The article draws our attention on the necessity of the correct
procedures during the interhospital transfers, which demand 1) the
stabilization of the patient before the transfer 2) an appropriate
decision of the transfer and communication between referring and receiving
teams 3) an adequate level of care during the critical moment of the
transfer.
Many guidelines of the scientific societies supp...
The article draws our attention on the necessity of the correct
procedures during the interhospital transfers, which demand 1) the
stabilization of the patient before the transfer 2) an appropriate
decision of the transfer and communication between referring and receiving
teams 3) an adequate level of care during the critical moment of the
transfer.
Many guidelines of the scientific societies support these procedures.
Probably, at least in Italy, the problem is not yet perceived in its
complexity.
Exist as well here “guidelines for the clinical-organization criteria of
the transfer of a patient in critical conditions” (A.S.P. – Agenzia di
Sanità Pubblica- Lazio, 2002) which reflect perfectly the ones mentioned
in the article and which are applied only partially.
Our relative experience in the Department of Emergency (D.E.) of the 2nd
level of the Policlinic Umberto 1st in Rome is following: from 1st of
January until June 30th, 2006, 861 accesses to the Emergency unit,
(1,1%, out of 77.597) were transferred from other hospitals to D.E. of
Policlinic.
Out of those 861, 361 (41,92%) were transferred in the critical clinical
conditions of these patients (according to the Kellermann’s criterions):
the transfer was considered appropriate (first criterion of the guidelines
of A.S.P.).
Other 500 patients out of 861 (58,07 %) were transferred in non-critical
clinical conditions, but with the request of consultancy or/and specialist
therapy (eg. neurosurgery, heartsurgery ); the necessity of competence was
confirmed for 230 patients (46%): the transfer was considered appropriate
(second criterion of the A.S.P. guidelines).
The specialist competence was excluded in 270 cases (54%) and the transfer
was considered inappropriate because of the presence of at least one of
following characteristics: the case was not particularly complex or the
resources and competences required for the adequate care were present in
the sending hospital. If the trasfert is inappropriate, it will involve
risk during the transport for the patient and the staff.
These data are an anticipation of our research; the elaboration of all
the data is taking place right now.
In our practice this vagally-mediated response to sublingual GTN is
not uncommon, and perhaps occurs more frequently in nitrate-naive
patients. Indeed this is the basis for its use in head-up tilt testing,
where it increases the sensitivity of the procedure to induce vaso-vagal
syncope. The traditional attribution of this response to the 'Bezold-
Jarish' reflex is now considered unlikely, although c...
In our practice this vagally-mediated response to sublingual GTN is
not uncommon, and perhaps occurs more frequently in nitrate-naive
patients. Indeed this is the basis for its use in head-up tilt testing,
where it increases the sensitivity of the procedure to induce vaso-vagal
syncope. The traditional attribution of this response to the 'Bezold-
Jarish' reflex is now considered unlikely, although credible alternative
explanations are few! The apparent use of aspirin to treat this patient's
hypertension is also worthy of comment.
I read this work with interest ..indeed CT examination can determine
contrast material leakage to the lesser sac and different peritoneal
spaces ,but ultrasonography with proper oral contrast can do the same .
gstrosonography is indicated for several reasons . gastric masses, gastric
polyps, reduced gastric capacity , wall thickening ,gastroesophegeal
reflux ,gastrodudenal reflux and gastric perfor...
