I think the model the Israeli medical services had adopted in the
development of emergency medicine is brilliant and something we should
deliberate adopting as modelling for the future of emergency medicine. It's
not a new idea as the Casualty Surgeons in the UK and countries affiliated
to this model in other parts of the world did way back in the 1960's
develop as a group of specialist orthopaedic sur...
I think the model the Israeli medical services had adopted in the
development of emergency medicine is brilliant and something we should
deliberate adopting as modelling for the future of emergency medicine. It's
not a new idea as the Casualty Surgeons in the UK and countries affiliated
to this model in other parts of the world did way back in the 1960's
develop as a group of specialist orthopaedic surgeons/general surgeons
with an interest in emergency care. Where it differed was they no longer
continued their primary speciality as there was no way to undertake both
because of the small numbers of individuals involved. It effectively
deskilled this group of people in their primary speciality. They remained
in the emergency departments initially in a leadership/administrative
capacity but over the years increasingly more in clinical delivery of
service. New trainees undertaking emergency medicine as a primary
speciality are coming with breath but not depth of the spectrum of
medicine.
We are effectively the last bastion of emergency care generalists
but because of our hospital based practice risk being labelled
referrologists as extended continuity of care has not been a feature of
emergency medicine practice. This hybrid model that the Israeli medical
service has adopted is one solution I think merits serious examination in
the development of career models and syllabuses in emergency medicine.
The
consultants of the emergency department could be general
surgeons, orthopaedic surgeons, anaethetists, physicians, general
practitioners who have dual specialisation and share the running of the
emergency department after finishing specialist training in both. They are
identified early in the basic training to fulfil this dual training. In
later years they can fall back on their primary speciality as the high
intensity activity of the EM starts to take its toll with increasing
age. It will also encourage movement which can be a problem in parts of the
world where emergency department specialist are seen as public hospital
based without much lateral movement to the private sector/private
hospitals.
I agree with the authors’ conclusion that a clinical diagnosis of
epididymitis without urology follow up is potentially hazardous. However,
the importance of testicular microlithiasis(TM) is difficult to
understand.
Retrospective evidence has revealed an association between TM and
testicular tumours to be as great as 40%. However, recent prospective
evidence in one study of 1504 asymptomatic men...
I agree with the authors’ conclusion that a clinical diagnosis of
epididymitis without urology follow up is potentially hazardous. However,
the importance of testicular microlithiasis(TM) is difficult to
understand.
Retrospective evidence has revealed an association between TM and
testicular tumours to be as great as 40%. However, recent prospective
evidence in one study of 1504 asymptomatic men has shown the prevalence
of TM to be between 4% and 14% depending on race affiliation and no cases
were associated with malignancy.[1] In the last decade the reporting of TM
has increased and cases of patients developing interval malignancies
exist. These cases have tended to be in atrophic testes or in patients
with other risk factors for testicular malignancy. This has led to many
patients with TM being commenced on ultrasound surveillance, although the
duration or efficacy of such management is not known. Therefore, some
urologists consider testicular biopsy to detect intratubular germ cell
neoplasia (carcinoma-in-situ) particularly in young men with atrophic
testes or other risk factors. If CIS is present then radiotherapy can be
offered with testicular preservation. If CIS is not found then indefinite
ultrasound surveillance may be avoided although the possibility of a false
negative biopsy exists.
Patients with epididymitis can be effectively treated by emergency
department staff and follow up should be performed by urologists. It is at
this time following consultation and careful examination of the testes
that an ultrasound may be performed but not specifically to detect
testicular microlithiasis.
Reference
(1) Peterson AC. Bauman JM. Light DE. McMann LP. Costabile RA. The
prevalence of testicular microlithiasis in an asymptomatic population of
men 18 to 35 years old. Journal of Urology 2001; 166(6):2061-4.
We read with interest the article by MJ Reed et al. As they have mentioned
there have been numerous attempts to devise scoring systems for airway
assessment, however these scores have been undermined by low sensitivity
and specificity. Furthermore Positive predictive values for these tests
range from 4 – 60% [1], we believe that such a low predictive value has
significant implications for airway manag...
