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
This paper shows a good outcome of undiagnosed cervical spine trauma
when the intubation was performed by a senior practioner, in an ED of a
UK.
In USA, for example, paramedics perform access to airway in the local
of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants,
this type of rescue is performed also by the Fire Departmet: there are
various Rescue Units without doctors. But here we have a difference: the
Fire Department is a department of the Military Police, and the soldier
that made the initial approach to one trauma patient in the
stree,generally aren’t whit a doctor with them. The system is generally
good: the time from one initial phone to dispatch an unit (the order to
send a car with or without a doctor is take from a senior MD) is about
seven minutes, even in a chaotic traffic: there are also motorcycles and
helychopters.But the FD soldiers of these unit only have a three months
“fellowship” in the biggest ER of the city, at the Hospital of the
University of Sao Paulo, and have the “practice” training in artificial
patients. In some cases they have to perform an intubation in the street,
these men with only the high school, a short stage and the real life.
The curious thing is that in a high number of cases attended by this
team in more than ten years, there aren’t notices of spinal lesions
worsened by them.
What can we conclude about these? They fix a collar in the patient,
put the victim in a rigid wood and there are not reports of worsened
lesions. In the beginning of this system, we doctors don’t agree with this
procedure, but the practice show the opposite. The training of soldiers by
good doctors can we assume that intubation in critical patients, like the
trauma ones, could be taken more seriously than when this type of training
is given to a medical student who does not to intube in his/her
professional life. Can these be correct?
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern eme...
I read with great interest the article by MC Howes. It concerns me
that much current practice in Emergency Medicine in the UK is still
dictated by those outside the speciality, who have little or no idea of
the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been
accepted both in the US and Australia as a part of modern emergency
medicine practice, the UK still cautions that use of general anaesthetic
(presumably including ketamine) should only be practiced by those trained
in paediatric or neonatal anaesthesia.
In our own (third world) department, ketamine is often used to sedate
children who need to undergo short, painful operations, including
manipulation of fractures and some suturing and incision and drainage
procedures.
We have a well written protocol (developed by my predecessor) which
has stood the test of time (it has been in force for the past 4 years with
no serious complications to date).
The key to safe and effective sedation hinges on the following:
careful selection of patients (including premorbid history, airway
assessment and fasting history); properly trained staff (for each
procedure, ther must be at least one person responsible for the airway who
can manage an emergent airway problem - this is NOT necessarily a
paediatric anaesthetist) and careful selection of drugs (we use ketamine
for all our younger children, with the addition of a small dose of
midazolam and atropine). Finally, the patient MUST be monitored carefully
until awake. In our department, pulse oximetry is mandatory, but the
importance of clinical observation is stressed to all staff.
I feel that it is more than time for practitioners in the UK to grasp
the nettle and produce their own guidelines regarding sedation in their
departments. This does not have to be 'sanctioned' by the Royal College of
Anaesthetists, though their input would be welcome. The important thing
for us to remember is that once we set ourselves certain standards, it is
our duty to live up to these, and in the case of untoward incidents, we
must be willing to accept responsibility. In the field of sedation in the
Emergency setting, the only professionals capable of creating meaningful
guidelines are Emergency Physicians.
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate anal...
Woollard and his colleagues' study on nalbuphine identifies the gap
that can exist between research and clinical practice. I resent the claims
in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have
been given nalbuphine pre hospital with very little benefit and lot of
problem. These patients get grossly inadequate analgesia, a fact admitted
in this study. Interestingly, the reduction in pain score is quoted, but
not the end pain score. A reduction from 9 to 6 may look impressive on
statistics, but is hardly worth talking about from the patients'
perspective. These patients get troublesome nausea. The worst is the
significantly high doses of morhine needed to overcome the antagonism,
which then keeps them longer in the department.Perhaps this aspect of
hospital data should have been included to illustrate the problem.
In the doses discussed, the drug is ineffective - both as an
analgesic and as a narcotic! Can patients be called drowsy, if their GCS
is unchanged? Is it worth championing an analgesic, if the patients
subsequently need double the predicted dose of morphine?
Lastly, if 30mg nalbuphine (currently permitted upper limit in north wales
paramedic protocol)fails to achieve good analgesia, what is research
proving by comparing 10mg x2 vs 5mg x 4?
Rather than pursue futile research question, is it not better to campaign
for change of practice to morphine, which is guaranteed to work?
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them a...
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN
guidelines on paediatric procedural sedation were rightly welcomed as a
chance to address issues which many emergency physicians felt had been
overlooked. Our colleagues from Australasia and the United States are
somewhat puzzled by our hesitation in adopting what is viewed by them as a
valuable adjunct in the care of children undergoing painful procedures in
the emergency department.
