How refreshing to read the excellent consensus view on pre-hospital
fluid resuscitation. At last it appears that a useful regimen is beginning
to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg
crystalloid bolus, repeated once if required and then followed by a third
bolus...
How refreshing to read the excellent consensus view on pre-hospital
fluid resuscitation. At last it appears that a useful regimen is beginning
to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg
crystalloid bolus, repeated once if required and then followed by a third
bolus of blood in extreme hypovolaemia still hold true?
2. In young shocked children, should we even permit the quoted two
attempts at cannulation before reaching for the relatively straightforward
and woefully under-utilised intraosseous needle?
3. Are there any indications at all for pre-hospital colloids...or
should all stocks be consigned to the realms of history?
4. In head-injured patients, is there a consensus view on the target
systolic pressure that should be sought in order to preserve cerebral
perfusion?
Hopefully these issues will be clarified in the not too distant
future, such that all pre-hospital emergency providers will be able to
offer uniform, evidence-based management, whilst awaiting that ever-
elusive ideal resuscitation solution!
We read with interest the well written article on infant head
injury [1]. We agree with the authors that there is little published data
on head injury specific to this age group.
The authors of this study do not comment on the distribution of head
injury with age from birth to one year. Our own study of 108 infants,
presenting over a two year period, suggests there may be a prevalence of...
We read with interest the well written article on infant head
injury [1]. We agree with the authors that there is little published data
on head injury specific to this age group.
The authors of this study do not comment on the distribution of head
injury with age from birth to one year. Our own study of 108 infants,
presenting over a two year period, suggests there may be a prevalence of
more severe head injury in the younger child [2]. Specifically, 20 (19%)
children were under 4 months, and 4 (20%) of these had major head injury.
This contrasts with only 1 (1%) major head injury in 88 children over 4
months. Further analysis has revealed that the pattern of causation is
different between these two groups. The younger immobile children have
predominately been dropped while being carried. This may result in fall
from a greater height, and subsequent greater injury.
It is important to recognise that head injuries, presenting to
emergency departments, may not be equally distributed through the first
twelve months of life in terms of numbers, mechanism of injury and
likelihood of serious head injury. We would suggest that children under
4months need especially close attention when presenting with head injury.
J. Gray
P. O’Connor
S. McGovern
References
1. Browning J, Reed M J, Wilkinson, A G , Beattie T. Imaging infants
with head injury: effect of a change in policy. Emerg Med J 2005;22: 33-
36.
2. O’Connor P, Gray J, McGovern S. Trends in head injury in children
under 1 year old presenting to an Emergency Department. (poster
presentation accepted 3rd European Congress of Emergency Medicine,
Leuven February 2005).
I read with interest the article and discussion on human bite
injuries by Henry et al (EMJ 2007; 24:455-458). I would like to make
reference to the particular importance of irrigation and debridement of
any such wound involving dental flora, as well as the high index of
suspicion required in an often unreliable cohort of patients.
We recently had a patient present to our department with a...
I read with interest the article and discussion on human bite
injuries by Henry et al (EMJ 2007; 24:455-458). I would like to make
reference to the particular importance of irrigation and debridement of
any such wound involving dental flora, as well as the high index of
suspicion required in an often unreliable cohort of patients.
We recently had a patient present to our department with a delayed
presentation (two weeks) of a metacarpal injury to his dominant hand
following a dental-related closed fist injury. He had a fluctuant swelling
over his third metacarpal head and an extensor lag of 10-15 degrees
(although, surprisingly, otherwise normal range of movement). Clinical
suspicion resulted in exploration in theatre and evidence of both extensor
tendon damage and a significant septic arthritis. This resulted in
thorough intra-articular and soft tissue irrigation as well as a degree of
surgical debridement.
Unfortunately, as an oversight, antibiotics were prescribed but not
dispensed and the patient was discharged without formal antimicrobials. On
reviewing the gentleman on day three he was making excellent clinical
progress and the decision was made to closely monitor and continue to
withhold antibiotics. He continued to make good clinical progress and made
an excellent recovery with full functional capacity.
Despite a significant septic arthritis this patient required no
antimicrobials and highlights once again the importance of meticulous
irrigation and debridement in the management of these cases.
The article by Dr N S Demiryoguran "on painless aortic dissection
with bilateral carotid involvement" is of great interest for emergency
physicians, reminding us of atypical presentations.
