We read the paper by Chong et al. [1] with great interest. However, we
have some doubts regarding their random sample. They had a list of 194
emergency physicians (EPs) and 330 general surgeons (GSs). Every third
case in the list was selected. There should be about 64 EPs and 110 GSs in
their study sample. However, exactly 90% of the expected numbers of
physicians composed their EPs (58) and GSs (99)...
We read the paper by Chong et al. [1] with great interest. However, we
have some doubts regarding their random sample. They had a list of 194
emergency physicians (EPs) and 330 general surgeons (GSs). Every third
case in the list was selected. There should be about 64 EPs and 110 GSs in
their study sample. However, exactly 90% of the expected numbers of
physicians composed their EPs (58) and GSs (99) samples. Is this a
coincidence or systematic error ? Although there may be no significant
change to their final results, we believe a solid study method is
necessary to make any contribution to science.
References
1. Chong CF, Wang TL, Chang H. Evaluation of blunt abdominal trauma:
current practice in Taiwan. 2005;22:113-115.
We read the interesting paper by Mirò et al [1], who found that in
the emergency department (ED) weekends are not characterized by a loss of
effectiveness compared to workdays. The possible reduction in staff and
loss of attention on weekends is a topic still under debate. A recent
study [2] analyzed the six more common urgent procedures usually utilized
in acute care hospitals, and found that only 5...
We read the interesting paper by Mirò et al [1], who found that in
the emergency department (ED) weekends are not characterized by a loss of
effectiveness compared to workdays. The possible reduction in staff and
loss of attention on weekends is a topic still under debate. A recent
study [2] analyzed the six more common urgent procedures usually utilized
in acute care hospitals, and found that only 5% of these were performed on
the weekend. However, though these procedures are not performed on weekend
for scheduled activities, they are promptly available in the case of
urgency. In the recent past, traditional estimates of emergency physician
have been first based on merely quantistic analysis (volume of patients
seen in ED), and successively improved by the utilization of multivariate
formulas considering other parameters, eg, lenght to stay, intensity and
type of services. However, determination of emergency physician workload
derives from several considerations, and it’s not the same to face with a
myocardial infarction or a minor trauma .
But the problem is: which kind
of urgent diseases are more likely to occur on weekend?
Several studies
have shown that weekend time is less likely to be interested by acute
cardiovascular events. Myocardial infarction occurrence is increased by
approximately 20% on Monday compared with other days of the week [3], and
also cardiac arrests are higher on Mondays, with lowest numbers over the
weekend [4]. Again, a significant Monday peak in the occurrence of
ischemic stroke has been reported as well [5]. It has been speculated that
the transition from the quiet life on weekends and the patients’s activity
(or change in activity) on Mondays may be responsible for the lower
occurrence of myocardial infarction and stroke on Saturday and Sunday and
the peak on Monday.
This could explain why, despite the possible condition of both reduced
staffing and availability of services during weekends, the adjusted odds
of death for patients admitted on weekends is only slightly increased (OR:
1.03, 95% CI: 1.01 to 1.06) [6], and suggest a lower severity of cases
admitted on weekend. Since acute diseases referring to the hospital
respect a temporal pattern of occurrence, it is possible that quantity and
quality of ED staffs might take into account the increased demand of
specific facilities in certains hours of the day [7] and days of the week
as well. Only as an example, it could possible to suggest a “monday-load”
staffing pattern for ambulances equipped with high-trained personnel
staffs transporting cardiovascular patients. The maximum demand on
facilities and professional health expertise may occur during different
days of the week and varying depending on diseases itselves.
References
(1) Mirò O, Sanchez M, Espinosa G, Millà J. Quality and effectiveness
of an emergency department during weekends. Emerg Med J 2004;21:573-4.
(2) Bell CM, Redelmeier DA. Waiting for urgent procedure on the weekend
among emergently hospitalized patients. Am J Med 2004;117:175-81.
(3) Willich SN, Lowel H, Lewis M, et al. Weekly variation of acute
myocardial infarction. Increased Monday risk in the working population.
Circulation 1994;90:87-93.
(4) Peckova M, Fahrenbruch CE, Cobb LA, et al. Weekly and seasonal
variation in the incidence of cardiac arrests. Am Heart J 1999;137:512-5.
