Thought provoking as this paper is, it doesn't take account of any
'special awareness' of the problem as percieved by the coronial &
reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater
than any other similar conurbation - only that those reacting to your
questions are more specifically looking for, and willing to ident...
Thought provoking as this paper is, it doesn't take account of any
'special awareness' of the problem as percieved by the coronial &
reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater
than any other similar conurbation - only that those reacting to your
questions are more specifically looking for, and willing to identify, such
apparent links than any other.
I read kennedy et al's article regarding the use of topical cocaine
and adrenaline with interest.
I have also seen instillagel (2% lignocaine and 0.25%
chlorhexidine)used with good effect when placed on childrens wounds to
allow exploration and closure within the emergency department setting.
The great advantages being that it is easily available within the
department and when wo...
I read kennedy et al's article regarding the use of topical cocaine
and adrenaline with interest.
I have also seen instillagel (2% lignocaine and 0.25%
chlorhexidine)used with good effect when placed on childrens wounds to
allow exploration and closure within the emergency department setting.
The great advantages being that it is easily available within the
department and when working out safe doses lignocaine is a familiar drug
and is also the drug of choice if supplemental injections are needed. If
these injections are placed through the cut edge where the gel has been
applied the distress to the child is minimal.
Aruni Sen’s evident distaste for nalbuphine seems to have
precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic.
We did, however, offer empirical evidence that it is effective for many
patients –just under half of those treated had a pain score of three or
less (‘mild’ pain) on arrival at hospital. Less tha...
Aruni Sen’s evident distaste for nalbuphine seems to have
precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic.
We did, however, offer empirical evidence that it is effective for many
patients –just under half of those treated had a pain score of three or
less (‘mild’ pain) on arrival at hospital. Less than 15% were reported as
receiving further analgesia within 30 minutes of admission to A&E. I
would challenge the view that a reduction of three to four points on the
numerical rating scale is ‘hardly worth talking about from the patient’s
perspective’. By definition, this is a reduction in the degree of pain
that the patient can perceive, and represents at worst a change from
‘severe’ to ‘moderate’ pain and at best a reduction from ‘severe’ or
‘moderate’ pain to ‘mild’ pain [2].
Aruni Sen implies that nausea is a routine consequence of nalbuphine
administration. Our research found this occurred in less than 21% of
patients.
The incidence of antagonism to morphine identified by A&E doctors
during our study was very low. Of 176 patients recruited, we had complete
data from receiving hospitals for 110, from which there were four cases of
claimed antagonism (3.6%, 95% CI 1 to 9%). Of these four patients, the
recorded dose of diamorphine administered in the A&E department was
5mg in two cases and 7.5mg in a third. The fourth patient received 30 mg:
this was the only reported incidence of administration of a higher than
usual dose of analgesia. We did not report the dose of analgesic required
for all patients in hospital as several different drugs were used in
various A&E departments, making comparison difficult.
‘Drowsiness’ was a patient reported side-effect, not a description of
observations made by paramedics. Clearly, patients were reporting a
subjective sensation whilst paramedics objectively documented the best
score obtained for each facet of the GCS.
We decided not to test a 30mg initial dose of nalbuphine during the
study as this is outside of the licensed dose range for all sources of
pain other than myocardial infarction.
This research was not conducted to champion nalbuphine. Rather, it
sought to determine which of two nalbuphine dosing regimens in use at that
time was the most effective, as when this study was conducted it was the
only intravenous analgesic that paramedics could legally administer. Since
the administration of morphine by paramedics became legal, its
introduction into UK ambulance services has been slow. Until this has been
completed, we hope our research will encourage the use of the most
effective dosing regimen for nalbuphine to enhance patient comfort.
References
(1) Woollard M, Whitfield R, Smith K, Jones T, Thomas G, Thomas G,
Hinton C. Less IS less: a randomised controlled trial comparing cautious
and rapid nalbuphine dosing regimens. Emerg Med J, 2004;21(3):362-364.
(2) Bondestam E, Hovgren K, Gaston JF, et al. Pain assessment by
patients and nurses in the early phase of acute myocardial infarction. J
Adv Nurs, 1987;12(6):677-82.
I agree with the comments by Dr Harden that assessment of cognitive
function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the
start of the first world war is also partly dependent on level of
education. As the war started 90 years ago, for the majority of our
patients this was a long time before they were born. Perhaps asking when...