I would like to emphysis the fact that the patient had vertigo, the
dissection was likely to involve the posterior circulation also (vertebral
arteries). A collegue of mine, Dr Michel Garner, has published...
The article by Dr N S Demiryoguran "on painless aortic dissection
with bilateral carotid involvement" is of great interest for emergency
physicians, reminding us of atypical presentations.
I would like to emphysis the fact that the patient had vertigo, the
dissection was likely to involve the posterior circulation also (vertebral
arteries). A collegue of mine, Dr Michel Garner, has published a very good
article on that subject (MedActuel FMC May 2003)
A gentleman presented to A&E at Lancaster following an RTA, and
was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been
across the centre of the steering wheel at the time of airbag discharge,
which is when the mercedes emblem became branded on his forearm. The mark
remained on the patient's forearm some weeks late...
A gentleman presented to A&E at Lancaster following an RTA, and
was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been
across the centre of the steering wheel at the time of airbag discharge,
which is when the mercedes emblem became branded on his forearm. The mark
remained on the patient's forearm some weeks later, although the patient
took it in good humour.
Photo available on request (patient has given consent for
publication), please contact rmcglone@lineone.net
We read with interest Williamson et al. [1] study on the use of audio
prompts in automatic external defibrillators to improve cardiopulmonary
resuscitation (CPR) in untrained & trained lay subjects. We report a
study from an emergency department (ED) using trained ED staff (doctors
& nurses) and paramedics.
Through our own departmental video audit we have observed great
variability...
We read with interest Williamson et al. [1] study on the use of audio
prompts in automatic external defibrillators to improve cardiopulmonary
resuscitation (CPR) in untrained & trained lay subjects. We report a
study from an emergency department (ED) using trained ED staff (doctors
& nurses) and paramedics.
Through our own departmental video audit we have observed great
variability in the rate of external cardiac compressions (ECC); median 140
compressions per minute (cpm) & range 100-180 cpm. This rapid rate of
ECC is of concern since it is faster than the recommended 100cpm [2].
Studies suggest that rescuers may fatigue after only 1 minute of CPR [3]
and there is an associated decline in the quality of chest compressions
with time [4].
We undertook 2 separate studies to test specifically whether a piece
of music influenced the rate of ECC when compared to nothing and a
metronome and another study to test whether using a specially adapted
clock compared to a metronome influenced the rate of ECC. In both studies
participants were video taped whilst performing CPR on an intubated
resuscitation manikin for 3 minutes in the resuscitation bay of the
Emergency Department and the rate of ECC subsequently analysed by using
video playback.
In the first study 50 participants were randomised in blocks of 5 to
listen to a minute of silence followed by a second minute of a randomly
selected piece of music and then a final minute of a recording of a
metronome set at a 100 beats per minute (bpm). Participants were not told
that the metronome was set at 100bpm. Three pieces of music had a rate of
100bpm and one much less than 100bpm and another much faster than 100bpm.
In the second study 43 participants were randomised (blocks of 10) to two
groups either metronome or ‘resuscitation-clock’. The metronome group
listened to a minute of silence followed by 2 minutes of a recording of a
metronome set to 100bpm. The ‘resuscitation-clock’ group listened to a
minute of silence and were then asked to look at the ‘resuscitation-clock’
and use it to help time the rate of ECC. The resuscitation clock was
essentially a normal clock with the numerals removed and the figures 25,
50, 75 and 100 placed at 3, 6, 9 & 12 o-clock respectively.
In the first study the rate of ECC was not statistically different
between either the silence, music or metronome groups (Freidmans test
X2=3.6, p=0.16), range 54-156, median 116cpm. Those participants who had
received formal CPR training within 3 months of taking part in the study
did not have a statistically different rate of ECC compared to those
without recent training (Mann-Whitney U test=139. p=0.14). In the second
study the metronome group achieved the target compression rate with a mean
of 99.8 (95% CI 99.2 to 100.4), compared to clock group mean 106.9 (95% CI
101.6 to 112.2) and the control (silence) group mean 114.6 (95% CI 109.6
to 119.3).
We concluded that without the use of auditory prompts trained ED
personnel are poor at performing ECC at 100bpm even if recent formal CPR
training has taken place. The use of a simple auditory prompt can help
trained personnel perform ECC at the correct rate.