We read with interest the article by MJ Reed et al. As they have mentioned
there have been numerous attempts to devise scoring systems for airway
assessment, however these scores have been undermined by low sensitivity
and specificity. Furthermore Positive predictive values for these tests
range from 4 – 60% [1], we believe that such a low predictive value has
significant implications for airway management particularly in the
Emergency Department. With a positive predictive value of 50% at least
half of difficult intubations are likely to be unexpected. Whilst the
morbidity associated with a difficult intubation is clear to all, some
patients may be subjected to unnecessarily invasive techniques that may
not be required.
In the words of Levintine “Direct Laryngoscopy with
pharmacological adjuncts is very successful, very fast and has low
complication rates” [2]. The authors of the study do not state at which LEMON
score a patient’s airway is anticipated to be difficult. Assuming a score
of >3 the positive predictive value would be 47%. The study quotes a
rate of 2% difficult intubations in the Emergency Department; the study
rate of 42 difficult intubations in 156 patients therefore seems to be
abnormally high, possibly due to the inclusion of grade II laryngoscopic
view as difficult. We would question the classification of Cormack and
Lehane grade II laryngoscopy as “difficult”, most Emergency Departments
are equipped with bougies making it possible to easily intubate with this
view [3].
Although the LEMON score is referred to as an “airway assessment” it
is in fact an intubation assessment. No patient dies from failure to
intubate, rather it is failed oxygenation. In the absence of an airway
assessment with 100% accuracy then airway assessment needs to be holistic.
The American Society of Anaesthesiologists published guidelines suggesting
airway assessment must also take into account difficulty in ventilation,
patient co-operation, potential surgical airway access and maintaining
oxygenation throughout airway management procedures as these problems may
occur alone or in combination [4]. Whilst anaesthestists have the luxury of
time when assessing an airway we feel the limited time in the Emergency
department would be better spent considering these issues rather than
calculating a LEMON score.
The harsh reality is that there will be no test that has 100%
specificity and sensitivity. The only way to deal with the airway in the
Emergency department is to be prepared for the unanticipated difficulties:
with experienced assistants, difficult airway trolleys and a plan B, all
of which should be standard practice. There is little margin for error in
airway management. We believe that a test that makes airway management
“more likely” to be difficult is of limited value in the emergency
department.
Dr S. Dorrian
SHO Critical Care New Cross hospital
Wolverhampton
Dr S. Nagaiyan
SpR Anaesthetics New Cross hospital
Wolverhampton
References
1. Das S, Pearce A. Pre-operative airway evaluation Anaesthesia 2002
Aug; 57(8):824.
2. Levitan RM, Kush S, Hollander JE Devices for difficult airway
management in academic emergency departments: results of a national survey
Annals of Emergency Medicine 1999 Jun; 33(6): 694-8.
3. Morton T, Brady S, Clancy M Difficult airway equipment in English
Emergency Departments Anaesthesia 2000 May; 55(5):485-8.
4. American Society of Anaesthesiologists Practice guidelines for
management of the difficult airway Anaesthesiology 2003 May; 98(5); 1269–77.
I feel that I must comment on S Masons view that Emergency Care
Practitioners (ECP's) should not be compared to Paramedics. Surely when
evaluating the impact of ECP's it is essential to compare the potential
patient outcome should the ECP not be available. In this scenario the
majority of patients would have been seen by a paramedic or Emergency
Medical Technician (EMT). Further to this the majo...
I feel that I must comment on S Masons view that Emergency Care
Practitioners (ECP's) should not be compared to Paramedics. Surely when
evaluating the impact of ECP's it is essential to compare the potential
patient outcome should the ECP not be available. In this scenario the
majority of patients would have been seen by a paramedic or Emergency
Medical Technician (EMT). Further to this the majority of ECP's are from
a paramedic background, therefore the ECP competencies are an extension of
existing paramedic skills.
The reality is that day to day paramedics are seeing exactly these
types of patients, indeed there is evidence to support the fact that the
majority of patients seen by 999 responders are patients with relatively
minor injuries and ailments, as well as patients suffering acute on
chronic episodes. There is also evidence that the current call
prioritisation systems used in the UK ambulance service are limited in
being able to accurately identify patient conditions from the initial
call. Small studies with ECP teams responding to 999 patients seem to
show similar impact as far as patients avoiding A&E attendance in category
A,B and C scenarios.
The case for Paramedic Practitioners must be considered. As far as
changes to my practice as a paramedic who has undertaken an ECP programme,
the patients that I see during my period of duty are the same as ever.