I agree with the comments by Dr Harden that assessment of cognitive
function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the
start of the first world war is also partly dependent on level of
education. As the war started 90 years ago, for the majority of our
patients this was a long time before they were born. Perhaps asking when
was the last time we won the World Cup, or some other significant event
would be an acceptable replacement. Judging by the way we played in Euro
2004, it could be a long time before we win anything of significance again
and perhaps this modification would require replacing too.
I was interested to read the letter by Pattinson et al [1] reviewing
the use of the single-use laryngeal mask airway (LMA-Unique) over a two-
year period in the ambulance service in Warwickshire. In their summary,
the authors commented that their success rates for LMA insertion were
similar to those reported in the literature and that the introduction of
LMAs, ‘had achieved the aims that were intended’...
I was interested to read the letter by Pattinson et al [1] reviewing
the use of the single-use laryngeal mask airway (LMA-Unique) over a two-
year period in the ambulance service in Warwickshire. In their summary,
the authors commented that their success rates for LMA insertion were
similar to those reported in the literature and that the introduction of
LMAs, ‘had achieved the aims that were intended’.
I was disappointed to find that there was no mention of patient
outcomes in this review, and I would have liked to have known if use of
the LMA had influenced the rates at which patients were admitted alive to
hospital and subsequently discharged home alive. Also, in those cases
where the LMA was used for conditions other than cardiac arrest, details
of SpO2 readings pre- and post-insertion would have provided useful
information regarding the efficacy of the LMA in prehospital care. I would
suggest that the introduction of any new device into emergency medicine
can only be judged to be a success if its use can be shown to have
improved the clinical outcome for patients, and the ability of staff to
utilise the device is not the same thing.
From the figures quoted, it would appear that there may have been
some reluctance by paramedics in Warwickshire to utilise the LMA, since
there were only 45 attempted LMA placements by paramedics during the
entire two years under study, and it would have been interesting to know
the number of tracheal intubations attempted over the same period. The
higher rate of successful LMA insertions by Warwickshire technicians as
opposed to paramedics (96% v. 82%) could simply reflect differences in the
complexity of cases treated, and a direct comparison of successful
insertion rates in cardiac arrest cases where there was unimpeded access
to the patient would have been interesting. The relatively small number of
LMA placements in this survey probably makes it impossible to come to any
firm conclusion as to whether use of the LMA is more efficacious than bag-
valve-mask ventilation (BVMV) or tracheal intubation (TI) in frontline
ambulance care, and what is urgently needed from the ambulance service is
a well-designed prospective study to address all these issues.
One final comment; the authors state that the LMA is ‘clearly
unrivalled in situations where intubation has failed or is impossible’.
This is certainly not the case, since the esophageal tracheal Combitube
(ETC), for example, is another effective rescue ventilation device [2]. The
ETC may, in fact, be a better rescue ventilation tool in cases where there
is reduced lung/chest wall compliance or where airway resistance is high
(e.g. severe bronchospasm), since the cuff of the standard LMA only
provides a reliable seal up to about 20 cmH2O of airway pressure.
Currently, the LMA and the ETC are the only two rescue ventilation devices
with an American Heart Association (AHA) Class IIa designation (ASA Class
IIa status is reserved for a therapeutic option for which the weight of
evidence is in favour of its usefulness and efficacy). However, other
rescue ventilation devices such as the King LTA, LMA-ProSeal and LMA-
Fastrach also show promise and deserve further study.
Unlike in the United States, the ETC has been used very little in
prehospital emergency care in the UK. In a recent postal survey [3], whilst
the availability of the LMA had increased from 10 to 26% since the
previous survey in 1997, no ambulance service in the UK was employing the
ETC, or any other alternate airway device. Fortunately, true ‘cannot
intubate, cannot ventilate’ situations are relatively rare. Nevertheless,
with only 26% of UK frontline ambulances carrying any type of rescue
ventilation device, it has to be questioned whether hypoxic patients who
are resistant TI and are unresponsive to BVMV are currently being offered
an acceptable standard of care in this country.
CONFLICT OF INTEREST STATEMENT: Dr Mason is Adviser in Pre-Hospital
Care to Intavent Orthofix, Maidenhead, UK - distributor of the LMA in the
UK.
References
(1) Pattinson K, Todd I Thomas J, Wyse M. A two year review of
laryngeal mask use by the Warwickshire ambulance service. Emerg Med J
2004;21:397.
