 'older' drugs
i.e midazolam alone (n=950) or even a combination of the two.
Fortunately no patients suffered long term morbidity despite 1 in 30
suffering some airway/respiratory complication. If powered to look for
rare complications such as failure to ventilate or aspiration the study
conclusions might not have been so rosy. The fallacy about rare
complications is that if one has got away for many years then it won't
happen. Whilst agreeing that procedural sedation can be delivered in the
ED, we owe it to ourselves as a specialty and more importantly to our
patients, to ensure we are aware of our limitations and are at all times
prepared for the 'worst case scenario'!
While studying for my upcoming FCEM critical appraisal examination I
happened to use this paper, with it's table of sensitivities,
specificities, PPV and NPVs, to practice some calculations. Unfortunately
it would appear that some errors have made it into the final publication
of this data (I am unsure whether they were simply transcribed
incorrectly). In the first line of the table the...
While studying for my upcoming FCEM critical appraisal examination I
happened to use this paper, with it's table of sensitivities,
specificities, PPV and NPVs, to practice some calculations. Unfortunately
it would appear that some errors have made it into the final publication
of this data (I am unsure whether they were simply transcribed
incorrectly). In the first line of the table the sensitivity and
specificity values seem to have been reversed. However (more worryingly as
it refers to the primary outcome) in the second line of the table the
specificity presented should be 94% based on the numbers given. Given that
the PPV and NPV remain unchanged when calculated this would appear to be a
genuine miscalculation and unfortunately this has also been published in
the results section of the abstract. Although this still would be below
the threshold sensitivity of 98% which had been set by the authors, it is
clearly far closer than one would otherwise have been lead to believe.
We thank Prof. Cooke for his interest in our article [1], and are
glad that our analysis has provoked debate. We would like to take this
opportunity to address his response to these analyses. His major
criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits
patients"
2. "...their conclusion that this shows more patients are waiting for
care is imprecise and possibly...
We thank Prof. Cooke for his interest in our article [1], and are
glad that our analysis has provoked debate. We would like to take this
opportunity to address his response to these analyses. His major
criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits
patients"
2. "...their conclusion that this shows more patients are waiting for
care is imprecise and possibly wrong"
3. That performance against the 4-hour target is inadequate as an
isolated measure.
An initial response is that as 98% of patients waited less than
4hours in the past and now 95% of patients wait less than 4hours (i.e.
throughput is reduced), and the load on the system has not changed (i.e.
input is the same) then necessarily the numbers waiting longer have
necessarily increased.
Our analyses [1] did not set out to address whether the standard
benefits patients but refer to literature that indicates:
(i) Longer time in ED is associated with access block [2-4]
(ii) Access block causes delays to care [5,6]
(iii) Delays to care lead to poor outcomes [5-8]
Therefore, if there are longer times in ED there is access block that
causes delay to care, leading to poorer outcomes. This argument is based
on the referenced research evidence in the main article and this reply.
We acknowledge that focussing on time alone, rather than the quality of
care can affect patient outcomes adversely, and urge not the attainment of
the standard alone, but attainment of the target through high quality care
Prof. Cooke says that care starts earlier, and because of this, a
longer ED wait does not imply a delay to care. We argue that:
(i) Delays in ED are symptomatic of a wider issue with the whole
system, and relating to delays in care both within and without ED [3,6,9].
(ii) Regardless of a 10-year shift to more care in ED, the gradual
shift towards this model will be negligible over the short timescale of
the step change exhibited in the data we analysed. That is to say if this
gradual shift towards more care in ED did affect waiting times, we might
have expected to see a gradual decline in the performance level over the
same period. This is not seen in the data, which fluctuated about the 98%
performance level, only dropping (and rapidly) upon announcement of the
change in operating standard.
(iii) Furthermore, treatment in ED can increase human resources needs
[9], increasing length of stay in ED, thus because of the increase in
resource need for these patients, less resource can be utilised elsewhere
thereby increasing the waits of others. Hence, new arrivals to a crowded
ED will wait longer, building a positive feedback loop.
