We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
m...
We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
message. The results provided in the abstract are potentially misleading;
the overall mortality for patients with extradural haematomas should not
be reported as 29.7%, but rather that 25 of 82 patients died. Similarly,
for patients with subdural haematomas, the mortality was not 66.4% but
that 38 of 57 patients died. A favourable outcome was seen for 13 patients
with extradural haemorrhages and bilateral fixed pupils and 3 of those
with subdural haematomas.
The authors are correct regarding the limitations of their study -
there is considerable potential for selection bias in the published
reports, the age ranges of the study patients are unclear, the delays to
surgery are largely unreported and none reported the presence or absence
of co-morbidities. Whether a pupil of 4mm should be considered fixed and
dilated is also open to question. None of the studies addressed whether
there was any direct injury to the face that might have produced traumatic
mydriasis. There is also no mention in either Scotter's paper or those
reviewed, about the value of aggressive pre-hospital care including
intubation, ventilation and administration of hypertonic fluids. A young
patient with an extradural haematoma who is rapidly resuscitated, arrives
in a neurosurgical centre within minutes of the pupils becoming fixed and
dilated might have reasonable expectations of survival. Equally, a patient
with a subdural haematoma who has fixed and dilated pupils on arrival of
the paramedics, who is transported to a district general hospital for
intubation and who is on anticoagulation has no need to be referred for
consideration of neurosurgery but rather should be allowed to die with
comfort and dignity.
We would also take issue with the statement that patients should be
able to undergo surgery within an hour of arrival following the
introduction of major trauma networks in the U.K. Outside of London, many
patients with major trauma are initially managed in district general
hospitals. In Wessex, nearly 50% of patients with an injury severity score
of >15 (major trauma) were admitted to trauma units (Trauma Audit
Research Network, personal communication). For many patients with severe
head injuries, the initial admitting hospital remains distant from the
regional neurosurgical service. Only by altering the referral pathways
have we any hope of reducing the time to surgery for these patients (2,
3).
The motives for Scotter's paper are laudable but the messages should
be taken with a drop of (hypertonic) saline solution.
References:
1. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of
patients with bilateral fixed dilated pupils secondary to traumatic
extradural or subdural haematoma who undego surgery: a systematic review
and meta-analysis. Emerg Med J 2015; 32: 654-659
2. Trebilcock H. The impact of increasing the running time to the
major trauma centre (MTC) to 60 minutes in the south west. Emerg Med J
2015; 32: e17-e18 doi:10.1136/emermed-2015-204980.18
3. Dickinson P, Eynon CA. Improving the timeliness of time-critical
transfers: removing 'referral and acceptance' from the transfer pathway.
Journal of the Intensive Care Society 2014; 15: 104-108
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrig...
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrigation is advisable. Ampoules or tap water dripped on whilst cutting
can aid here.
For ease, it is advisable to cut the ring twice from both sides so
that the ring falls off making it a 'one man job'. Failing that, if the
ring is cut only once, a method will be needed to force the ring open
enough to be removed from the finger which could involve more staff, tools
and brute force.
As shown in the article, a method of forcing the ring open when it
has only been cut once would be to feed a couple of straightened
paperclips through each side of the cut and grip with pliers. It may be
only necessary to spring the ring open a short distance to remove it.
A single unused blade will cut off one or two titanium rings with
ease. New blades are available from specialist jewellery tool companies.
Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variable...
Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variables, it is not particularly surprising that they are closely related.
The major problem is that both scoring systems do not have a particularly strong relationship to mortality. Previous research on EWS in sepsis have shown AUC figures of around 0.6-0.7, much less than the figures presented here (1-3). A recent paper by Kaukonen et al (4) (published after this paper was submitted), has shown that the SIRS criteria are also not particularly ideal for defining 'cut off points' in patients with sepsis.
The authors suggest that using an EWS of >=3 has a NPV of 99.5% for 'severe sepsis', and a specificity of 77%. However, in Corfield et al's paper on sepsis mortality, the same cut off has an NPV of only 92.3% and a specificity of 11%(1)!
Subsequent data from that paper show that the mortality of patients with NEWS between 0-4 are almost identical (EWS =0, mortality 18.8%, EWS = 1, mortality 18.8%, EWS =2, mortality 19.3%, EWS=3, mortality = 20%, EWS =4, mortality = 21.3%).
Without presenting figures for mortality in this dataset, it is hard to know the relevance of using the cut off they suggest. Sepsis is clearly a condition which has a significant mortality attached, but this does not appear to be well related to either SSC definitions or EWS figures, apart from in extremes.
