24 e-Letters

published between 2020 and 2023

  • Behind the scenes of COVID-19- Thoughts about illicit drug use during a pandemic

    The enforcement of lockdown in the UK in March 2020 saw businesses shut up shop and most of the general population barricade themselves in the safety of their homes. NHS and community facilities had to implement downgraded versions of their services to comply with social distancing with a reduced workforce available to deliver these services. One such cohort affected by these measures is those who take recreational drugs, either socially or habitually.

    The number of people who use recreational drugs regularly is unknown. NHS Digital data states that there were 14,053 patients admitted to hospital with ‘poisoning by illicit drugs’ in England in 2018. 53% of these patients were male and two-thirds fell into the 16-44yrs age bracket. Men were more than twice as likely to use cannabis or cocaine compared to women and older age groups were more likely to use opiates alone (1).

    One in 12 adults were found to have taken an illicit drug between 2016 and 2017 (1). Whilst lockdown may have caused many inconveniences to the everyday lives of most of us, many habitual drug users have found themselves with additional stressors extending beyond contracting COVID-19 itself. This may not be someone’s chosen path in life but it is the reality that many are living with. This lifestyle is intertwined with medical and psychological difficulties which may necessitate NHS support.

    If your first thought upon waking is how you are going to obtain your next fix, then how are...

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  • Sustainable models of rostering for COVID19 crisis

    The courage with which emergency medicine specialists are responding to COVID19 crisis is admirable. They are in a situation similar to the battlefields of first World War. It is a protracted war unlike the disasters and tsunamis that we have faced in recent times. Lord Moran in his seminal book "The Anatomy of Courage" based on his WW1 experience of treating medical emergencies had noted that battle fatigue would set in the most courageous of soldiers after 30 days of trench warfare. This led to the deployment of battalions in formations, which provided relief to those in the front lines through planned rotation. This model may be useful in developing systems of rostering which provide planned periods of relief and recuperation for medics and paramedics manning the front lines of COVID 19 crisis.

  • NEWS used without clinical judgement is of limited value

    Finnikin and colleagues describe a large data set of retrospectively calculated National Early Warning Scores (NEWS) in a system that was not using or responding to NEWS. Understanding the relationship between NEWS and referral practices is an important area of research which could help shed some light on the impact of introducing NEWS into primary care.

    The first important point is that only 31% (74,992/242,451) of patients who had face-to-face encounters had a full set of observations and the clinical characteristics of the 69% excluded from the study are unknown. In our experience, GPs tend to perform a full set of observations on patients who appear more unwell so it is possible that the population studied may not be representative.

    Finnikin and colleagues found that only 6.9% of patients referred to hospital had a NEWS≥5 and 69% with a NEWS ≥5 were not referred. There is emerging evidence that NEWS calculated by GPs at referral correlates with mortality (data from West of England accepted for publication) so the fact that it did not correlate with referral is of concern. Scott et al in the West of England (1, 2) and Inada Kim et al in Wessex (unpublished data) have demonstrated that the higher the NEWS on referral or arrival, the more likely the patient is to be admitted and the more likely the patient is to die.

    The lack of linkage to any outcomes is a major weakness of this work. While an increase in admissions of 16.2% is not ideal in an alr...

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  • Overdiagnosis and typicality of symptoms in suspected myocardial infarction

    Both in the context of suspected acute myocardial infarction(AMI)(1) and in the context of its close mimic, suspected pulmonary embolism(PE)(2) there is an appreciable risk of overdiagnosis even when clinicians rely on typicality of AMI symptoms(1) or typicality of PE symptoms the latter as portrayed in clinical decision rules(2). Furthermore, both AMI and PE may have, in common, some atypical features such as atypical retrosternal pain(3)(4), which may sometimes be associated with raised serum troponin(4), and ST segment elevation in the absence of coronary artery occlusion, a feature documented both in Type 2 AMI(5) and also in PE(6). The differential diagnosis of atypical retrosternal pain also includes atypical thoracic aortic dissection(TAD) where the atypical feature may be the absence of back pain in a patient presenting with retrosternal pain.(7). In view of these considerations(3)(4)(5)(6)(7) the time is long overdue for point of care transthoracic echocardiography(TTE) to be incorporated into the IMPACT protocol to facilitate the distinction between AMI, PE, and TAD. TTE would identify stigmata of PE such as right ventricular dilatation, elevated pulmonary artery systolic pressure(8), or even pulmonary emboli in transit through the cardiac chambers . Furthermore, when appropriately focused, TTE can identify "red flags" for TAD such as direct signs of TAD(for example presence of an intimal flap separating two aortic lumens), thoracic aortic d...

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