However I am now more able to manage patients in a much more appropriate
way in being able to refer them to numerous care pathways or treat and
discharge them.
As paramedic education is moving on in order to truly reflect the
patients that they are seeing in the modern health care system, then the
competencies included in ECP programmes need to be incorporated into
standard paramedic education. Continuing to imagine that paramedics are
only involved in delivering ALS type interventions to the seriously sick
and injured is flawed. Whilst this is a vital part of the role the
reality is that 80% or more of the patients that they see do not fit into
this situation.
Introducing another tier into the system will just increase "hand
off's" for patients. Surely providing high level patient assessment
skills that allow safe and sensible decisions to be made about the care
that patients recieve should be focused on the first practitioner to see
them, more often than not a paramedic.
With interest we read the paper by van der Wulp et al.(1) It is
important that the system is evaluated since it is consensus based and
applied very commonly in emergency care.
The study evaluated the reliability and validity of the Manchester
Triage System (MTS). Validity was assessed by comparing the triage results
(vignettes) of 55 nurses with the triage results of two MTS experts who
ap...
With interest we read the paper by van der Wulp et al.(1) It is
important that the system is evaluated since it is consensus based and
applied very commonly in emergency care.
The study evaluated the reliability and validity of the Manchester
Triage System (MTS). Validity was assessed by comparing the triage results
(vignettes) of 55 nurses with the triage results of two MTS experts who
applied the MTS to the same vignettes.
This approach represents a reliability study that determined
agreement of the MTS application in practice between nurses and experts.
To assess validity of a triage system which can be considered as a
diagnostic test, criteria for diagnostic research has to be applied. The
gold standard has to be assessed independent of the triage result and has
to be predictive for patient outcome such as disease severity.(2)
Furthermore, a gold standard for urgency aims to discriminate between
those patients whose condition will worsen if no immediate care is
delivered and patients who can safely wait. Several standards are
described: urgencies attributed by experts independent of the triage
outcome, admission rate, resource use, or the reference standard for
urgency.(3, 4)
The conclusion of this study should be that the participating nurses
correctly applied the MTS in 67% compared to experts.(1) Sensitivity and
specificity can be used to quantify the performance of a triage system, if
it is evaluated as a diagnostic test. When reliability is studied, a kappa
is more appropriate. Therefore, it cannot be concluded that sensitivity of
the MTS is higher in children and the results cannot be compared to the
results described in the paper by Roukema et al.(3)
We realize that it is difficult to validate triage systems due to a
lack of agreement on how to judge the appropriateness of a visit to the
emergency department.
References
1.Van der Wulp I, van Baar ME, Schrijvers AJ. Reliability and
validity of the Manchester Triage System in a general emergency department
patient population in the Netherlands: results of a simulation study.
Emerg Med J 2008;25(7):431-4.
2.Hardern RD. Critical appraisal of papers describing triage systems.
Acad Emerg Med 1999;6(11):1166-71.
3.Roukema J, Steyerberg EW, van Meurs A, Ruige M, van der Lei J, Moll
HA. Validity of the Manchester Triage System in paediatric emergency care.
Emerg Med J 2006;23(12):906-10.
4.Van Veen M, Steyerberg E, Ruige M, Van Meurs A, Roukema J, Van der
Lei J, et al. The Manchester Triage System in paediatric emergency care:
validity and pitfalls. BMJ, in press 2008.
Wise et al are to be commended for an excellent “save” as we like to
say in the USA.1 I wonder, however, if the very midst of CPR is the best
timing for a surgical amputation. Surgery, even the life saving maneuver
described, invariably stresses the body. If at all possible, it should be
delayed until medical resuscitation is complete because surgical mortality
in cases such as the authors describe...