Did the authors collect any mortality or outcome data in this cohort?
Thanks,
Fergus Hamilton
1 )Corfield, A. R., Lees, F., Zealley, I., Houston, G., Dickie, S., Ward, K., & McGuffie, C. (2014). Utility of a single early warning score in patients with sepsis in the emergency department. Emergency Medicine Journal : EMJ, 31(6), 482-7. doi:10.1136/emermed-2012-202186
2) ??ld?r, E., Bulut, M., Akal?n, H., Kocaba?, E., Ocako?lu, G., & Ayd?n, ?. A. (2013). Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department. Internal and Emergency Medicine, 8(3), 255-60. doi:10.1007/s11739-012-0890-x
3) Geier, F., Popp, S., Greve, Y., Achterberg, A., Gl?ckner, E., Ziegler, R., ... Christ, M. (2013). Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wiener Klinische Wochenschrift, 125(17-18), 508-15. doi:10.1007/s00508-013-0407-2
4)Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D. J., & Bellomo, R. (2015). Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. New England Journal of Medicine, 372(17), 150317020036009. doi:10.1056/NEJMoa1415236
Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questi...
Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questions.In one
regard, I view this as a positive result in that it showed advanced ground
paramedic care in the Sydney region of New South Wales,provided quality
care to severe head injured patients that was not significantly improved
upon by addition of a prehospital HEMS physician led team.
The other prehospital RCT of advanced interventions including RSI
for severe head injured patients was another Australian study by Bernard
et al in Melbourne, Victoria and this did show improved eGOS. It was a
paramedic delivered RSI intervention and therefore taken together HIRT and
the Melbourne MICA trial would suggest adding prehospital RSI to the NSW
paramedic skill set might in fact be the more EBM supported approach for
the severe head injured patient.
We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is...
We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is helpful to
show that those who call 999 are found to be genuinely sicker!
(1) Who needs an expert? A tool for optimal triage of general
surgical patients in the Emergency Department. European Journal of Trauma
and Emergency Surgery
April 2014, Volume 40, Issue 1 Supplement, S76
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effective...
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effectively, information about a patient's pain and suffering. We believe
that the PENS tool is effective in meeting these objectives.
The authors remind us that managing a patient's pain and suffering
requires that healthcare providers be aware of the constellation of
unpleasant sensations experienced by the patient. These sensations may be
caused by illness or injury (i.e., their pain). Their pain, a distinct
entity, may be associated with both mental and emotional distress, such as
fear, anxiety, and uncertainty; and with physical sensations caused by
hunger, thirst, nausea, dizziness, fatigue, and the unpleasant features of
ambient light, temperature, and noise (i.e., their suffering).
Managing pain and suffering begins with asking the right questions.
PENS, an acronym pronounced as a word, is an abbreviation for the elements
of Pain/Discomfort; Emotions/Expectations; Nausea/Nutrition (Elimination);
and Sensory-Stimuli/Sleep. The "PENS assessment" begins with asking the
patient: "Are you in pain?" It ends with asking: "Is there anything else
that I can do for you?"
We use PENS in transport medicine as a prompt to ask questions that
allow us to mitigate pain and suffering in both initial and subsequent
patient assessments. We use the "E" for "Expectations" in PENS as a prompt
for asking the patient questions such as: "Do you understand what our
plans are?" because such questions provide the means for initial creation
and ongoing modification of healthcare plans, and are the basis for shared
decision-making. We have found that during transitions of care
("handoffs") the information that we elicited from PENS assessments is the
type of information that other healthcare providers often find most
useful. Finally, we have found the PENS tool to be easy to remember, and
simple to apply.
Mark J. Greenwood, DO, JD, FAAEM, FCLM;
Emily J. Bennett, MSN, APRN-BC, EMT-P.
Grand Rapids, MI, USA.
mkjhgd@aol.com
I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidi...
I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidisciplinary team. In the particular case of paediatric
resuscitation, in many hospitals the paediatric cardiac arrest team may
comprise emergency physicians, paediatricians and anaesthetists, as well
of course as emergency and paediatric nursing staff, all of whom may train
separately in their own departments. This can lead to incongruities in the
approach that is taught, and is a missed opportunity to foster better
teamwork and communication between the doctors and allied health
professionals playing these different roles during the management of time-
critical emergencies.