References
1. Williamson et al. Effects of automatic external defibrillator
audio prompts on cardiopulmonary resuscitation performance. Emerg Med J
2005; 22: 140-143.
2. Lockey A, Nolan J. Cardiopulmonary resuscitation in adults. BMJ 2001;
323:819-820.
3. Javier Ochoa F, Ramalle-Gomora E, Lisa V, Saralegui I. The effect of
rescuer fatigue on the quality of chest compressions. Resuscitation
1998;37:149-52.
4. Ashton A, McCluskey A, Gwinnutt CL, Keenan AM. Effect of rescuer
fatigue on performance of continuous external chest compressions over 3
min. Resuscitation 2002; 55:151-155.
As Anaesthetists we question the validity of the statement “rapid
sequence induction (RSI) can be performed safely in the district general
hospital (DGH) by both Anaesthetic and Emergency physicians, with
comparable success rates and complication rates”.
Firstly, we would consider the definition of successful intubation
“in less than or equal to three attempts”. Some failed intubation
al...
As Anaesthetists we question the validity of the statement “rapid
sequence induction (RSI) can be performed safely in the district general
hospital (DGH) by both Anaesthetic and Emergency physicians, with
comparable success rates and complication rates”.
Firstly, we would consider the definition of successful intubation
“in less than or equal to three attempts”. Some failed intubation
algorithms recommend two attempts others three to four yet all state that
patient position or equipment should be altered to enable success at
second attempt1,2,3,4,5,6. This emphasises the importance of a successful
first attempt, optimal patient positioning before intubation and
minimising repeat laryngoscopy.
The data demonstrate a higher rate of success on first attempt in the
Anaesthetic cohort compared to the Emergency Physician cohort (92%
compared to 82% p-value 0.056), further supported by Cormack-Lehane grade
I/II view 98% Anaesthetists, 86% Emergency Physicians (EP) (p-value
0.038).
Secondly, the groups differ in seniority of personnel with 60%
Anaesthetic intubations being performed by SHO’s compared to 11% EP SHO’s,
45% EP Consultants.
Thirdly, interpretation of the data is limited because the samples
differ significantly in age and are therefore not comparable. (Those
intubated by EP’s ranging form 6-88 years old, Median 51.5, those
intubated by Anaesthetists ranging form 0-82, Median 42, p-value 0.004).
This raises the possibility of selection bias in those intubated by
anaesthetists. It is not possible to determine if selection extrapolates
to other indications of difficult intubation as this is not documented.
The age difference between the groups is important clinically as
there are anatomical differences in infants and children influencing
intubation technique. The aetiology of the conditions requiring
intubation will vary with age as will co-morbidity and propensity to
develop specific complications e.g. children are more prone to de-
saturation where as the elderly are prone to hypotension at induction.
These confounding factors will limit interpretation of complication rates.
The omission of data regarding indication for RSI influences the
interpretation of success rates as certain circumstances e.g. trauma
necessitating C spine stabilisation will limit views at laryngoscopy. The
primary pathology may also effect the development of complications.
The study includes de-saturation, aspiration, oesophageal intubation,
trauma, hypotension and cardiac arrest as complications. The inclusion of
cardiac arrest as a direct complication of RSI is questionable. It may
be more likely to occur because of primary pathology or other complication
e.g. hypoxia, hypotension.
De-saturation occurred more frequently in those intubated by
Anaesthetists. This could be due to the age differences, complications of
RSI (e.g. endobronchial intubation) or primary pathology (e.g. difficult
ventilation in thoracic trauma).
The incidence of hypotension was equal between the groups yet both
were of similar haemodynamic stability prior to induction and Etomidate (a
more haemodynamically stable drug) was preferentially used by Emergency
Physicians. This could be due to an older age group, incorrect dose or
primary pathology.
As a single centre, observational study it can only provide
information regarding local practice and is unable to indicate intubation
procedure in all Scottish DGH. As it is neither randomised nor blinded so
may be prone to bias.
To Conclude: We think that this study shows the majority of RSI (56%)
were performed by Anaesthetists, that Emergency Physicians can perform
rapid sequence induction successfully when required and that the
acquisition of this skill is important for both specialities.
We agree that training of rapid sequence induction should highlight
the importance of a successful first attempt.