I read this work with interest ..indeed CT examination can determine
contrast material leakage to the lesser sac and different peritoneal
spaces ,but ultrasonography with proper oral contrast can do the same .
gstrosonography is indicated for several reasons . gastric masses, gastric
polyps, reduced gastric capacity , wall thickening ,gastroesophegeal
reflux ,gastrodudenal reflux and gastric perforation, all can be seen with
careful examination . with use of a gelatian as an oral contrast material
all gastric wall layers can easily seen . the gelatin can be prepared
from the gelatin capsules[ e.g. antibiotic capsules after their evacuation
] by boiling one of them in the water or from a hard gelatin used for
sweet production . a few drops aided to the water can produce a
hyperechoic fluid in its early phase . by rapid examination of the
traumatized patient any gastric leakage can be detected by seeing the
hyperechoic material out side the stomach . the late phase of the contrast
is hypoechoic in nature . pancreas is easily seen by using the full
stomach as a window pancras {head-body-tail - ] splenic hilum ,left renal
vein and artery all can be examined . gelatin is not harmful as we
already use it as a drug or food ,easily prepared , stored even at room
temperature, cheap and has two phases of echogenisty and long acting
[its action lasts for 25 minutes at least ]
The recent Best Evidence topic report article by Fayomi (1), clearly
illustrates the dangers of too narrow a focus when practising Evidence
Based Medicine. Firstly, the search strategy is too narrow, as three
papers (2, 3, 4) which have studied this have been missed. All of these
papers found tissue turgor time to be closely associated with the presence
of dehydration, while the paper cited by Gore...
The recent Best Evidence topic report article by Fayomi (1), clearly
illustrates the dangers of too narrow a focus when practising Evidence
Based Medicine. Firstly, the search strategy is too narrow, as three
papers (2, 3, 4) which have studied this have been missed. All of these
papers found tissue turgor time to be closely associated with the presence
of dehydration, while the paper cited by Gorelick et al (5) found this
sign to be very specific, but of low sensitivity.
Secondly, the focus of the question is too narrow. A number of studies,
incuding Gorelick et al (5), has revealed that combination of clinical
findings traditionally associated with dehydration greatly enhanced
accuracy, sensitivity and specificity (4, 5, 6, 7, 8). Accuracy,
sensitivity and specificity figures of over 80% have been published, with
combinations of clinical signs (5). In addition, some of these papers have
demonstrated improvements in clinical care of the dehydrated patients with
the use of scoring systems for dehydration based on combinations of
clinical signs.
Many of the clinical signs of dehydration individually have high
specificity , but low sensitivity. Combinations of signs are more
accurate, especially when used by experienced clinicians, and are probably
accurate for lower levels of dehydration than classically taught (4, 5, 6,
7, 8). There is a tendency therefore to over-estimate the level of
dehydration, and this can lead to over-treatment. However, there is an
absence of any useful proven prospective diagnostic tools, and clinical
examination is still an therefore an acceptable method for determining
treatment.
The usefulness of the Best Evidence topic reports have been debated in the
correspondence section of the EMJ on previous occasions, it should be
remembered that like all medical literature, interpretation and
implementation should be considered with caution, especially with regard
to a wider, more strategic aspect.
Yours faithfully
Simon Smith
Consultant in Emergency Medicine
References
1 Fayomi O. ‘Is skin turgor reliable as a means of assessing hydration
status in children?’ Emerg Med J. 2007; 24(2); 124-125
2 Laron Z. ‘Skin turgor as a quantitative index of dehydration in
children.’ Pediatrics. 1957; 19:816-22
3 Mackenzie A, Barnes G, Shann F. ‘Clinical signs of dehydration in
children.’ Lancet. 1989; 2:605-607
4 Duggan C, Refat M, Hashem M, et al. ‘How valid are the clinical signs of
dehydration in infants?’ J Pediatr Gastroenterol Nutr 1996; 22: 56-61
5 Gorelick MH, Shaw KN, Murphy KO. ‘Validity and reliability of clinical
signs in the diagnosis of dehydration in children.’ Pediatrics. 1997;
99(5)
6 Vega RM, Avner JR. ‘A prospective study of the usefulness of clinical
and laboratory parameters for predicting percentage of dehydration in
children.’ Pediatr Emerg Care. 1997; 13:179-19
7 Santosham M, Brown KH, Sack BB. ‘Oral rehydration therapy and dietary
therapy for acute childhood diarrhoea.’ Pediatr Rev. 1987; 8:273-278
8 Fortin J, Parent MA. ‘Dehydration scoring system for infants.’ Trop
Pediatr Environ Child Health. 1978; 24:110-114
In the study by Menzies and Manji[1] which aimed to test the ability
of paramedics to utilise the intubating laryngeal mask airway (ILMA) to
intubate a manikin, the authors state that the ILMA has a learning curve,
and that the results from their study reflected this.