(iv) There have been concerns about the rises in ambulance to
hospital handover times (at least in London), which could represent an
embodiment of access block [4,11].
Prof. Cooke refers to the median in some "time to care" measures, in
doing so he puts undue emphasis on shorter waits (those below the median)
since the measure is strictly positive and thus bounded by zero below but
essentially unbounded above. This means that with a median of 4 hours 50%
of patients would be seen in less than 4 hours, and another 50% will
continue to wait for an amount of time that is not indicated by the
median. The median and the mean are problematic, both introducing biases
that take no account of the length of the long waits. Distribution of the
values is of more importance in assessing system performance.
That "...the use of a single target was subject to much criticism" is
of less concern once a systems-thinking approach is adopted [12,13]. To
attain the 4-hour target for waits in ED, the whole hospital system must
be operating efficiently (i.e. without access block) to ensure that a
patient is admitted, transferred, or discharged from the ED. If these
throughputs are not achieved, because of other processes in the system not
operating efficiently, then the patients will necessarily have waited
longer - as found in our analyses - and as aforementioned suffer worse
outcomes. In addition, we have found (unpublished data) that measures of
these processes and sub-processes are no more or less sensitive than the
single measure of ED waiting time, the additional granularity adds nothing
to the understanding of the overall performance of the system. Consider:
if to exit the ED A, B, and C must happen then measuring how long it takes
to complete A, B, C separately is the same as measuring the time taken to
complete all three. If one suspects that A is taking too long, one should
measure A, but to assess the system the "global" measure of ED waiting
times is more pertinent, because of its ties with overall hospital
performance. Examination of the distribution of waiting times would be
valuable in determination of flows.
Fifth, the comparison of the 95% standard to lower standards in other
countries , whilst useful background information is neither an argument in
criticism of this analysis, nor in support of lowering the standard in
this country; and recall that Scotland has kept the target at 98%. Whilst
it is the actual performance level that matters, the level at which the
target is set is relevant: we show that following the lowering of the
target for England, the performance level dropped. This occurred upon
announcement of the new lower standard and in advance of the official
adoption [1]. Consequently, we note a lower target level has resulted in
lower performance with lower throughputs and thus longer waits, meaning
worse outcomes [1,9,14].
Additionally, the impact of increased time in ED on patient
experience should not be forgotten, nor should the additional economic
cost; not just to the hospital and its staff, but also to the patient in
lost time.
References
1. Woodcock T, Poots AJ, Bell D (2012) The impact of changing the 4 h
emergency access standard on patient waiting times in emergency
departments in England. Emergency Medical Journal doi:10.1136/emermed-
2012-201175
2. Dunn R (2003) Reduced access block causes shorter emergency
department waiting times: An historical control observational study.
Emergency Medicine (Fremantle) 15(3):232-238
3. Richardson DB, Mountain D (2009) Myths versus facts in emergency
department overcrowding and hospital access block. Medical Journal of
Australia 190(7):369-374
4. Fatovich DM, Nagree Y, Sprivulis P (2005) Access block causes
emergency department overcrowding and ambulance diversion in Perth,
Western Australia. Emergency Medical Journal 22:351-354
5. Richardson DB (2006) Increase in patient mortality at 10 days
associated with emergency department overcrowding Medical Journal of
Australia 184(5): 213-216
6. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U,
McCarthy M, John McConnell K, Pines JM, Rathlev N, Schafermeyer R, Zwemer
F, Schull M, Asplin BR and Society for Academic Emergency Medicine,
Emergency Department Crowding Task Force (2009) The Effect of Emergency
Department Crowding on Clinically Oriented Outcomes. Academic Emergency
Medicine 16: 1-10
7. Mir? O, Antonio MT, Jim?nez S, De Dios A, S?nchez M, Borr?s A,