Wise et al are to be commended for an excellent “save” as we like to
say in the USA.1 I wonder, however, if the very midst of CPR is the best
timing for a surgical amputation. Surgery, even the life saving maneuver
described, invariably stresses the body. If at all possible, it should be
delayed until medical resuscitation is complete because surgical mortality
in cases such as the authors describe can exceed 40%.2
We wholeheartedly agree that the only way to control the massive
rhabdomyolysis and hyperkalemia in their patient was to quickly eliminate
the intracellular toxin leak from the leg. The authors briefly mention
tourniquet application, but they do not state whether they considered it
at the time. There is some fairly good experience with “physiologic
amputation” or “cryoamputation” and we believe that the strategy deserves
some elaboration for the readers.2-4
To perform, firmly apply 1-2 tourniquets to the extremity above the
level of injury or entrapment and then apply dry ice distal to the
tourniquet. Combat surgery hospitals from World War II through current
conflicts have performed the procedure not infrequently.5 Physiologic
amputation rapidly reduces myoglobin and other intracellular toxins due to
crushed, ischemic or septic extremities.2, 3 One center reported a
dramatic reduction in myoglobinuria within 24 hours of tourniquet
application and the physiologic tourniquets have allowed definitive
surgery to be delayed for up to 32 days.3
Physiologic amputation of the nonviable extremity should be
considered for similar clinical scenarios as described by the authors.
References
1. Wise R, Higginson I, Benger J, Rawlinson N. Lower limb amputation
with CPR in progress: recovery following prolonged cardiac arrest.
Emergency Medicine Journal 2006;23(3):e20.
2. Hunsaker RH, Schwartz JA, Keagy BA, Kotb M, Burnham SJ, Johnson G,
Jr. Dry ice cryoamputation: a twelve-year experience. Journal of Vascular
Surgery 1985;2(6):812-6.
3. Winburn GB, Hawkins ML, Wood MC. Physiologic amputation prevents
myoglobinuria from lower extremity myonecrosis. Southern Medical Journal
1993;86(10):1101-5.
4. Winburn GB, Wood MC, Hawkins ML, Wynn JJ, Nesbit RR, Wray CH, et
al. Current role of cryoamputation. American Journal of Surgery
1991;162(6):647-50; discussion 650-1.
5. First United States Army Report of Operations: 1 August 1944-22
February 1945. Medical Section Report Annex 11. Government Printing Office
1946:131-196.
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortali...
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortality have plateaued. Documented middle grade involvement is unchanged from 1989.
This lack of improvement in the involvement of consultants and middle grades is of concern, and there is great pressure from many sides to increase senior cover on the shop floor. This includes BAEM's 1995 recommendations for increasing the levels of senior staff in A&E departments.[2] Many of these recommendations were repeated in the Workforce Planning Document from BAEM and FAEM[3]: one of the main recommendations of this paper is that shop floor consultant cover should be available 12 hours a day, 7 days a week. This is to achieve the objective of allowing all patients to have an experienced clinician (Specialist Registrar, Non consultant career grade, consultant) either care for them directly, or supervise their care closely. In addition, the recently published NHS Plan made plain the government's intention to have more consultants involved in patient care.[4]
To investigate the current level of availability and involvement of senior and middle grade doctors in patient care in A&E departments, we undertook a survey of the 12 A&E departments in the South West deanery. These departments see between 24,500 and 85,000 new patients each year, and are staffed by between one and five consultants. We looked at the level of medical staff actually available to see new patients throughout two days in April 2001, and obtained information on all patients presenting on those two days, including triage category and level of seniority of doctor involved in their care.
Nine departments responded. No department provided 12-hour consultant cover. Most had at least 12-hour cover from a middle grade doctor, and 3 departments provided 24-hour middle grade cover. Consultant cover was poor: at the maximum, only 5 departments had a consultant on the shop floor at 1200 on Wednesday - other times had lower levels of cover. The level of middle grade and senior cover in these departments was worse at night and at the weekend.
The proportions of patients in each triage category seen by more experienced doctors or with more experienced doctors involved in their care is shown in the table.
Table
Number (%) of patients:
Triage
Total number of patients
Seen initially by experienced doctor
Seen during visit by experienced doctor
With experienced doctor involvement
1
20
2 (10)
13 (65)
13 (65)
2
163
32 (20)
46 (28)
59 (36)
3
502
124 (25)
174 (35)
219 (44)
4&5
1304
337 (26)
381 (29)
418 (32)
Total
1989
495 (25)
614 (31)
709 (36)
("experienced doctor" = consultant, SpR or NCCG)
As expected, there is a trend towards senior and middle grade involvement in the more seriously ill patients (although our sample is too small too prove a statistical relationship). 65% of Triage category 1 patients had senior or middle grade involvement, compared to 32% of category 4&5. Serious problems occasionally occur in patients triaged to category 4 or 5: in our sample, one patient died and one was admitted to HDU despite being triaged priority 4.