It is certainly true that early papers drew attention to a learning
curve, and there were suggestions that it could take up...
In the study by Menzies and Manji[1] which aimed to test the ability
of paramedics to utilise the intubating laryngeal mask airway (ILMA) to
intubate a manikin, the authors state that the ILMA has a learning curve,
and that the results from their study reflected this.
It is certainly true that early papers drew attention to a learning
curve, and there were suggestions that it could take up to twenty uses for
an operator to become proficient at intubation via the ILMA.[2] However,
the ‘educated jiggle’ that enabled early users to become proficient at
intubation was clarified during fibreoptic studies undertaken by
consultant anaesthetist, Dr Chandy Verghese. Careful attention to his two-
stage technique (commonly called the “Chandy manoeuvre”[3]) has greatly
improved first-time success rates for intubation via the ILMA and has all
but eliminated the lengthy learning curve previously described.
The first part of the Chandy manoeuvre involves grasping the ILMA by
its handle and moving it back and forth in the sagittal plane while noting
the tidal volume and resistance to manual ventilation, in order to
optimise ventilation through the device. The second part then involves
lifting the handle of the ILMA at a 45° angle to the patient's chest. This
helps to align the angled ramp inside the mask’s distal airway aperture
with the longitudinal axis of the upper trachea, so facilitating smooth
passage of the tube into the trachea.
In their paper, Menzies and Manji omit to say if the Chandy manoeuvre
was taught to their paramedics. One is inclined to assume that it was,
since we are told that 21/23 (91.3%) of the group were able to intubate
the manikin via the ILMA at the first attempt, despite the fact that none
had previous exposure to the device and the group had received only a
short lecture and instructions in its insertion. One paramedic required a
second go and the remaining candidate succeeded at the third attempt. I
would suggest that the results contradict the authors’ assertion that
there was a significant learning curve for intubation via the ILMA amongst
the paramedics in their study. The results were all the more impressive
for the fact that all 23 candidates had been unable to intubate the
manikin in this 'difficult intubation' scenario using a Macintosh
laryngoscope.
Whether or not the results could be replicated in actual patients
remains to be tested, but the high first-time success rate in this manikin
study would appear to justify further investigation. In a case report
published in 2001[4], I concluded that the ILMA might be of value, both as
an airway adjunct in its own right and as a device to facilitate tracheal
tube placement, in situations where pre-hospital care providers possess
limited intubation skills. My subsequent prehospital experience with the
ILMA has confirmed its utility in trauma situations, both as a rescue
ventilation device and as a seamless method for tracheal intubation. The
current availability of an affordable, single-use version of the ILMA,
coupled with the findings of Menzies and Manji, should encourage further
study by UK ambulance services.
REFERENCES:
1. Menzies R, Manji H. The intubating laryngeal mask: is there a role
for paramedics? Emerg. Med. J. 2007;24;198-199.
2. Baskett PJF, Parr MJ, Nolan JP. The intubating laryngeal mask.
Results of a multicentre trial with experience of 500 cases. Anaesthaesia
1998;53:1174-9.
3. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use
of the intubating LMA-Fastrach in 254 patients with difficult-to-manage
airways. Anesthesiology. 2001;95:1175–1181.
4. Mason AM. Use of the intubating laryngeal mask airway in pre-
hospital care: a case report. Resuscitation 2001;51:91-95.