Mill? J (1999) Decreased health care quality associated with emergency
department overcrowding. European Journal of Emergency Medicine 6(2):105-
107
8. Richardson DB (2002) The access-block effect: relationship between
delay to reaching an inpatient bed and inpatient length of stay. Medical
Journal of Australia 177(9):492-495
9. Cameron PA (2006) Hospital overcrowding: a threat to patient
safety? Medical Journal of Australia 184(5):203-204
10. Drummond AJ (2002) No room at the inn: overcrowding in Ontario's
emergency departments. Canadian Journal of Emergency Medicine. 4(2):91-
97
11. Health Service Journal (2011) Continued under-performance on
ambulance handover times at London A&Es. 26 May 2011 [accessed 30 Aug
2012]: http://www.hsj.co.uk/hsj-local/acute-trusts/homerton-university-
hospital-nhs-foundation-trust/continued-under-performance-on-ambulance-
handover-times-at-london-aes/5030315.article
12. Forero R, Hillman KM, McCarthy S, Fatovich DM, Joseph AP,
Richardson DB (2010) Access block and ED overcrowding. Emergency Medicine
Australia 22(2): 119-135
13. Khanna S, Boyle J, Good N, Lind J (2012) Unravelling
relationships: Hospital occupancy levels, discharge timing and emergency
department access block. Emergency Medicine Australia doi: 10.1111/j.1742
-6723.2012.01587.x
14. Sprivulis PC, Da Silva J-A, Jacobs IG, Jelinek GA, Frazer ARL
(2006) The association between hospital overcrowding and mortality among
patients admitted via Western Australian emergency departments. Medical
Journal of Australia 184(5): 208-212
Krikscionaitiene et al. 1 reported that lightweight rescuers require
special attention during CPR (cardiopulmonary resuscitation) training,
with an emphasis on correct body posture and positioning of body mass to
ensure CCs (chest compressions) are performed according to the European
Resuscitation Council Guidelines for Resuscitation 2010. We routinely
educate rescuers with regard to appropriate postu...
Krikscionaitiene et al. 1 reported that lightweight rescuers require
special attention during CPR (cardiopulmonary resuscitation) training,
with an emphasis on correct body posture and positioning of body mass to
ensure CCs (chest compressions) are performed according to the European
Resuscitation Council Guidelines for Resuscitation 2010. We routinely
educate rescuers with regard to appropriate postures for high quality
chest compressions including kneeling as closely beside the victim as
possible, body positioning directly above the victim's chest,
straightening of both arms, and placing the heel of the palm on the lower
half of the sternum with the fingers interlocked. Despite teaching these
postures to the rescuers to encourage adequate CCs during CPR training, we
have encountered CCs of insufficient depth performed by low-weight adults,
especially women and young students. As a result, the eleven of us, who
are AHA (American Heart Association) Basic Life Support instructors,
shared our educational experiences and discussed how we could motivate
these trainees to perform CCs of the recommended depth. Positioning of the
rescuer more than 90 degrees above the victim's chest might enable the
rescuer to use his or her body weight more effectively to achieve
sufficient CC depth. However, this method could prevent complete chest
recoil, which is an important component of CCs.2 The "lifting the heel of
the hand slightly off the chest" technique might compensate for the
incomplete recoil.3 Above all, we believe that trainees should be given
sufficient time during CPR education to observe and put into practice a CC
depth of 5-6 cm. We would like to get from the authors some insight and
information regarding good methods related to the rescuer's posture or
instructor's teaching skills to ensure sufficient CC depth.
Reference
1. Krikscionaitiene A, Stasaitis K, Dambrauskiene M, et al. Can
lightweight rescuers adequately perform CPR according to 2010
resuscitation guideline requirements? Emergency medicine journal?: EMJ.
2012:2011-2013. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22345324.
Accessed July 6, 2012.
2. Niles DE, Sutton RM, Nadkarni VM, et al. Prevalence and
hemodynamic effects of leaning during CPR. Resuscitation. 2011;82 Suppl
2:S23-6.
3. Aufderheide TP, Pirrallo RG, Yannopoulos D, et al. Incomplete
chest wall decompression: a clinical evaluation of CPR performance by
trained laypersons and an assessment of alternative manual chest
compression-decompression techniques. Resuscitation. 2006;71:341-51.