The European Working Time Directive and use of laryngeal mask devices
limits opportunity for trainees in both specialities to acquire this
skill. Trainee Emergency Physicians are further limited by the presence of
Anaesthetists, Anaesthetic trainees by the use of regional techniques
reducing the frequency of intubation/RSI. It is recognised that frequent
exposure to RSI/intubation is important for maintaining skills7
RSI and intubation are only one method of maintaining oxygenation and
ventilation. It must not be forgotten that oxygenation and ventilation
are key to survival8.
References
1. K G Allman, I H Wilson: Failed Intubation Oxford Handbook of
Anaesthesia 2004 37:874-875
2. G E Morgan, M S Mikhail, M J Murray: 2002 5:74-75
3. American Association Anaesthesiologists website
4. World Health Organisation Essential Surgical Care Manual website
www.steinergraphics.com/surgical005-145.1F.html
5. C Pinnock, T Lin, T Smith: Fundamental of Anaesthesia 2003 Ch 2 31-36
6. Difficult Airway Society RSI flow chart 2004.
www.das.uk.com/guidelines.rsi
7. T Heidegger, H J Greig, B Ulrich, G Kreienbuhl: Validation of a Simple
Algorithm for Tracheal Intubation: Daily Practice is key to success in
Emergencies- an assessment of 13,248 Intubations. Anaesthesia and
Analgesia 2001 92:517-522
8. J Hulme, G D Perkins: Critically injured patient, inaccessible airways
and laryngeal mask airways. Emergency Medical Journal 2005 22:742-744
The paper by Terris [1] on reducing waiting times in the ED using
consultant/Senior Nurse triage and subsequent papers by Subash on team
triage and Mitchell on Senior House Officer time-motion study in this
month's EMJ is giving me serious concerns we have missed the woods for the
trees. Our core activity of giving high quality emergency care to those who
truly need it is being diluted by the increasin...
The paper by Terris [1] on reducing waiting times in the ED using
consultant/Senior Nurse triage and subsequent papers by Subash on team
triage and Mitchell on Senior House Officer time-motion study in this
month's EMJ is giving me serious concerns we have missed the woods for the
trees. Our core activity of giving high quality emergency care to those who
truly need it is being diluted by the increasing demands of functioning as
a safety net for resource limited access to primary/community care.The
emergency department is now becoming an access path of least resistance
for one and all who choose to attend it as there is no waiting list for
appointments. Our efforts to improve the efficient processing of patients
who really need to attend as an emergency using yardsticks like 4 hour
processing is increasingly having a knock on effect in the general public
taking advantage of this efficiency.
Anecdotally I am certainly seeing
patients who are using us as a one stop convenient point of access for
minor injuries/illness simply because we are providing a far more efficient
service than their primary care providers. I don't personally have a
problem with who I see but lets not pretend we are only an emergency
department if we are masquerading as an easy access primary care
centre. Lets also not rush around like headless chickens processing
patients quickly here and there with so called consultant/senior nurse led
input/triage trying to keep these 4 hour targets if we are indeed
functioning as a glorified primary care centre. Lets also not deny junior
doctors the opportunity to undertake varied clinical activity just so they
can process patients quicker. There is a teaching and training function
that is integral to the future of the NHS as a whole and the papers seem
to suggest this is not happening as well as it should.
If a patient has to
wait because
a) a medical student has to be trained to take a good
history, examination, Inx or
b) a junior doctor gains confidence in making
decisions, deliberating on those decisions, discussing and learning lessons
from those decisions or
c) because a distressed wife of a cardiac arrest
victim needed the empathetic ear and care of a senior experienced senior
nurse that needs to be part and parcel of the service agreement.
I think
its time we put a brake on this fast food restaurant mentality in clinical
emergency medicine. For one thing, it's not sustainable without a massive
influx in the workforce at middle grade/ senior level in all departments
and there aren't the bodies out there for it. I think the job now is to
make the practice of emergency medicine and workplace clinically
stimulating, challenging and fun for all practitioners medical, nursing and
allied staff and the rest will take care of itself. I hope!.
References
(1) Terris J,
Leman P, O’Connor N, Wood R. Making an IMPACT
on emergency department flow: improving patient processing assisted by
consultant at triage.Emerg. Med. J., Sep 2004; 21: 537 - 541.