Following comments from some hospitals that not all the senior involvement might have been documented, we undertook a one-day audit of our own department, looking at whether the involvement of more senior medical staff is actually recorded in patient's notes. On the day studied, 218 patients were seen, of which 61 (28%) were seen initially by a senior or middle grade doctor. Of the 157 seen initially by a SHO, 39 had a senior or middle grade involved in their care at some stage (either seeing the patient, or giving advice on their care). Thus 100 patients (46%) had senior or middle grade involvement. Unfortunately, of the 39 patients for whom SHOs asked advice, this involvement of the more experienced doctor was only documented in seven (18%).
Whilst we acknowledge that our study was too small to draw statistical conclusions from, there is documented experienced staff involved in the care of 36% of patients. In many ways this is better than the impression given in many documents that A&E is still a service provided primarily by SHOs,[5,6] but it is concerning that the proportion of patients seen solely by a SHO (54%) appears to be little improved, despite increasing numbers of consultants and middle grade staff, since the Platt report in 1967, which found that 66% of patients were seen by a SHO only.
We have approached BAEM to raise the possibility of this study being expanded across the country. In the meantime, even if senior and middle grade doctors involved in the care of patients, this involvement may not be getting documented.
References
(1) Lecky FE, Woodford M, Bouamra O, et al. Lack of change in trauma care. Emerg Med J 2002;19:520-3
(2) BAEM. Planning for increased senior staff cover in Accident and Emergency departments. London: BAEM, 1995.
(3) Department of Health. Workforce planning in A&E medicine 2001-2010. BAEM, London 2001. The NHS Plan. London: Department of Health, 2000.
(4) Department of Health The NHS Plan. London: Department of Health, 2000.
(5) Audit Commission By Accident or Design London: Audit Commission, 1996.
(6) National Audit Office NHS Accident and Emergency Departments in England. London: National Audit Office, 1992.
(7) Accident and Emergency Services The Standing Medical Advisory Committee. London: HMSO, 1962.
The letter by C D Okereke [1] “Head injury transfers: arm of greatest
delay” confirms that considerable delays persist in the transfer of
patients with traumatic brain injury from district general hospitals to
regional neurosurgical units. Our own data indicates that emergency
craniotomy for traumatic brain injury was achieved in only 1 out of 24
patients [2] within the recommended four hour target [...
The letter by C D Okereke [1] “Head injury transfers: arm of greatest
delay” confirms that considerable delays persist in the transfer of
patients with traumatic brain injury from district general hospitals to
regional neurosurgical units. Our own data indicates that emergency
craniotomy for traumatic brain injury was achieved in only 1 out of 24
patients [2] within the recommended four hour target [3] and we are currently
investigating how transfer strategies can be refined to meet this target.
Mr Okereke poses two questions:
Why see the scans images before sanctioning a transfer? Are there concerns
relating to the radiologists interpretation of the scans?
From a neurosurgical perspective, I agree with Mr Okereke that it is
not always necessary to see the CT scan images before transfer. There is a
population of patients who need urgent transfer to the neuro-surgical unit
irrespective of the interpretation of the CT scan by the neurosurgical
unit. For example, patients with deteriorating levels of consciousness and
a space occupying haematoma should be accepted at the time of referral not
at the time of review of the CT scan. There are exceptions to this rule,
however, notably patients who are hypotensive with ongoing blood loss who
may require urgent extra-cranial surgery and patients in whom the
prognosis is deemed hopeless from the onset. In these patients it is
essential to see the scan to determine the suitability and timing of
transfer. Mr Okereke eludes to taxi transfer of images which inevitably
leads to delays. It is of paramount importance that district general
hospitals have an electronic image link with the regional neurosurgical
unit.
Should it be a matter of policy that all isolated severe head
injuries (GCS <_8 be="be" taken="taken" directly="directly" to="to" the="the" neurosurgical="neurosurgical" centres="centres" p="p"/> Whilst this concept would reduce delay in the definitive management
of patients with severe head injuries there are a number of concerns in
implementing such a policy at the present time. Firstly, two of the major
factors in determining outcome are the presence of hypoxia and hypotension
as secondary insults. Comatose patients therefore require urgent placement
of a definitive airway (cuffed tube in the trachea)[4] and fluid
resuscitation. This is likely to be achieved more rapidly by transferring
patients short distances to district general hospitals than by longer
primary transfers to neurosurgical units unless patients can be intubated
at the scene which requires both the expertise to place the endotracheal
tube and to administer sedating and paralysing drugs. Such expertise is
not yet universally available. Secondly, it is often difficult in the
field to distinguish between patients who are comatose with an isolated
head injury from those who are harbouring other injuries, for example,
thoracic, abdominal or pelvic haemorrhage. The priority in these patients
is to treat shock with urgent extra-cranial surgery. Thirdly, it is not
currently logistically appropriate that all patients with isolated head
injuries are transferred to regional neurosurgical units. There is a
population of patients who present with an isolated head injury who may
not require neuro-critical care, for example those with a seizure and
normal CT scan. There is also a population of patients with devastating
injuries with no chance of survival in whom transfer is clearly
inappropriate.