(2) Rich JM, Mason AM, Bey TA, Krafft P, Frass M. The critical
airway, rescue ventilation and the Combitube: Part 1. AANA J 2004;72(1):17
-27.
(3) Roberts K, Allison KP, Porter KM. A review of emergency equipment
carried and procedures performed by UK front line paramedics.
Resuscitation 2003;58(2):153-8.
Dyson et al [1] use a pragmatic design to address an interesting
question, but I am concerned that the statistical analysis may be
inappropriate and could have led to erroneous conclusions being drawn. The
study is a cluster randomised controlled trial. Instead of randomising
individual House Officers (HOs), the authors have randomised groups of HOs
(those working at the same hospital). This is entirely...
Dyson et al [1] use a pragmatic design to address an interesting
question, but I am concerned that the statistical analysis may be
inappropriate and could have led to erroneous conclusions being drawn. The
study is a cluster randomised controlled trial. Instead of randomising
individual House Officers (HOs), the authors have randomised groups of HOs
(those working at the same hospital). This is entirely appropriate. As the
authors point out, randomising individual HOs would risk contamination
between the two study groups by HOs sharing aide memoires.
However, if groups, rather than individuals, are randomised then the
use of standard statistical techniques may be inappropriate. These
techniques assume that all observations (i.e. all individuals) are
independent of each other. Yet in a cluster trial this may not be true.
HOs at the same hospital are likely to share characteristics and learning
experiences, and thus be more similar to each other than HOs at different
hospitals. Assuming independence in these circumstances may lead to an
overestimate of statistical power of the study and an underestimate of the
P value.
For this reason, cluster trials should be published with an estimate
of the degree of clustering within groups (the intraclass correlation
coefficient) and the effect that this has upon statistical power (the
design effect). The potential effect of clustering should be considered in
the sample size calculation and analysis should take potential clustering
into account. The fewer groups randomised and the more individuals there
are per group, the greater the potential impact of any clustering. This
study involved randomising eight hospitals, with presumably 15-20 HOs per
hospital, so the potential effect of clustering should not be ignored.
Before we can accept the conclusions of this study we need some more
information. What was the intraclass correlation coefficient for these
data? How many HOs were included from each hospital? Was analysis
undertaken at group (hospital) or individual (HO) level? If an individual
level analysis was undertaken, was this adjusted for potential clustering?
Cluster trials are a valuable tool in emergency medicine research,
and this study is a good example, yet care needs to be taken in
statistical analysis and reporting. This issue has been addressed by the
NHS Health Technology Assessment Programme [2], the BMJ [3], and the
emergency medicine literature [4]. Guidelines have recently been published
for reporting cluster trials [5], we should ensure that articles in the
EMJ follow them.
References
(1) Dyson E, Voisey S, Hughes S, Higgins B, McQuillan PJ. Educational
psychology in medical learning: a randomised controlled trial of two aide
memoires for the recall of causes of electromechanical dissociation. Emerg
Med J 2004;21:457-460.
(2) Ukoumunne et al. Methods for evaluating area-wide and organisation-
based interventions in health and health care: a systematic review. Health
Technology Assessment 1999;3(5).
(3) Campbell M, Grimshaw J. Cluster randomised trials: time for
improvement. BMJ 1998;317:1171-2.
(4) Wears RL. Statistical methods for analyzing cluster and cluster-
randomized data. Academic Emergency Medicine 2002;9:330-341.
(5) Campbell MK, Elbourne DR, Altman DG, for the CONSORT Group. CONSORT
statement: extension to cluster randomised trials. BMJ 2004;328:702-8.
For feeble-minded souls such as myself, the aide mémoire has played a
key part in my professional life. Some 30 years ago whilst demonstrating
anatomy at Cambridge, I devised numerous mnemonics to assist with
teaching. To illustrate their power, whilst I have forgotten the names of
virtually all my students and most of my fellow demonstrators, I can
recall each and every segment of the right lung, all...
For feeble-minded souls such as myself, the aide mémoire has played a
key part in my professional life. Some 30 years ago whilst demonstrating
anatomy at Cambridge, I devised numerous mnemonics to assist with
teaching. To illustrate their power, whilst I have forgotten the names of
virtually all my students and most of my fellow demonstrators, I can
recall each and every segment of the right lung, all the branches of the
internal carotid artery and many other obscure anatomical facts without
the slightest difficulty, despite their total irrelevance to my current
clinical practice. It was with great interest, therefore, that I read the
article by Dyson et al [1]. describing their aide mémoire for
electromechanical dissociation, and I welcome it as a significant
improvement on the traditional ‘4Hs & 4Ts’ method of recalling
potentially reversible causes of pulseless electrical activity.