(5) Manfredini R, Casetta I, Paolino E, et al. Monday preference in onset
of ischemic stroke. Am J Med 2001;111:401-3.
(6) Cram P, Hillis SL,Barnett M, Rosenthal GE. Effects of weekend
admissions and hospital teaching status on in-hospital mortality. Am J Med
2004;117:151-7.
(7) Manfredini R, la Cecilia O, Boari B, et al. Circadian pattern of
emergency calls: implications for ED organization. Am J Emerg Med
2002;20:282-6.
I don't think the sgarbossa criteria are that useful. In the example
ECG, the 2 strikingly obvious criteria that would indicate acute MI are
the hyperacute T waves laterally (the absolute height of the T wave being
greater than that of the the QRS) and the high ST to T ratio laterally. It
is only Anterior MIs that are difficult to diagnose in the presence of
LBBB. The presence of hyperacute Ts is s...
I don't think the sgarbossa criteria are that useful. In the example
ECG, the 2 strikingly obvious criteria that would indicate acute MI are
the hyperacute T waves laterally (the absolute height of the T wave being
greater than that of the the QRS) and the high ST to T ratio laterally. It
is only Anterior MIs that are difficult to diagnose in the presence of
LBBB. The presence of hyperacute Ts is specific and sensitive. Pure
elevation thresholds are not. The only merit of the sgarbossa criteria is
that it'll pick up lateral elevation where there is usually depression and
T wave inversion without MI
We appreciate the thoughtful comments of Dr. Yen et al. regarding the
sampling process of our study. In our telephonic survey of doctors, every
third case from a list of 194 emergency physicians (EPs) and 330 general
surgeons (GSs) was randomly selected to derive our study sample. Enrolled
cases with invalid or expired contact information (6 EPs and 11 GSs) were
subsequently excluded before formal...
We appreciate the thoughtful comments of Dr. Yen et al. regarding the
sampling process of our study. In our telephonic survey of doctors, every
third case from a list of 194 emergency physicians (EPs) and 330 general
surgeons (GSs) was randomly selected to derive our study sample. Enrolled
cases with invalid or expired contact information (6 EPs and 11 GSs) were
subsequently excluded before formal telephone interviews were arranged.
Only respondents of valid telephonic contacts (45 EPs and 64 GSs) were
included in the final statistical analysis. As stated in our discussion,
there are some limitations with telephonic survey. Nevertheless, this
simple research technique offers the biggest cost advantage in the survey
of public or experts' opinion within a short time frame, as illustrated in
our study.
I was interested to read the case report on histamine fish poisoning
by Attaran et al.[1] Having recently reviewed the subject, I am aware that
this journal has highlighted this common condition in 1997 with another
case report,[2] adding to an expanding library of over 150 citations in
popular databases in the past quarter century.
Despite underreporting, the condition still accounte...
I was interested to read the case report on histamine fish poisoning
by Attaran et al.[1] Having recently reviewed the subject, I am aware that
this journal has highlighted this common condition in 1997 with another
case report,[2] adding to an expanding library of over 150 citations in
popular databases in the past quarter century.
Despite underreporting, the condition still accounted in the 1990s
for 32% of reported UK illness associated with fish/shellfish[3] and 50%
in the USA[4] and is credited with about 5% of USA food-borne illness.[5]
As noted in this latest report, even with all the publicity, the condition
is often misdiagnosed. It seems that case reports, which in this case add
no new evidence to the current knowledge base, are not sufficiently
effective in keeping clinicians aware of the condition.
To demonstrate this, consider the report of two anaphylaxis-
associated deaths in asthmatic children, by Rainbow et al, a few pages
away in the same issue of the Emergency Medical Journal.[6] The first case
is of an asthmatic child who died, despite resuscitation attempts, from a
suspected anaphylactic reaction after eating a meal of seafood. The
authors note, however, that no definite trigger for anaphylaxis was
identified on RAST testing for crab, chicken and peanut. The mast cell
tryptase levels measured were within normal limits, not suggestive of an
anaphylactic reaction. And yet, food-borne amine poisoning seems not to
have been considered, despite having been previously reported with both
crab and chicken.[7] Had an assay of the implicated food been conducted,
yielding a positive result, it could have been a potential opportunity to
double the number of reported deaths[4] from the condition.