Youngsuk Cho* and Jaehoon Oh* contributed equally to this letter
We read with interest the article "SOFAR Study" discussing the role
of ultrasonography in acute ankle injuries.
The authors must be appreciated in covering a topic of huge importance for
ED, however there seem to be certain issues in the methodology adopted .
ED doctors trained in basic ultrasonography for 2 days did the
Ultrasonography. Was the sonography done by the same observer all the time
or if by different then what...
We read with interest the article "SOFAR Study" discussing the role
of ultrasonography in acute ankle injuries.
The authors must be appreciated in covering a topic of huge importance for
ED, however there seem to be certain issues in the methodology adopted .
ED doctors trained in basic ultrasonography for 2 days did the
Ultrasonography. Was the sonography done by the same observer all the time
or if by different then what was the interobserver reliability in
diagnosis ?
The change of scan criteria from 8 cm to 10 cm seems to be arbitrary.
Kalyani et al(2010) in a comprehensive review of maisonneuve injury
suggested taking full length radiographs of tibia & fibula along with
ankle.
The author has not commented on the average time taken by the doctor
to complete a scan with a diagnosis in the study patients. Actual cost-
effectiveness in ED setting cannot be established without consideration of
time.
It would be in the interest of readers if authors could provide some
answers to the queries raised .
References :
Kalyani BS, Roberts CS, Giannoudis PV.The Maisonneuve injury : a
comprehensive review
Orthopedics. 2010 Mar;33(3):196-7.
The responder makes some valuable remarks about our study, which are
to some extent covered in the discussion section of our paper. Firstly,
intoxication was defined as any patient evaluation because of ingestion,
injection or inhalation of, or exposure to, a deleterious agent. This
definition covers both intoxicated and exposed patients. Secondly, our
algorithm provides cut off values of vital signs which appeared to be...
The responder makes some valuable remarks about our study, which are
to some extent covered in the discussion section of our paper. Firstly,
intoxication was defined as any patient evaluation because of ingestion,
injection or inhalation of, or exposure to, a deleterious agent. This
definition covers both intoxicated and exposed patients. Secondly, our
algorithm provides cut off values of vital signs which appeared to be
safe. We aimed to make this algorithm simple and sensitive and included
all ECG abnormalities. Of course future larger scale prospective research
should decide what patients with ECG abnormalities and what abnormalities
of vital sign can be safely sent home. Thirdly, the outcome of the
algorithm was based on the findings during a 6 h observation in the ED. In
our hospital, this observation period is advised for intoxication
patients, but it may be shorter at the discretion of the treating
physician. For slow release preparations a longer observation time (so
admission in the hospital) is recommended by the algorithm. Lastly, we
took treatment as Gold Standard. The advantage of this approach is that
there is no need for retrospective subjective judgment whether this
treatment is necessary or not. However, in our studies we had a few
patients with unnecessary treatments, which reduced the sensitivity of our
algorithm.
We agree with the responder that poisoned patients are an extremely
heterogeneous population making the development of an algorithm complex.
However, what we show is that the usage of this simple algorithm can
already reduce admissions compared to day to day care of intoxicated
patients in the Netherlands. We feel the algorithm should be used to aid
the clinician to make a first judgment whether to admit or not. However,
the algorithm should be validated in a larger scale prospective study
before it can be used for the ultimate decision to admit an intoxicated
patient.
As a Best Evidence Topic Review Dr May asks whether suxamethonium
increases intracranial pressure in patients with traumatic brain
injury.(1) It is an important question given the risks of secondary brain
injury caused by a rise in intracranial pressure.
The "clinical bottom line" states that "...the superior intubation
conditions created by suxamethonium in comparison with rocuronium mean...
As a Best Evidence Topic Review Dr May asks whether suxamethonium
increases intracranial pressure in patients with traumatic brain
injury.(1) It is an important question given the risks of secondary brain
injury caused by a rise in intracranial pressure.
The "clinical bottom line" states that "...the superior intubation
conditions created by suxamethonium in comparison with rocuronium mean
that suxamethonium should remain the first choice agent for neuromuscular
blockade."