I was intrigued, however, to observe that the authors had chosen to
work with the term ‘electro-mechanical dissociation’ (EMD) rather than
‘pulseless electrical activity’ (PEA) which has become the more commonly
used phrase in recent years. I suspect that this may have had something to
do with the fact that they were able make the EMD acronym appear in the
second of the two triangles (representing Electrolyte + metabolic, Massive
hypothermia and Drugs + toxins) as a reminder of the final three causes of
EMD. If so, I’m not sure that the word ‘massive’ really works in front of
‘hypothermia’ since it is not an adjective normally associated with this
condition, being more commonly applied to describe a heart attack, stroke
or pulmonary embolus. For me, use of the word ‘massive’ in this context
seems just a bit too contrived.
After wrestling with the conundrum, I can reveal that the authors
could indeed have utilised the more widely accepted PEA acronym, and still
have had it appear in the second of the two triangles. This can be done by
defining the final three causes of PEA as: Pharmacological + toxic,
Electolytic + metabolic, and Algidity. For those unfamiliar with the word
algidity, the dictionary definition is chilliness or coldness, and
especially (in the medical sense) ‘coldness with collapse’ [2]. An
additional advantage of using the PEA rather than the EMD acronym would be
that the initial letter of PEA would remind readers that there are 3Ps
(Pneumothorax (tension), Pulmonary embolus and Pericardial tamponade) in
the first of the two triangles.
So it has to be two-and-a-half cheers for Dyson et al. and more aide
mémoires please!
References
(1) Educational psychology in medical learning: a randomised
controlled trial of two aide memoires for the recall of causes of
electromechanical dissociation. Dyson E, Voisey S, Hughes S, Higgins B,
McQuillan PJ. Emerg Med J 2004;21:457-460.
(2) See: http://cancerweb.ncl.ac.uk/cgi-bin/omd?algidity published by
Dept. of Medical Oncology, University of Newcastle upon Tyne.
The correspondence between Professor Mackway Jones [1] and Dr Locker et al.[2] and
Dr Webster [3] raises some interesting points about how Best Bets are developed.
Best Bets represent an admirable attempt to improve the evidence on which
our practice is based and no one should underestimate the hours of work
that go into this. Of course, the biggest problem for Best Bets is that
the answer...
The correspondence between Professor Mackway Jones [1] and Dr Locker et al.[2] and
Dr Webster [3] raises some interesting points about how Best Bets are developed.
Best Bets represent an admirable attempt to improve the evidence on which
our practice is based and no one should underestimate the hours of work
that go into this. Of course, the biggest problem for Best Bets is that
the answers are just not available for many of the questions posed and the
equivocal nature of many conclusions reflects this.
The review process described by Mackway-Jones sounds agonising and
painstaking, however it was not enough to convince me of its robustness.
There are a number of important differences between his group's
'specialist peer review' and the peer review employed successfully in
biomedical journals that weaken my confidence in the Best Bets. From the
description of the review process, the peer review does not sound
anonymous. While many reviewers do not mind disclosing their identity,
potential anonymity is an important strength of the peer review process.
There is no description of how many Best Bets submitted are rejected. I
would have much greater confidence in the process if I knew that a
proportion of Best Bets were rejected because the question was unimportant
or unanswerable, the methodology flawed, or the conclusions unreasonable.
Mackway-Jones assertion that the 'specialist peer review' process would
stand up to the traditional peer review process may be true, but is
unproven.
The review process that Mackway-Jones describes may be very good at the
methodological aspects, but surely experts in the content should also be
involved. The great success of POEMs in the BMJ is partly due to their
scarcity (only one per issue). It may be time to restrict the Best Bets to
'less of the best'.
There is a great untapped reservoir of carefully reviewed literature
available to us and surely the time is ripe for the journal to find a way
to work the best Clinical Topic Reviews submitted for the FFAEM exam into
their journal?
References
1. Mackway-Jones K. BestBETs reply from the BestBETs group. Emerg Med J 2004 21: 523.
2. T E Locker, K Hogg, R Mahu, and I Crawford. Vasopressin or adrenaline in cardiac resuscitation: Authors’ reply. Emerg Med J 2004 21: 522.