Just as there is a drive for conformity in the design and
availability of equipment for emergencies, which has been identified as an
important factor in increasing the efficacy and efficiency of care for
critically ill patients[2], perhaps the need for better conformity of
training also needs to be recognised. As this paper demonstrates the
effectiveness of observation-based simulation training, this may open a
way for multiple departments to train jointly, so that the
multidisciplinary team managing paediatric emergencies develop a cohesive
approach with stronger interdisciplinary communication and and teamwork.
References
1 Simulation training based on observation with minimal participation
improves paediatric emergency medicine knowledge, skills and confidence.
Scott A Bloch, and Amy J Bloch. Emerg. Med. J. 2015 32:195-202
2 Timing and teamwork--An observational pilot study of patients referred
to a Rapid Response Team with the aim of identifying factors amenable to
re-design of a Rapid Response System. Peebles, Emma et al. Resuscitation,
83(6):782-787
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realis...
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realise that some form of compulsory pre-
hospital training in all medical curriculums is only likely to happen if
the General Medical Council specifically requests it.
However at present, evidence to illustrate to the GMC the real value of
such training is lacking. This must change if it is to be a credible
competitor for precious curriculum time.
The Undergraduate Pre-Hospital Care Committee hopes that through co-
ordination of student pre-hospital care events, sharing of information and
literary review, as well as a now standardised and followed-up feedback
system for pre-hospital training, the evidence-base will grow. I urge
anyone involved in student pre-hospital care activities throughout the UK,
to get in touch with the Committee and together let's make sure the
necessary evidence for such vital training actually exists.
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical gradua...
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical graduates have knowledge of twenty first century management of emergencies in the pre-hospital situation. However in this area of medicine, where any medical practitioner can unexpectedly be required to help, it is important to ensure all medical graduates have knowledge of what interventions should not be undertaken as well as these that should be undertaken.
With a new GMC recognised sub-speciality of Pre-Hospital Emergency Medicine it is timely that the teaching of undergraduate of pre-hospital emergency medicine is standardised within the undergraduate curriculum.
Yours sincerely
Dr Colville Laird,
Chairman of The Faculty of Pre-hospital Care RCSEd
Email: claird@basics-scotland.org.uk
Mobile: 07768855798
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was...
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was the main driver of my practice style. It was
very rewarding and I am thrilled to see it championed so.
We were surprised by the EMJ decision to publish the study by Scotter et al (1) A number of previous studies including those studied by Scotter and colleagues have concluded that bilateral, fixed, dilated pupils in the context of severe head injury are not universally predictive of poor outcome. Performing a meta-analysis of five, retrospective, cohort studies, one of which was conducted before 1988 does not change this m...
Just to clarify, they can be cut off using the same tool for cutting off precious metal rings found in most high street jewellers. Probably the only stipulation is that the blade is in new/really good condition and lubrication is used e.g. Aquagel,(although a lubrication oil on the blade such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with irrig...
Dear editor I wish to congratulate the authors of the HIRT trial on finally publishing their results. Whilst a negative trial for primary outcomes, to me it highlighted the major challenges in conducting high quality RCTs in prehospital setting. Few countries have been able to perform this level of prehospital research and it can only advance the future planning of prehospital studies trying to examine the very same questi...
We congratulate the authors on this excellent piece of work and are particularly pleased to see method of arrival in their tool as a predictor of admission. In a similar piece of work to predict surgical admissions in our institution we found the same effect (1). At a time when it seems to be politically expedient to scapegoat patients for the overcrowding in our departments and lack of available beds on the wards it is...
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding us of what is our primary objective as healthcare providers -- to relieve pain and suffering; and for providing the evidence that suggests that we often are failing in this objective. As medical crewmembers in helicopter EMS, we appreciate the need to elicit accurately, and to relay effective...
I read with interest the study by Bloch and Bloch demonstrating the effectiveness of observation-based simulation training. As they discussed, simulation training not only improves attendees' knowledge and skills but can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on a departmental basis. However, increasingly emergency medicine involves a multidi...
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre- Hospital Training should be included in all Undergraduate Medical Curriculums. They will be pleased to hear that a nationwide Faculty of Pre -Hospital Care Undergraduate Committee has been set-up, aiming to springboard ideas and information about events, funding and training in pre-hospital care, to all healthcare students. Antrum and Ho quite rightly realis...
Dear Editor
ANTRUM AND HO (EMJ 2015;32:171-172)
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical gradua...
Your article on ED patients' suffering came to me only this week through Medscape.com. I would like to thank you for your analysis and for bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in the scientific literature. When I started practice in 1983 in a busy urban academic Emergency Department in Baltimore, Maryland, and for the next twenty-five years, THIS was...
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