In summary, I agree with Mr Okereke that the concept of transferring
all patients with isolated severe head injuries directly to neurosurgical
centres is attractive but at present would produce significant problems.
However, given the evidence that specialised neuro-critical care has the
potential to improve outcome in patients with diffuse injury as well as
those with mass lesions [5-7] we should be ensuring that all patients likely
to benefit should be transferred. Direct transfer to neurosurgical units
may become possible in the future but would require widespread
implementation of personnel with the ability to intubate patients in the
field which requires expertise in the use of sedation and paralysis, rapid
transport systems from the field to the regional neurosurgical unit
(distances in some regions in excess of 100 miles), capability for extra-
cranial surgery in all regional neurosurgical units and an expansion in
the number of neuro-critical care beds.
PJ Hutchinson
Academic Department of Neurosurgery, University of Cambridge,
Addenbrooke’s Hospital, UK
Address for correspondence:
Mr PJ Hutchinson
University of Cambridge Department of Neurosurgery
Box 167
Addenbrooke’s Hospital
Cambridge
CB2 2QQ
UK
Telephone +44 1223 336949
Fax +44 1223 216926
E-mail pjah2@cam.ac.uk
References
(1) Okereke CD. Head injury transfers: arm of greatest delay. Emerg
Med J 2004;21:397.
(2) Sergides IG, Howarth S, Whiting G, Hutchinson PJ. Is the
recommended four hour target from injury to emergency craniotomy for head
injury achievable? Br J Neurosurg 2004;abstract in press.
(3) Royal College of Surgeons of England. Report of the working party
on the management of patients with head injuries. London: RCS, 1999.
(4) American College of Surgeons Committee on Trauma. Advanced Trauma
Life Support for Doctors. Chicago: American College of Surgeons, 1997.
(5) Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick
PJ. Specialist neurocritical care and outcome from head injury. Intensive
Care Med 2002;28:547-53.
(6) Polderman KH, Tjong Tjin Joe R, Peerdeman SM, Vantertop WP,
Girbes AR. Effects of therapeutic hypothermia on intracranial pressure and
outcome in patients with severe head injury. Intensive Care Med
2002;28:1563-73.
(7) Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury
improved by an organised secondary insult program and standardised
neurointensive care. Crit Care Med 2002;30:2129-34.
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
The definition of massive transfusion has little clinical significance during trauma resuscitation and even so, remains debated with an acute definition likely to be more effective than the traditional definition. (2) Massive blood transfusion during trauma resuscitation is rarely based on a target haemoglobin and current experience with thromboelastography suggests that platelet function rather than absolute platelet counts should direct platelet transfusion. The ideal ratio of packed red blood cells to fresh frozen plasma similarly has been gleaned from retrospective associations only, confounded by multiple biases. Recent randomised controlled trials have failed to show any outcome benefit from the stated indication for recombinant factor VIIa.
Attempts to develop massive transfusion protocols supported by inadequate evidence have previously resulted in marked variability in practice.(3) A massively haemorrhaging trauma patient presents a challenging scenario to most emergency physicians and in the face of poor level of evidence to guide practice, it is not surprising that most use clinical gestalt (referred by the authors as "guess"). Rather than criticising the knowledge of emergency physicians or imposing non-evidence based "protocols", research efforts should be directed at multicentre, outcome focused randomised controlled trials comparing different but valid strategies in managing massive haemorrhage. Only then can we embark on developing effective massive transfusion guidelines.
References
1. Milligan C, Higginson I, Smith JE. Emergency department staff knowledge of massive transfusion for trauma: the need for an evidence based protocol. Emerg Med J. 2010 (In Press). doi:10.1136/emj.2009.088138.