3. A P Webster. BETs—Should they be published in the journal? Emerg Med J 2004 21: 522-523.
The Emergency Department (ED) at Alder Hey Children’s Hospital,
Liverpool
has several years experience using topical adrenaline and cocaine gel
(topAC)
as an anaesthetic for suturing lacerations of head and body in children.
We,
therefore, read the article by Kennedy et al. with interest.[1]
An audit conducted within our department showed similar results to
Kennedy’s with a high degr...
The Emergency Department (ED) at Alder Hey Children’s Hospital,
Liverpool
has several years experience using topical adrenaline and cocaine gel
(topAC)
as an anaesthetic for suturing lacerations of head and body in children.
We,
therefore, read the article by Kennedy et al. with interest.[1]
An audit conducted within our department showed similar results to
Kennedy’s with a high degree of operator and patient/parent satisfaction.
The dose of topAC used according to our protocol is based on wound
length
(1ml per 1cm wound up to a maximum of 3ml; minimum age 3 years). No
adverse effects have occurred in the time topAC has been in use. However,
we
noted that topAC was not being used in the ED in all situations when it
may
be beneficial as there were concerns regarding toxicity and potential
fatal
outcome. Additionally, the cocaine component requires the gel to be
handled
as a controlled substance, which can cause practical difficulties.
Consequently, we are currently piloting the use of an alternative
topical
anaesthetic. A solution containing lidocaine, epinephrine and tetracaine
(LET)
is in common usage in the USA and is available in the UK as a special
preparation. It has been shown to be as effective as infiltrated
lidocaine,
topAC and tetracaine, adrenaline and cocaine gel (TAC) for anaesthetising
lacerations prior to suturing.[2,3]
We, our patients and their families have found the LET solution
provides as
effective anaesthesia for repair of lacerations of face and scalp. On the
occasions when supplemental infiltrated lidocaine has been required,
injection has been less painful to administer.
Additional advantages are that topical anaesthetics make wound
inspection
and toilet more comfortable and do not cause tissue distortion, allowing
for
more accurate wound closure.
We now plan to formally introduce LET solution into the ED and
withdraw
topAC. Our protocol will aim to apply LET to suitable wounds at triage
thus
enabling adequate assessment and repair of wounds while reducing delay in
the ED. We will continue to audit and assess its use.
Dr. A. B. Stewart,
Consultant Paediatric Accident and Emergency Medicine
References
1. Kennedy DWG, Shaikh Z, Fardy MJ, Evans RJ, Crean StJ. Topical
adrenaline
and cocaine gel for anaesthetising children’s lacerations. An audit of
acceptability and safety. Emerg Med J 2004;21:194-196
2. Bush S. Is cocaine needed in topical anaesthesia? Emerg Med J
2002;19:
418-422
3. Brent AStG. The Management of Pain in the Emergency Department.
Pediatr
Clin N Am 2000; 47(3):651-679
In the paper of SGA Brown [1] adrenaline was
administered to 19 patients of 21, 3 of which in stage II and 5 in stage I
of Muller's grading of systemic allergic reactions, we think that
adrenaline administrationat at this stage is excessive and potentially
hazardous in respect to signs and symptoms, although the patients were
continuously monitored. We think adrenaline administration should be
avoided o...
In the paper of SGA Brown [1] adrenaline was
administered to 19 patients of 21, 3 of which in stage II and 5 in stage I
of Muller's grading of systemic allergic reactions, we think that
adrenaline administrationat at this stage is excessive and potentially
hazardous in respect to signs and symptoms, although the patients were
continuously monitored. We think adrenaline administration should be
avoided or carefully tritated especially in older and cardiopatic
patients in stage I and II of Muller's classification; and reserved only
for severe cases of anaphylactic reactions presenting with stridor,
wheezing, respiratory distress and clinical signs of shock.[2]
Besides,
discharge home after a symptom free interval of only two hours is probably
not safe, both for the risk of biphasic anaphylactic reaction (3) and
possibility of late side effects due to adrenaline intravenous
administration, especially in cardiopatic patiens. Moreover one of the
indications for starting the protocol was also , as stated at point 6,
only the request of a trial partecipant. We think this is not a reliable
way for assessing the clinical status of a patient on the base of which to
decide administration of adrenaline. Besides could be more useful and
safe to know data about hypoxia and acidosis trough haematic serial
samples, rather than performing spirometry.