In 1973, a single mackerel-related outbreak resulted in 2656 known
cases.[7] One hopes that early recognition and notification might nip the
next potential major incident in the bud. Indeed, prevention seems to be
the only current option for improving outcomes. As this condition is worth
repeated mention then perhaps it merits a place as a step in anaphylaxis
management algorithms and their instruction.
References
(1) Attaran RR, Probst F. Histamine fish poisoning: a common but
frequently misdiagnosed condition. Emergency Medicine Journal 2002;
19(5): 474-475
(2) Stell IM. Trouble with tuna: two cases of scombrotoxin poisoning.
Journal of Accident & Emergency Medicine 1997; 14(2): 110-111
(3) Gillespie IA, Adak GK, O'Brien SJ. General outbreaks of infectious
intestinal disease associated with fish and shellfish, England and Wales,
1992-1999. Communicable Disease & Public Health 2001; 4(2): 117-123
(4) Lehane L, Olley J. Histamine fish poisoning revisited.
International Journal of Food Microbiology 2000. 58(1-2): 1-37
Thank you for a very interesting and informative article. It may be
of interest to readers that a book on Larrey provides fascinating further
reading about this remarkable man. The book is difficult to get hold of,
and I am afraid that I have forgotten the source by which I acquired my
two copies several years ago. The details are as follows:
Thank you for a very interesting and informative article. It may be
of interest to readers that a book on Larrey provides fascinating further
reading about this remarkable man. The book is difficult to get hold of,
and I am afraid that I have forgotten the source by which I acquired my
two copies several years ago. The details are as follows:
Author: Dr. Robert Richardson
Title: Larrey: Surgeon to Napoleon's Imperial Guard
Publisher: Quiller Press, London
Published: 1974 with a revised edition in 2000
ISBN: 1-899163-60-3
I do often wonder how many of us involved in the application of the
principles of triage, (be it in the pre-hospital field or otherwise), know
of its origins. I unfortunately had cause to ponder on this whilst I was
collecting my thoughts preparatory to explaining to the press the use of
triage and Triage Labels following the 7/7 bombings, during which I was
triaging patients at Russell Square Tube Station.
In the book Dr. Richardson relates the tale of an episode during the
battle of Waterloo. Although not medical in nature as such, I think it
might be of interest:
"Who is that bold fellow?" asked the Duke of Wellington. "It's
Larrey," someone answered. "Tell them not to fire in that direction; at
least let us give the brave man time to gather up the wounded." And so
saying he doffed his hat. "Who are you saluting?" enquired the Duke of
Cambridge. "I salute the courage and devotion of an age that is no longer
ours," said Wellington, pointing at Larrey with his sword.
As a further point of interest the author has also written
extensively on other medical matters.
The problem is that patients (and untrained health workers) assume
that the
glue should be used on skin the same way it's used to glue a broken cup:
put
the glue in the middle and push the edges together. Used this way the
outcome
is poor with either medicinal-grade or ordinary cyano-acrylate glue.
Conflicts of Interest:
I've used superglue to cover my own minor hand laceration...
The problem is that patients (and untrained health workers) assume
that the
glue should be used on skin the same way it's used to glue a broken cup:
put
the glue in the middle and push the edges together. Used this way the
outcome
is poor with either medicinal-grade or ordinary cyano-acrylate glue.
Conflicts of Interest:
I've used superglue to cover my own minor hand laceration, (sustained
while on
a camping trip) with no adverse effect.
I read with interest Brooks audit of FAST in a 100 Blunt Abdominal
Trauma and 10 penetrating abdominal injuries done by 3 non-radiologists
members of of the emergency department. Ultrasound imaging as a diagnostic
modality is unique for us in A&E as it requires skills in both image
acquisition and interpretation where we have traditionally had only to
deal with the latter for plain films or CT/MRI...
I read with interest Brooks audit of FAST in a 100 Blunt Abdominal
Trauma and 10 penetrating abdominal injuries done by 3 non-radiologists
members of of the emergency department. Ultrasound imaging as a diagnostic
modality is unique for us in A&E as it requires skills in both image
acquisition and interpretation where we have traditionally had only to
deal with the latter for plain films or CT/MRI. The sensitivity of
ultrasound in picking up even small volumes of free fluid especially in
Morrison's pouch is without doubt and confirmed by this audit. It also
raises the point that contemporaneous CT scanning may not pick
the fluid up even if its used as the gold standard. DPL provided its done
well may resolve the issue but then again may not if its a small bleed
with equivocal results.