This statement is neither supported by the author's literature review
nor the available published evidence. A Cochrane review on this topic
concluded that, when given at a dose of 1.2mg/kg, rocuronium provides no
difference in intubating conditions when compared with suxamethonium.(2)
Indeed, this was also the conclusion of a recent BestBET.(3) Unlike
suxamethonium, rocuronium is not associated with a potential rise in
intracranial pressure and is therefore considered by many to be the
evidence-based first-choice agent for neuromuscular blockade in head-
injured patients.
I support Dr May in concluding that suxamethonium is unlikely to be
associated with a clinically significant rise in intracranial pressure.
However, the clinical bottom line not only makes an assertion unrelated to
the question posed but it is also inaccurate and misleading. This is not
the first time that a clinical bottom line has been questionable - perhaps
it is time to review the editorial process again?(4)
Yours sincerely,
Alistair Steel
Consultant Anaesthetist
Queen Elizabeth Hospital, Kings Lynn, UK
1) May N, Anderson K
Suxamethonium for RSI and intubation in head injury
Emerg Med J 2012;29:511-4.
2) Perry JJ, Lee JS, Sillberg VAH, Wells GA
Rocuronium versus succinylcholine for rapid sequence induction intubation
(Review)
The Cochrane Library 2008
3) Herbstritt A, Amarakone K
Is rocuronium as effective as succinylcholine at facilitating laryngoscopy
during rapid sequence intubation?
Emerg Med J 2012;29:256-8.
4) French J, Steel A, Clements R, et al.
BestBETS: A Call for Scrutiny
Emerg Med J 2006;23:490
In a recent publication by Ambrosius et al1, the authors designed two
algorithms to predict the necessity of hospital treatment for acutely
poisoned patients presenting to the emergency department. While we
applaud the authors' efforts to undertake a difficult task, we have some
concerns about this study.
In contrast to the title, the study conducted a retrospective review
of patients already admitted or discha...
In a recent publication by Ambrosius et al1, the authors designed two
algorithms to predict the necessity of hospital treatment for acutely
poisoned patients presenting to the emergency department. While we
applaud the authors' efforts to undertake a difficult task, we have some
concerns about this study.
In contrast to the title, the study conducted a retrospective review
of patients already admitted or discharged. Moreover, it is unclear if
the patients were "intoxicated" or merely exposed. Although both
algorithms demonstrate good sensitivity, most of this stems from the
characteristics included in Box 1 of Figure 1, such as abnormal vital
signs. Discharging patients with abnormal vitals is unlikely regardless
of any algorithm. Also, relying on just one set of vital signs may be
misleading as they may change dynamically. Additionally, the inclusion of
"ECG abnormalities" is curtailed without a definition of the specific
abnormality. No management strategy is offered for patients who present
asymptomatic but may develop delayed toxicity, such as the child who
ingests a sulfonuria. Furthermore, the gold standard stated for verifying
the algorithms is the treatment received during admission. However, the
necessity of treatments provided, such as supplemental oxygen or N-
acetylcysteine, is not explained.
Creating an algorithm for handling all poisoned patients seems like
an attractive proposition; however, poisoned patients are an extremely
heterogeneous population making this task particularly complex.
References:
1. Ambrosius RGA, Vroegop MP, Jansman FGA et al, Acute intoxication
patients presenting to an emergency department in the Netherlands: admit
or not? Prospective testing of two algorithms. EMJ BMJ, (29) 467-472, 2012
We wish to comment on the study by Freeston et al (ref. 1) describing
the relationship between depth of sedation, patient recall and
satisfaction. As anaesthetists we feel that the need for conscious
sedation is still being ignored. The doses and combinations of sedative
and analgesic agents used in this study would raise concerns in our
practice. In particular, one patient (number 17) described as being of ASA
III physic...
We wish to comment on the study by Freeston et al (ref. 1) describing
the relationship between depth of sedation, patient recall and
satisfaction. As anaesthetists we feel that the need for conscious
sedation is still being ignored. The doses and combinations of sedative
and analgesic agents used in this study would raise concerns in our
practice. In particular, one patient (number 17) described as being of ASA
III physical status received 10mg midazolam and 9mg morphine prior to
manipulation of a fractured talus and navicular bone.