References
1.SGA Brown, KE Blackman, V Stenlake, and R J Heddlel.: Insect sting
anaphylaxis; prospective evaluation of treatment with intravenous
adrenaline and volume resuscitation. Emerg Med J 2004; 21: 149-154.
2. Montanaro A, Bardana EJ Jr.: The mechanism, causes and the treatment of
anaphylaxis. J Invest Clin Immunol 2002;2:2-11.
3. Brazil E, MacNamara AF.: “Not so immediate” hypersensitivity- the
danger of biphasic anaphylactic reactions. J Accid Emerg Med 1998; 15: 252
-3.
Gori L, Cinotti S, Pappagallo S.
Department emergency medicine, Az USL 11 Empoli, ITALY
S. Giuseppe Hospital Viale Boccaccio 3 – 50053 Empoli, ITALY
tel: +39- 0571-702365 e-mail:s.cinotti@usl11.toscana.it
Dear Editor
Thought provoking as this paper is, it doesn't take account of any 'special awareness' of the problem as percieved by the coronial & reactive health service opinions upon which it is based.
It might not be the case that Brighton's problems are any greater than any other similar conurbation - only that those reacting to your questions are more specifically looking for, and willing to ident...
Dear Editor
I read kennedy et al's article regarding the use of topical cocaine and adrenaline with interest.
I have also seen instillagel (2% lignocaine and 0.25% chlorhexidine)used with good effect when placed on childrens wounds to allow exploration and closure within the emergency department setting.
The great advantages being that it is easily available within the department and when wo...
Dear Editor
Aruni Sen’s evident distaste for nalbuphine seems to have precipitated a somewhat hasty and inaccurate reading of our paper [1].
Firstly, we did not claim that nalbuphine is an effective analgesic. We did, however, offer empirical evidence that it is effective for many patients –just under half of those treated had a pain score of three or less (‘mild’ pain) on arrival at hospital. Less tha...
Dear Editor
I agree with the comments by Dr Harden that assessment of cognitive function is important in the acutely confused patient.
However maybe a slight modification is necessary. Knowledge of the start of the first world war is also partly dependent on level of education. As the war started 90 years ago, for the majority of our patients this was a long time before they were born. Perhaps asking when...
Dear Editor
I was interested to read the letter by Pattinson et al [1] reviewing the use of the single-use laryngeal mask airway (LMA-Unique) over a two- year period in the ambulance service in Warwickshire. In their summary, the authors commented that their success rates for LMA insertion were similar to those reported in the literature and that the introduction of LMAs, ‘had achieved the aims that were intended’...
Dear Editor
Dyson et al [1] use a pragmatic design to address an interesting question, but I am concerned that the statistical analysis may be inappropriate and could have led to erroneous conclusions being drawn. The study is a cluster randomised controlled trial. Instead of randomising individual House Officers (HOs), the authors have randomised groups of HOs (those working at the same hospital). This is entirely...
Dear Editor
For feeble-minded souls such as myself, the aide mémoire has played a key part in my professional life. Some 30 years ago whilst demonstrating anatomy at Cambridge, I devised numerous mnemonics to assist with teaching. To illustrate their power, whilst I have forgotten the names of virtually all my students and most of my fellow demonstrators, I can recall each and every segment of the right lung, all...
Dear Editor
The correspondence between Professor Mackway Jones [1] and Dr Locker et al.[2] and Dr Webster [3] raises some interesting points about how Best Bets are developed.
Best Bets represent an admirable attempt to improve the evidence on which our practice is based and no one should underestimate the hours of work that go into this. Of course, the biggest problem for Best Bets is that the answer...
Dear Editor
The Emergency Department (ED) at Alder Hey Children’s Hospital, Liverpool has several years experience using topical adrenaline and cocaine gel (topAC) as an anaesthetic for suturing lacerations of head and body in children. We, therefore, read the article by Kennedy et al. with interest.[1]
An audit conducted within our department showed similar results to Kennedy’s with a high degr...
Dear Editor
In the paper of SGA Brown [1] adrenaline was administered to 19 patients of 21, 3 of which in stage II and 5 in stage I of Muller's grading of systemic allergic reactions, we think that adrenaline administrationat at this stage is excessive and potentially hazardous in respect to signs and symptoms, although the patients were continuously monitored. We think adrenaline administration should be avoided o...
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