Competing interests: AMM is clinical adviser to The Laryngeal Mask
Company Ltd, St Helier, Jersey, Channel Islands, UK; and also to Intavent
Orthofix Ltd, Maidenhead, UK, distributor of LMA devices in the UK and
Eire. Both are unsalaried positions, but the author has received payment
for advisory work undertaken for both companies in connection with the use
of LMA devices in prehospital care.
Scaphoid fracture is considered the most frequent fracture among the
carpal bone fractures . it has a high rate of complication .early
detection and proper management prevent this complication . conventional
and helical CT can detect this type of fracture . multiplanar examination
require coronal and axial reconstruction whish is not as the same quality
as the axial cuts . real coronal and sagit...
Scaphoid fracture is considered the most frequent fracture among the
carpal bone fractures . it has a high rate of complication .early
detection and proper management prevent this complication . conventional
and helical CT can detect this type of fracture . multiplanar examination
require coronal and axial reconstruction whish is not as the same quality
as the axial cuts . real coronal and sagittal cuts are required .to
overcome this problem we used special techniques . for sagittal cuts the
patient lie in prone position with abducted shoulder , flexed elbow and
extended wrist the scanogram is done . and the cuts are taken at the same
technique as the axial cuts .for the coronal cuts abduction of the
shoulder and flexion of the elbow and external rotation of the wrist with
the palm of the hand is supported on the head is the ideal technique . the
scanogram is taken and the examination is continued as the axial technique
. the coronal examination is more familiar to the physician but the
sagittal cuts are more accurate in detection of cortical disruption . the
speed of multidetector CT is more beneficial for moving organs to complete
the examination in one breath. but with static examination of the wrist it
has only one advantage to reduce radiation dose .The radiation dose in
spite this high speed is fivefolds the radiation dose of the helical CT.
with multidetector examination as the reconstruction of the images have
the same quality as the original examination so we recommend to examine
the affected hand in coronal cuts with small width and shorter time of
examination with focused rays on the hand to decrease the pitch so the
total dose is markedly reduced . however if we examine the patient in real
axial ,coronal and sagittal technique the total dose is 60% of single
examination of the multidetector CT .the high dose of radiation with the
high incidence of carpal bone fractures at young adult will increase the
risk of cancer as they have long life expectancy than elderly peoples
.so CT examination should be done with failure of other modalities to
catch the carpal fractures . the ultrasonography can diagnose any cortical
bone discontinuity in any of carpal bones .but due to high rate of
scaphoid fracture the ultrasonography research is directed to this bone .
the radio-luno-capitate axis is considered the main landmark in sagittal
plain . to catch the other carpal bones we advise to begin with the base
of the metacarpal bones and follow the know anatomy .in sagittal view
bony discontinuity is detected and any related hematona is seen . in axial
view the double contour of the fractured bone is seen . increase the gain
and zooming will focus the attention to the bony surfaces .soft tissue
examination is another advantage of ultrasonography . so ultrasonography
should be the first modality of imaging that used in wrist injuries we
should remember that multidetector CT availability dose not mean
safety........
We welcome the stimulating comments of Quinn et al. in response to our previously published paper. We recognise that the topic breached here is both an emotive one and also in the main very subjective.
It is extremely difficult to conduct a direct comparison of paramedic -led versus physician-led performance on exactly the same case, other than
through moulage scenarios. No two pre-hospital c...
We welcome the stimulating comments of Quinn et al. in response to our previously published paper. We recognise that the topic breached here is both an emotive one and also in the main very subjective.
It is extremely difficult to conduct a direct comparison of paramedic -led versus physician-led performance on exactly the same case, other than
through moulage scenarios. No two pre-hospital care missions are ever the
same, and we agree with Quinn at al. that there are a multitude of
confounding factors, many of which are beyond being controlled for. It is
therefore that we feel that the situation at the Great North Air Ambulance
was unique in trying to address these issues as virtually all controllable
confounders (equipment, crew number, mission case mix) were actually
matched for both groups (other than entrapments). We also recognise that
our study was not powered to look at some of the main issues, as sample
sizes in excess of 2000 cases would have been required, clearly exceeding
the annual flight mission numbers of virtually any HEMS provider in the
UK.