(2)
Subash F,
Dunn F, McNicholl B, Marlow J. Team triage
improves emergency department efficiency
Emerg. Med. J., Sep 2004; 21: 542 - 544.
(3) Mitchell J,
Hayhurst C, Robinson SM. Can a senior house
officer’s time be used more effectively?
Emerg. Med. J., Sep 2004; 21: 545 - 547.
I must congratulate the authors for coming up with such a simple flow
chart which is very clear regarding how should the junior doctors manage
Paracetamol overdose.
However,if I go by this flow chart then SHOs in Paediatrics prescribe
potentially hepatotoxic dose of Paracetamol to probably all the " high
risk groups". Consider the case of a child...
I must congratulate the authors for coming up with such a simple flow
chart which is very clear regarding how should the junior doctors manage
Paracetamol overdose.
However,if I go by this flow chart then SHOs in Paediatrics prescribe
potentially hepatotoxic dose of Paracetamol to probably all the " high
risk groups". Consider the case of a child with cystic fibrosis (or say
epilepsy on carbamazepine)who is reviewed for a viral fever and is
prescribed Paracetamol ( which in accordance with " Medicines for
Children" would be ) 15 mg/kg/dose, 4-6 hourly ( max 90mg/kg/day for kids
>3 months ). If we go by this flow chart ,then, if the child recieves 5
0r 6 doses over 24 hours then he is at risk of hepatotoxicity ( Iatrogenic
!!!). This apparant incompatibility between guidelines issued on behalf of
NPIS and " Medicines for Children" needs sorting out or further
clarification.
References
1)Wallace CI, Dargan PI, Jones AL. Paracetamol overdose : an evidence
based flow chart to guide management. Emerg Med J 2002;19:202-5.
2)The Medicines Committee of The Royal College of Paediatrics and Child
Health and Neonatal and Paediatric Pharmacists Group. Medicines for
Children 2003, page 470.London : Royal College of Paediatrics and Child
Health Publications 2003.
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding
emergency oxygen therapy. It also outlines a protocol for the management
of COPD patients that we feel differs only slightly from that proposed by
the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and
ou...
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding
emergency oxygen therapy. It also outlines a protocol for the management
of COPD patients that we feel differs only slightly from that proposed by
the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and
outcomes of 27 COPD patients treated with uncontrolled high-flow
oxygen(HFO) prior to or during emergency admissions to their hospital. PO2
values ranged between 9.6 and 37.7 kPa on HFO and were as low as 4.0 kPa
on room air. Respiratory acidosis was severe with a mean pH of 7.21 and 6
patients were incorrectly diagnosed as asthmatic.
This is typical of what happens in many other hospitals and is one of
the reasons why guidelines were developed in the North-West. The essence
of these guidelines is to start initially with HFO(to relieve hypoxia) and
then titrate it to maintain an oxygen saturation of 90-92%(to minimise
hypercapnia) . If this had been done in the above patients none would have
arrived at hospital with such high oxygen levels and the degree of
respiratory acidosis would have been much, much less.
Starting with HFO is deemed appropriate in a pre-hospital setting
because of the immediate dangers of hypoxia and the frequent lack of a
definite diagnosis in this setting illustrated well by the incorrect
initial diagnosis of many of the Norwich patients. Patients should only
stay on HFO if they need it .
Although not published in detail in the initial guidelines we did
mention an “alert system” which could be used to protect vulnerable COPD
patients, especially those with previous episodes of respiratory failure.
This has subsequently been added to the guidelines currently used in the
North-West. Here patients with known COPD are given a “COPD Alert” card by
their respiratory physician when seen as out-patients. On the card is
written a target oxygen saturation which corresponds to their PO2 when
stable and a recommended initial FiO2 which patients are to be started on
when they present with an acute exacerbation, based on the results of
previous blood gas measurements. Again the FiO2 is titrated upwards or
downwards to ensure this oxygen saturation is reached and to prevent over
or under-oxygenation. The target oxygen saturation is often between 85 and
90%, the recommended FiO2 is invariably 24 or 28% and Venturi masks are
recommended as soon as practical (usually on arrival in the Emergency
Department). The revised guidelines also advise limiting oxygen-driven
nebuliser treatment to 6 minutes for patients with COPD because many
patients spend their entire ambulance journey and much of the first hour
in the Emergency Department receiving high flow oxygen from a nebuliser
facemask.