To me a well acquired and interpreted negative
initial FAST scan is very reassuring that the blood is probably not coming
from the belly and positive FAST with clinical signs of abdominal injury
and hemodynamic compromise is a reason to go straight to the operating
theatre. The added pre-test high index clinical suspicion of an experienced
"hand" on the belly before the jelly with the ability to serially repeat
the ultrasound should enhance the pick-up rates although most
studies/audits don't look at this aspect of the workup. Otherwise, it can
inadvertently start generating large numbers of true negatives as there
was really no serious pre-test concerns of abdominal injury.
We read with interest the recent articles on the NICE guidelines in
Head Injury patients. A clinical case that stresses the importance of
clinical suspicion is presented.
A 29 year old male presented to the Emergency Department with a
history of assault by a metal object. Despite a brief loss of
consciousness (LOC), he self-presented complaining of a mild headache and
one episode of vomi...
We read with interest the recent articles on the NICE guidelines in
Head Injury patients. A clinical case that stresses the importance of
clinical suspicion is presented.
A 29 year old male presented to the Emergency Department with a
history of assault by a metal object. Despite a brief loss of
consciousness (LOC), he self-presented complaining of a mild headache and
one episode of vomiting. Examination did not reveal any external signs of
injury. There were no features warranting an urgent CT scan using the NICE
guidelines. Admission was for the LOC and mechanism of injury.
He complained of right sided diplopia and mild headache the following
day; but examination was unremarkable. Opthalmology review was normal.
Later, he became suspicious of some ward visitors fearing they were his
assailants. Psychiatric review concurred post-injury stress syndrome.
Again, CT was not indicated using the NICE criteria; but clinical
suspicion of the above led to request for a CT Head which revealed a
probable subarachnoid haemorrhage with right parietal lobe calcification.
An MRI scan demonstrated an arterio-venous malformation (AVM) with a small
subarachnoid bleed. Neurology review led to a Magnetic Resonance Angiogram
at a tertiary centre. It was likely therefore, that the patient had not
been a victim of an assault.
In this era of increasing guidelines, there may be an over-reliance
on these, both by medical staff and radiology departments. Our patient
would not have qualified for a CT scan when using guidelines alone and may
easily have been discharged without investigation. A high index of
clinical suspicion led to the subsequent management. This was especially
important in our case as AVM’s do have a substantial risk of re-bleed.
The case illustrates that although guidelines should be followed,
clinicians should understand their limitations and use them in combination
with their clinical skills in the management of this complex group of
patients.
In response to Drs Gilligan and Campbell, a study carried out in our
ED has shown some interesting findings.
We examined SHO workload on cohorts of ED SHOs in our department,
(paediatric ED in a major tertiary centre), between February 2000 and
February 2005. SHOs from February 2000 to February 2001 (2 cohorts), saw
22798 patients, 62.52% of total attendances. SHOs from February 2004 to
F...
In response to Drs Gilligan and Campbell, a study carried out in our
ED has shown some interesting findings.
We examined SHO workload on cohorts of ED SHOs in our department,
(paediatric ED in a major tertiary centre), between February 2000 and
February 2005. SHOs from February 2000 to February 2001 (2 cohorts), saw
22798 patients, 62.52% of total attendances. SHOs from February 2004 to
February 2005 saw 23627 patients, 62.2% of total patients. There were 8
full time ED SHOs in each cohort, each working a full shift rota, which
was unchanged through the study period. The rota is fully European
Working Time Directive compliant.
By comparison, ED middle grades saw 5577 patients between Feruary
2000 and February 2001 (15.29%)and 5585 patients between February 2004 and
February 2005 (14.7%). ED consultants showed the biggest change, seeing
597 patients between February 2000 and February 2001 (1.64%), and 1152
patients between February 2004 and February 2005 (3.03%). Nurse
Practitioners saw 464 patients from February 2000 to February 2001
(1.27%), and 1157 patients from February 2004 to February 2005 (3.04%).
The total number of new patient episodes was 36463 from February 2000 to
2001 and 37986 from February 2004 to 2005.