But apart from all that, attendance time is only one performance
indicator in pre-hospital medicine, and in our opinion is of less
importance than the quality of care delivered at the roadside and, of
course, ultimate patient outcome.
We agree with Quinn et al. that observational studies are what they
say: observation, and are therefore of a rather low evidence level. But
observations do one thing very well: they spark ideas for further
research.
Finally, we welcome Quinn's et al. call for well-formulated,
structured and collaborative research proposals in order to address the
issues surrounding physician-delivered pre-hospital care in the UK.
Bibliographic errors are almost unknown if one can use reference
managers like EndNote, RefMan, ProCite etc. Reference managers are
reference management software packages, used to manage bibliographies and
references when writing articles. The software can not only download
references directly from the electronic databases like PubMed, EmBase etc.
but can also automatically format the citation into wh...
Bibliographic errors are almost unknown if one can use reference
managers like EndNote, RefMan, ProCite etc. Reference managers are
reference management software packages, used to manage bibliographies and
references when writing articles. The software can not only download
references directly from the electronic databases like PubMed, EmBase etc.
but can also automatically format the citation into whatever format the
user wishes from a list of over two thousand different styles. Instead of
spending hours typing bibliographies or using index cards to organize the
references(and forever increasing the chances of errors), one can do it
the easy way using these reference managers. Many reference managers like
Aigaion, Bibus, Connotea, JabRef, Pybliographer etc are open source and
are available free of cost. Use of reference managers can make
bibliographic errors a history.
Intramuscular hematomas may presented with huge cystic masses, tender on ultrasonography
examination with peritoneal or pleural reaction that make the diagnosis
so diffecult to know the real origin of the cystic mass.To solve the
problem of
examining the tender masses thick layer of gel is used to reduce the
direct contact of the probe with the tender masses . in c...
Intramuscular hematomas may presented with huge cystic masses, tender on ultrasonography
examination with peritoneal or pleural reaction that make the diagnosis
so diffecult to know the real origin of the cystic mass.To solve the
problem of
examining the tender masses thick layer of gel is used to reduce the
direct contact of the probe with the tender masses . in cases that
show uncertain origin the ultrasonographic aspiration after local
infiltration anesthesia should be done . this will help in =1-
determine
the nature of the fluid content
=2 – reduce the size of the cystic mass to normalize the disturbed
anatomy and the site of origin could be determined =3- reduce the
tension
inside the muscle and reduce the pain intensity= 4- reduce the need of
surgical intervention as a diagnostic tool and in some cases with
marked
reduction of mass the conservative treatment may be a good alternative
to
therapeutic surgical intervention . this ultrsonographic intervention
is
practically used in cases of rectus sheath, Pectorals muscle
haematomas
with or without intraperitoneal or intrapleural reaction respectively
the simple aspiration for just reduction of cystic masses is used
also
in the intra-abdominal cystic masses of uncertain origin . in
contrast
cystic masses with suspected origin that rise the danger of aspiration
like complicated aortic aneurysm the intraperitoneal injection of
saline
can clearly differentiate the retroperitoneal from intraperitoneal
masses . the suprarenal and pelvic masses can be clearly localized by
this preoperative technique
Negative exploration results dose not denote absence of foreign
bodies. It is interesting to describe an unusual case. 12 years old boy
explored twice with negative results for foreign bodies. By plain X ray
there was no foreign body. By ultrasonography the wooden foreign body
was located at the FPL tendon in its long axis. at the time of soft
tissue abscess formation the tendon was in reactiv...