In keeping with our hospital's sedation policy, in the pain clinic we
restrict our maximum doses of midazolam to 5mg and fentanyl to 250mcg for
day case procedures. The majority of patients require between 1 to 2mg of
midazolam and 50 to 100mcg of fentanyl. The doses of midazolam
administered in this study exceed the maximum dose of 7.5mg recommended by
the British National Formulary for conscious sedation. (ref. 2)
From their paper we could not ascertain whether the opioid(s) was
administered before the sedative agent of choice in keeping with current
recommendations. The decision to assess recall after one hour post
midazolam administration must be queried given its powerful amnesic
properties; (ref. 3) and the method of determining patient satisfaction
not included. In addition there are no details documenting whether or not
patients were discharged home or admitted for post procedural observation
as this too would influence the choice of sedo-analgesia.
We would urge a balanced approach to conscious sedation; and even consider
general anaesthesia for this group of patients with a wide range of
patient age, ASA grade and pathology.
References
1 Freston J et al. Procedural sedation and recall in the emergency
department: the relationship between depth of sedation and patient recall
and satisfaction (a pilot study). Emergency Medicine Journal 2012; 29:670-
672
2 Joint Formulary Committee. British National Formulary. 63 ed.
London: BMJ Group and Pharmaceutical Press; 2012
3 Polster M et al. Comparison of the sedative and amnesic effects of
midazolam and propofol. British Journal of Anaesthesia 1993; 70:612-616
Conflict of Interest:
Dr W F de Mello is a faculty member of the "Sedation for non-anaesthetists" course and a member of the University Hospital of South Manchester sedation committee.
We agree with the conclusions of the article of van Hoving et al. (1)
that for focused ultrasound programs "any curriculum needs to reflect the
local burden of disease". As shown in the study, HIV and tuberculosis (TB)
represent a large share of this burden in many departments in Sub-Saharan
Africa.
Unfortunately the authors failed to indicate in their article the
scope of the modules they describe...
We agree with the conclusions of the article of van Hoving et al. (1)
that for focused ultrasound programs "any curriculum needs to reflect the
local burden of disease". As shown in the study, HIV and tuberculosis (TB)
represent a large share of this burden in many departments in Sub-Saharan
Africa.
Unfortunately the authors failed to indicate in their article the
scope of the modules they describe. In the Program of the "EMSSA
Preconference workshop" 2012 (2) brief descriptions are given. Based on
these, we assume that many of the 505 ultrasound scans done for
"Pulmonary" as well as of the 219 done for "Cardiac" were addressing
pleural and pericardial effusions and thus target the question of
extrapulmonary forms of tuberculosis (EPTB) in HIV positive patients. If
this is the case, one might assume that the proportion of ultrasound exams
addressing FASH (Focused assessment with Sonography for HIV/TB), i.e. the
detection of pleural, pericardial, abdominal and disseminated forms of
EPTB is even higher then the 178 exams that the article suggests.
The use of the FASH as part of the emergency medicine sonography
curriculum in an high prevalence setting is highly recommended. In fact,
we first developed and described (3) the content of the FASH course in a
rural hospital in KwaZulu-Natal, South Africa. Since that time we and
others have used its curriculum in 2 to 3 day courses in different African
countries and settings such as a referral TB department in Accra, Ghana
(T. Heller, personal communication) or during courses for local doctors
and final year students in Beira, Mozambique (4). As the majority of HIV
and TB patients in South Africa are primarily seen in smaller, rural
district hospitals, which lack formal emergency departments, dissemination
of the FASH method in these institutions should be also a priority.
"The way forward" for focused ultrasound for HIV/TB should aim to
bring a high coverage by simple diagnostic methods like FASH to HIV
patients in places where prevalence and case load is highest and imaging
resources are scarce. These may include HIV programs, TB departments,
rural hospitals in high prevalence settings along with emergency
departments in Sub-Saharan Africa.