The issue of using Venturi masks pre-hospital was also one we
considered. In rural areas when ambulance journeys are prolonged we felt
they should be used. However in urban areas where ambulance journeys are
often less than 10 minutes and patients are often being treated with
bronchodilators through oxygen driven nebulisers we felt that they would
be of limited value and may delay getting patients to hospital. We have
had some feedback from the Joint Royal Colleges Ambulance Liaison
Committee indicating agreement with this.
At present, we have received very positive feedback from different
sources around the UK. The guidelines we have produced are often very
similar to guidelines that have been developed for use in other regions as
is the case, we believe, with Norwich.
We are currently working closely with the above Joint Royal Colleges
Ambulance Liaison Committee, the British Association for Accident and
Emergency Medicine and the British Thoracic Society to try to get
agreement at a national level.
We would be happy to forward copies of the current guidelines and COPD Alert cards to anybody
who may be interested.
Please contact rossmurphy@doctors.org.uk
Dear Editor
How refreshing to read the excellent consensus view on pre-hospital fluid resuscitation. At last it appears that a useful regimen is beginning to emerge from the fog of controversey!
There are however several points that merit further clarification:
1. In paediatric trauma resuscitation, does the 20ml per kg crystalloid bolus, repeated once if required and then followed by a third bolus...
Dear Editor,
We read with interest the well written article on infant head injury [1]. We agree with the authors that there is little published data on head injury specific to this age group.
The authors of this study do not comment on the distribution of head injury with age from birth to one year. Our own study of 108 infants, presenting over a two year period, suggests there may be a prevalence of...
Dear Editor,
I read with interest the article and discussion on human bite injuries by Henry et al (EMJ 2007; 24:455-458). I would like to make reference to the particular importance of irrigation and debridement of any such wound involving dental flora, as well as the high index of suspicion required in an often unreliable cohort of patients.
We recently had a patient present to our department with a...
Dear Editor,
The article by Dr N S Demiryoguran "on painless aortic dissection with bilateral carotid involvement" is of great interest for emergency physicians, reminding us of atypical presentations.
I would like to emphysis the fact that the patient had vertigo, the dissection was likely to involve the posterior circulation also (vertebral arteries). A collegue of mine, Dr Michel Garner, has published...
DearEditor
A gentleman presented to A&E at Lancaster following an RTA, and was surprised when he was correctly identified as a Mercedes driver.
He was wearing a short sleeved shirt and his right arm had been across the centre of the steering wheel at the time of airbag discharge, which is when the mercedes emblem became branded on his forearm. The mark remained on the patient's forearm some weeks late...
Dear Editor,
We read with interest Williamson et al. [1] study on the use of audio prompts in automatic external defibrillators to improve cardiopulmonary resuscitation (CPR) in untrained & trained lay subjects. We report a study from an emergency department (ED) using trained ED staff (doctors & nurses) and paramedics.
Through our own departmental video audit we have observed great variability...
Dear Editor,
As Anaesthetists we question the validity of the statement “rapid sequence induction (RSI) can be performed safely in the district general hospital (DGH) by both Anaesthetic and Emergency physicians, with comparable success rates and complication rates”.
Firstly, we would consider the definition of successful intubation “in less than or equal to three attempts”. Some failed intubation al...
Dear Editor
The paper by Terris [1] on reducing waiting times in the ED using consultant/Senior Nurse triage and subsequent papers by Subash on team triage and Mitchell on Senior House Officer time-motion study in this month's EMJ is giving me serious concerns we have missed the woods for the trees. Our core activity of giving high quality emergency care to those who truly need it is being diluted by the increasin...
Dear Editors,
I must congratulate the authors for coming up with such a simple flow chart which is very clear regarding how should the junior doctors manage Paracetamol overdose. However,if I go by this flow chart then SHOs in Paediatrics prescribe potentially hepatotoxic dose of Paracetamol to probably all the " high risk groups". Consider the case of a child...
Dear Editor
We read with interest the above letter by Howard and Harrison.
It eloquently highlights the concerns many physicians have regarding emergency oxygen therapy. It also outlines a protocol for the management of COPD patients that we feel differs only slightly from that proposed by the North-West Oxygen Group (NWOG).
In their letter the authors describe the arterial blood gases and ou...
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