It can be seen that the number of patients seen by ED SHOs has not
varied significantly over this 5 year period. In both absolute and
percentage terms, the figure remains constant. Similarly, middle grade
workload remains essentially unchanged. The major point of note is the
increased input of consultants and nurse practitioners. This represents a
considerable change in the delivery of emergency care provision.
The impact of the European Working Time Directive and Modernising
Medical Careers will almost certainly have a further significant effect on
working patterns and hence service delivery and EM training. The delivery
of patient care is anecdotally shifting away from an SHO delivered service
to utilising other grades of medical staff, or other health care
professionals altogether (ENPs/ECPs). Although this trend is borne out of
necessity, caution is needed to prevent detrimental impact on the training
of Emergency Medicine doctors and, ultimately, patient care.
Dear Editor,
We read the paper by Chong et al. [1] with great interest. However, we have some doubts regarding their random sample. They had a list of 194 emergency physicians (EPs) and 330 general surgeons (GSs). Every third case in the list was selected. There should be about 64 EPs and 110 GSs in their study sample. However, exactly 90% of the expected numbers of physicians composed their EPs (58) and GSs (99)...
Dear Editor
We read the interesting paper by Mirò et al [1], who found that in the emergency department (ED) weekends are not characterized by a loss of effectiveness compared to workdays. The possible reduction in staff and loss of attention on weekends is a topic still under debate. A recent study [2] analyzed the six more common urgent procedures usually utilized in acute care hospitals, and found that only 5...
Dear Editor,
I don't think the sgarbossa criteria are that useful. In the example ECG, the 2 strikingly obvious criteria that would indicate acute MI are the hyperacute T waves laterally (the absolute height of the T wave being greater than that of the the QRS) and the high ST to T ratio laterally. It is only Anterior MIs that are difficult to diagnose in the presence of LBBB. The presence of hyperacute Ts is s...
Dear Editor,
We appreciate the thoughtful comments of Dr. Yen et al. regarding the sampling process of our study. In our telephonic survey of doctors, every third case from a list of 194 emergency physicians (EPs) and 330 general surgeons (GSs) was randomly selected to derive our study sample. Enrolled cases with invalid or expired contact information (6 EPs and 11 GSs) were subsequently excluded before formal...
Dear Editor
I was interested to read the case report on histamine fish poisoning by Attaran et al.[1] Having recently reviewed the subject, I am aware that this journal has highlighted this common condition in 1997 with another case report,[2] adding to an expanding library of over 150 citations in popular databases in the past quarter century.
Despite underreporting, the condition still accounte...
Dear Editor,
Re: Dr. Robertson-Steel.
Thank you for a very interesting and informative article. It may be of interest to readers that a book on Larrey provides fascinating further reading about this remarkable man. The book is difficult to get hold of, and I am afraid that I have forgotten the source by which I acquired my two copies several years ago. The details are as follows:
Author: Dr. Ro...
Dear Editor,
The problem is that patients (and untrained health workers) assume that the glue should be used on skin the same way it's used to glue a broken cup: put the glue in the middle and push the edges together. Used this way the outcome is poor with either medicinal-grade or ordinary cyano-acrylate glue.
Conflicts of Interest:
I've used superglue to cover my own minor hand laceration...
Dear Editor
I read with interest Brooks audit of FAST in a 100 Blunt Abdominal Trauma and 10 penetrating abdominal injuries done by 3 non-radiologists members of of the emergency department. Ultrasound imaging as a diagnostic modality is unique for us in A&E as it requires skills in both image acquisition and interpretation where we have traditionally had only to deal with the latter for plain films or CT/MRI...
Dear Editor,
We read with interest the recent articles on the NICE guidelines in Head Injury patients. A clinical case that stresses the importance of clinical suspicion is presented.
A 29 year old male presented to the Emergency Department with a history of assault by a metal object. Despite a brief loss of consciousness (LOC), he self-presented complaining of a mild headache and one episode of vomi...
Dear Editor,
In response to Drs Gilligan and Campbell, a study carried out in our ED has shown some interesting findings.
We examined SHO workload on cohorts of ED SHOs in our department, (paediatric ED in a major tertiary centre), between February 2000 and February 2005. SHOs from February 2000 to February 2001 (2 cohorts), saw 22798 patients, 62.52% of total attendances. SHOs from February 2004 to F...
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