Negative exploration results dose not denote absence of foreign
bodies. It is interesting to describe an unusual case. 12 years old boy
explored twice with negative results for foreign bodies. By plain X ray
there was no foreign body. By ultrasonography the wooden foreign body
was located at the FPL tendon in its long axis. at the time of soft
tissue abscess formation the tendon was in reactive stage so he had
exploration twice with negative results .Intratendinous wooden foreign
body is extremely rare . This is a extremely rare finding by
ultrasonography . So ultrasonography should be the first imaging modality
prior to exploration ... thanks
Dear Editor
The article draws our attention on the necessity of the correct procedures during the interhospital transfers, which demand 1) the stabilization of the patient before the transfer 2) an appropriate decision of the transfer and communication between referring and receiving teams 3) an adequate level of care during the critical moment of the transfer. Many guidelines of the scientific societies supp...
Dear Editor,
In our practice this vagally-mediated response to sublingual GTN is not uncommon, and perhaps occurs more frequently in nitrate-naive patients. Indeed this is the basis for its use in head-up tilt testing, where it increases the sensitivity of the procedure to induce vaso-vagal syncope. The traditional attribution of this response to the 'Bezold- Jarish' reflex is now considered unlikely, although c...
Dear Editor
I read this work with interest ..indeed CT examination can determine contrast material leakage to the lesser sac and different peritoneal spaces ,but ultrasonography with proper oral contrast can do the same . gstrosonography is indicated for several reasons . gastric masses, gastric polyps, reduced gastric capacity , wall thickening ,gastroesophegeal reflux ,gastrodudenal reflux and gastric perfor...
Dear Editor,
The recent Best Evidence topic report article by Fayomi (1), clearly illustrates the dangers of too narrow a focus when practising Evidence Based Medicine. Firstly, the search strategy is too narrow, as three papers (2, 3, 4) which have studied this have been missed. All of these papers found tissue turgor time to be closely associated with the presence of dehydration, while the paper cited by Gore...
Dear Editor
In the study by Menzies and Manji[1] which aimed to test the ability of paramedics to utilise the intubating laryngeal mask airway (ILMA) to intubate a manikin, the authors state that the ILMA has a learning curve, and that the results from their study reflected this.
It is certainly true that early papers drew attention to a learning curve, and there were suggestions that it could take up...
Dear Editor
Scaphoid fracture is considered the most frequent fracture among the carpal bone fractures . it has a high rate of complication .early detection and proper management prevent this complication . conventional and helical CT can detect this type of fracture . multiplanar examination require coronal and axial reconstruction whish is not as the same quality as the axial cuts . real coronal and sagit...
Dear Editors,
We welcome the stimulating comments of Quinn et al. in response to our previously published paper. We recognise that the topic breached here is both an emotive one and also in the main very subjective.
It is extremely difficult to conduct a direct comparison of paramedic -led versus physician-led performance on exactly the same case, other than through moulage scenarios. No two pre-hospital c...
Dear Editor
Bibliographic errors are almost unknown if one can use reference managers like EndNote, RefMan, ProCite etc. Reference managers are reference management software packages, used to manage bibliographies and references when writing articles. The software can not only download references directly from the electronic databases like PubMed, EmBase etc. but can also automatically format the citation into wh...
Dear Editor .
Intramuscular hematomas may presented with huge cystic masses, tender on ultrasonography examination with peritoneal or pleural reaction that make the diagnosis so diffecult to know the real origin of the cystic mass.To solve the problem of examining the tender masses thick layer of gel is used to reduce the direct contact of the probe with the tender masses . in c...
Dear Editor
Negative exploration results dose not denote absence of foreign bodies. It is interesting to describe an unusual case. 12 years old boy explored twice with negative results for foreign bodies. By plain X ray there was no foreign body. By ultrasonography the wooden foreign body was located at the FPL tendon in its long axis. at the time of soft tissue abscess formation the tendon was in reactiv...
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