Having witnessed many situations where there has been only a stark
choice between wrapping a child in a blanket to do "a quick couple of
sutures" or transferring the child for a general anaesthetic and overnight
stay in hospital I sincerely hoped there might in future be better ways of
doing things. While I wouldnt rush to start using ketamine on every unruly
child the increasing body of research on this (from the UK) does not
support the notion that this is a colossally dangerous technique.
The majority of emergency medicine specialist registrars are now
competent in rapid sequence intubation by the end of their training and
many have formal training in safe sedation (including standardised
simulator training. Procedural sedation in paediatric emergency medicine
is not practiced in any of the three children's hospitals in Scotland but
many paediatric emergency medicine trainees have learned these techniques
in Australasia.
The arguments put forward against the use of ketamine are sadly
familiar to those of us who practice rapid sequence intubation in A&E.
In the same way, skilled, responsible and properly trained emergency
physicians will simply start doing it and zealously auditing it's safety
until it is considered normal.
It is only a matter of time until Neil Morton's own hospital appoints
an emergency physician who has this training and it is introduced safely
and effectively. These clinicians are very far removed from the "cowboys"
we are constantly being characterised as.
Reference
1. N S Morton. Ketamine is not a safe, effective, and appropriate technique for emergency department paediatric procedural sedation. Emerg Med J 2004; 21: 272-273.
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people with delirium do not have their delirium detected by A&E staff, leading to poor outcomes.[2] Routine use of even basic screening instruments such as the AMTS [3] would help detection, but such routine use is rare.
We agree that it is useful to be able to compare the AMTS in an acute event with previously measured values, but for this comparison to be valid it is crucial that the same questions are used. It is therefore unfortunate that the version of the AMTS presented differs from the original one, and that the quoted cut-off score is incorrect.[3] It has previously been demonstrated that doctors are inconsistent when trying to assess cognition using the AMTS4, and we believe that use of the correct questions and scoring in Table 1 will help matters.
Table 1
Please follow scoring instructions.
A correct answer scores 1 mark. No half-marks are given. A score of 6 or below is abnormal
Question
Assessment
Rating
1 How old are
you?
Score for exact age
only
2 What is your
date of birth?
Only date and month
needed
3 What is the
year now?
Score for exact year
only
4 What is the
time of day?
Score if within 1hr
of correct time
5 Where are we?
What is this building?
Score for exact
place name e.g. “hospital” insufficient
Now ask subject to
remember an address: 42, West Street
6 Who is the
current monarch?
Score only current
monarch
7 What was the
date of the 1st World War?
Score for year
of start or finish
8 Can you count
down backwards from 20 to 1?
Score if no mistakes
or any mistakes corrected spontaneously
9 Can you tell me
what those 2 people do for a living?
Score if
recognises role of 2 people correctly e.g. Dr, nurse
10 Can you
remember the address I gave you?
Score for exact
recall only
TOTAL
/10
References
1. Wardrope J,.Mackenzie R. The system of assessment and care of the primary survey positive patient. Emergency Medicine Journal 2004;21:216-25.
2. Sanders AB. Missed delirium in older emergency department patients: a quality-of-care problem. Ann.Emerg.Med. 2002;39:338-41.
3. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8.
4. Holmes J,.Gilbody S. Differences in use of abbreviated mental test score by geriatricians and psychiatrists. BMJ 1996;313:465.
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...
Dear Editor
This paper shows a good outcome of undiagnosed cervical spine trauma when the intubation was performed by a senior practioner, in an ED of a UK.
In USA, for example, paramedics perform access to airway in the local of an accident, and they are members of the Fire Department of some city.
In Sao Paulo, the largest city of Brazil, with 10 million habitants, this type of rescue is perfor...
Dear Editor
I read with great interest the article by MC Howes. It concerns me that much current practice in Emergency Medicine in the UK is still dictated by those outside the speciality, who have little or no idea of the needs of our patients, or the settings in which we work.
I was not surprised to read that, while ketamine sedation has been accepted both in the US and Australia as a part of modern eme...
Dear Editor
Woollard and his colleagues' study on nalbuphine identifies the gap that can exist between research and clinical practice. I resent the claims in this paper that nalbuphine somehow is an effective analgesic.
Since 1996, I have been receiving patients in my hospital who have been given nalbuphine pre hospital with very little benefit and lot of problem. These patients get grossly inadequate anal...
Dear Editor
Neil Morton's points are concise and thought provoking as always.[1] The withdrawal and ongoing reevaluation of the SIGN guidelines on paediatric procedural sedation were rightly welcomed as a chance to address issues which many emergency physicians felt had been overlooked. Our colleagues from Australasia and the United States are somewhat puzzled by our hesitation in adopting what is viewed by them a...
Dear Editor
We do not want to detract from the overall value of the recent article by Wardrope and MacKenzie,[1] but we feel it important to point out our concerns over the proposed assessment of cognitive function.
Cognitive impairment due to dementia and delirium is common in emergency situations but formal assessment of cognitive function is rare. This could explain why at least 67% of older people wi...
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