2. Mitra B, Cameron PA, Gruen R, et al. The definition of massive transfusion in trauma: a critical variable in examining evidence for resuscitation. Eur J Emerg Med. 2010 (In Press). doi: 10.1097/MEJ.0b013e328342310e
3. Schuster KM, Davis KA, Lui FY, et al. The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion? Transfusion 2010; 50(7): 1545-1551.
I can only sympathise with the author that primary care medicine
does not interest him. The good news is that it does interest some other
clinicians.
In Leeds (West Yorkshire) we are commissioning a new Walk In Centre
that will be strategically placed in front of the Emergency Department.
There will be no other way to walk into the department, than through the
Walk In Centre. In this way, t...
I can only sympathise with the author that primary care medicine
does not interest him. The good news is that it does interest some other
clinicians.
In Leeds (West Yorkshire) we are commissioning a new Walk In Centre
that will be strategically placed in front of the Emergency Department.
There will be no other way to walk into the department, than through the
Walk In Centre. In this way, the primary care patients will be Seen,
Treated and Discharged without ever the Emergency Physicians even knowing
that they have arrived.
Dear Editor
I think the model the Israeli medical services had adopted in the development of emergency medicine is brilliant and something we should deliberate adopting as modelling for the future of emergency medicine. It's not a new idea as the Casualty Surgeons in the UK and countries affiliated to this model in other parts of the world did way back in the 1960's develop as a group of specialist orthopaedic sur...
Dear Editor
I agree with the authors’ conclusion that a clinical diagnosis of epididymitis without urology follow up is potentially hazardous. However, the importance of testicular microlithiasis(TM) is difficult to understand.
Retrospective evidence has revealed an association between TM and testicular tumours to be as great as 40%. However, recent prospective evidence in one study of 1504 asymptomatic men...
Dear Editor,
We read with interest the article by MJ Reed et al. As they have mentioned there have been numerous attempts to devise scoring systems for airway assessment, however these scores have been undermined by low sensitivity and specificity. Furthermore Positive predictive values for these tests range from 4 – 60% [1], we believe that such a low predictive value has significant implications for airway manag...
Dear Editor,
I feel that I must comment on S Masons view that Emergency Care Practitioners (ECP's) should not be compared to Paramedics. Surely when evaluating the impact of ECP's it is essential to compare the potential patient outcome should the ECP not be available. In this scenario the majority of patients would have been seen by a paramedic or Emergency Medical Technician (EMT). Further to this the majo...
Dear editor,
With interest we read the paper by van der Wulp et al.(1) It is important that the system is evaluated since it is consensus based and applied very commonly in emergency care.
The study evaluated the reliability and validity of the Manchester Triage System (MTS). Validity was assessed by comparing the triage results (vignettes) of 55 nurses with the triage results of two MTS experts who ap...
Dear Editor,
Wise et al are to be commended for an excellent “save” as we like to say in the USA.1 I wonder, however, if the very midst of CPR is the best timing for a surgical amputation. Surgery, even the life saving maneuver described, invariably stresses the body. If at all possible, it should be delayed until medical resuscitation is complete because surgical mortality in cases such as the authors describe...
Dear Editor
We read with interest the article and accompanying editorial by Lecky et al. in this month's Emergency Medicine Journal.[1] Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortali...
Dear Editor
The letter by C D Okereke [1] “Head injury transfers: arm of greatest delay” confirms that considerable delays persist in the transfer of patients with traumatic brain injury from district general hospitals to regional neurosurgical units. Our own data indicates that emergency craniotomy for traumatic brain injury was achieved in only 1 out of 24 patients [2] within the recommended four hour target [...
Milligan, et al. (1) provides valuable insight into the varied management of massive haemorrhage post trauma. However, the conclusions that emergency physicians lacked core knowledge and were unaware of how to prevent and treat early coagulopathy appear unfounded. It would be more prudent to conclude that a paucity of high level of evidence guiding trauma resuscitation was responsible for this varied practice.
The defin...
Dear Editor,
I can only sympathise with the author that primary care medicine does not interest him. The good news is that it does interest some other clinicians.
In Leeds (West Yorkshire) we are commissioning a new Walk In Centre that will be strategically placed in front of the Emergency Department. There will be no other way to walk into the department, than through the Walk In Centre. In this way, t...
Pages