1)vanHoving DJ, Lamprecht HH, Stander M, Vallabh K, Fredericks D,
Louw P, M?ller M, Mala JJ: Adequacy of the emergency point-of-care
ultrasound core curriculum for the local burden of disease in South
Africa. Emerg Med J doi:10.1136/emermed-2012-201358
3)Heller T, Wallrauch C, Lessells RJ, Goblirsch S, Brunetti E : Short
Course for Focused Assessment with Sonography for Human Immunodeficiency
Virus/Tuberculosis: Preliminary Results in a Rural Setting in South Africa
with High Prevalence of Human Immunodeficiency Virus and Tuberculosis. Am
J Trop Med Hyg 2010 March; 82(3): 512-515.
We were intrigued to read that procedural sedation by emergency physicians is safe and effective whilst admitting that complications do occur. To us this is a contradiction in terms. Following the NAP4 project into airway complications we know that aspiration is still the commonest cause of death (1,3). Furthermore, patients undergoing airway manoeveres in the ED and ICU are generally more challenging, with a higher inci...
Dear Editor and Authors,
While studying for my upcoming FCEM critical appraisal examination I happened to use this paper, with it's table of sensitivities, specificities, PPV and NPVs, to practice some calculations. Unfortunately it would appear that some errors have made it into the final publication of this data (I am unsure whether they were simply transcribed incorrectly). In the first line of the table the...
We thank Prof. Cooke for his interest in our article [1], and are glad that our analysis has provoked debate. We would like to take this opportunity to address his response to these analyses. His major criticisms seem to be:
1. " ...they fail to address the key issue of whether it benefits patients"
2. "...their conclusion that this shows more patients are waiting for care is imprecise and possibly...
Dear Sir,
Krikscionaitiene et al. 1 reported that lightweight rescuers require special attention during CPR (cardiopulmonary resuscitation) training, with an emphasis on correct body posture and positioning of body mass to ensure CCs (chest compressions) are performed according to the European Resuscitation Council Guidelines for Resuscitation 2010. We routinely educate rescuers with regard to appropriate postu...
We read with interest the article "SOFAR Study" discussing the role of ultrasonography in acute ankle injuries. The authors must be appreciated in covering a topic of huge importance for ED, however there seem to be certain issues in the methodology adopted . ED doctors trained in basic ultrasonography for 2 days did the Ultrasonography. Was the sonography done by the same observer all the time or if by different then what...
The responder makes some valuable remarks about our study, which are to some extent covered in the discussion section of our paper. Firstly, intoxication was defined as any patient evaluation because of ingestion, injection or inhalation of, or exposure to, a deleterious agent. This definition covers both intoxicated and exposed patients. Secondly, our algorithm provides cut off values of vital signs which appeared to be...
Dear Editor
As a Best Evidence Topic Review Dr May asks whether suxamethonium increases intracranial pressure in patients with traumatic brain injury.(1) It is an important question given the risks of secondary brain injury caused by a rise in intracranial pressure.
The "clinical bottom line" states that "...the superior intubation conditions created by suxamethonium in comparison with rocuronium mean...
In a recent publication by Ambrosius et al1, the authors designed two algorithms to predict the necessity of hospital treatment for acutely poisoned patients presenting to the emergency department. While we applaud the authors' efforts to undertake a difficult task, we have some concerns about this study.
In contrast to the title, the study conducted a retrospective review of patients already admitted or discha...
We wish to comment on the study by Freeston et al (ref. 1) describing the relationship between depth of sedation, patient recall and satisfaction. As anaesthetists we feel that the need for conscious sedation is still being ignored. The doses and combinations of sedative and analgesic agents used in this study would raise concerns in our practice. In particular, one patient (number 17) described as being of ASA III physic...
Sir:
We agree with the conclusions of the article of van Hoving et al. (1) that for focused ultrasound programs "any curriculum needs to reflect the local burden of disease". As shown in the study, HIV and tuberculosis (TB) represent a large share of this burden in many departments in Sub-Saharan Africa.
Unfortunately the authors failed to indicate in their article the scope of the modules they describe...
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