I would like to thank Body and Foex for their thought-provoking
article, and also Cattermole and Challen for their replies. Too often in
the culture of emergency medicine, the philosophical underpinnings of
thought and action are neglected. When is there time to reflect?
One highlight of their discussion of utilitarianism is the inclusion
of emotional factors into the weighing of what actions can be counted as...
I would like to thank Body and Foex for their thought-provoking
article, and also Cattermole and Challen for their replies. Too often in
the culture of emergency medicine, the philosophical underpinnings of
thought and action are neglected. When is there time to reflect?
One highlight of their discussion of utilitarianism is the inclusion
of emotional factors into the weighing of what actions can be counted as
Good (or cost-effective). False-positive tests occasion much suffering at
times, and this needs to be recognized. Many of our strategies of care
would be well served through this form of examination. For example,
practitioners who treat indigent patients disrespectfully with the
intention of making them reflect upon the error of their ways or use the
emergency department less often.
The challenge of utilitarian analysis is the consideration of all
possible ramifications of action, and the subsequent calculation of costs
and benefits on all levels - physical, economic, emotional... Faced with
such complexity, a return to "primum non nocere" becomes attractive. And
yet there needs to be a balance between action guided by ideals and action
guided by calculation. It is possible that Hippocrates also said
"secundum, consider all consequences of your words and deeds."
The article by Higginson made me think about our specialty and
whether we have got a missing link. However, it reminded me to look at the
Way Ahead document produce by the UK College of Emergency Medicine in
2008. Surely this provides an excellent service concept for our specialty?
The document provides clear guidance as to what our core and extended
services should be and how we should consider delivering them. I wonder...
The article by Higginson made me think about our specialty and
whether we have got a missing link. However, it reminded me to look at the
Way Ahead document produce by the UK College of Emergency Medicine in
2008. Surely this provides an excellent service concept for our specialty?
The document provides clear guidance as to what our core and extended
services should be and how we should consider delivering them. I wonder
whether the author had read this....maybe he should.
With great interest we read the recent article by Bevan and
colleagues reporting how predictive ALT is for liver injury in children
with blunt abdominal trauma. In the result section the authors describe
the following: "The presence or absence of liver injury can be predicted
with a sensitivity of 96% and a specificity of 80%". In their conclusion
they reported: "a threshold of >104 IU/L gave a 96% specificity for
t...
With great interest we read the recent article by Bevan and
colleagues reporting how predictive ALT is for liver injury in children
with blunt abdominal trauma. In the result section the authors describe
the following: "The presence or absence of liver injury can be predicted
with a sensitivity of 96% and a specificity of 80%". In their conclusion
they reported: "a threshold of >104 IU/L gave a 96% specificity for
the detection of liver injury". We would like to emphasize the difference
and think the authors mean 96% sensitivity in their conclusion section.
We read with interest Manini et al’s 1 recent paper suggesting ischaemia-modified albumin assays could assist in decreasing the rate of inappropriate discharges from the ED, and that further studies into diagnostic tools for use in chest pain are warranted.
We conducted an audit at Ealing Hospital that also supports the need for developing new diagnostic algorithms for chest pain. Medical histories of 14...
We read with interest Manini et al’s 1 recent paper suggesting ischaemia-modified albumin assays could assist in decreasing the rate of inappropriate discharges from the ED, and that further studies into diagnostic tools for use in chest pain are warranted.
We conducted an audit at Ealing Hospital that also supports the need for developing new diagnostic algorithms for chest pain. Medical histories of 147 patients admitted to the Emergency Department’s Chest Pain Unit for monitoring were studied. All patients gave a history consistent with chest pain of cardiac origin. We studied whether positive troponin-T results correlated with the presence of Framlingham cardiovascular risk factors, or with a past medical history of cardiac or vascular disease (i.e. a history of angina, coronary artery bypass grafting, previous MI, stroke, TIA, heart failure, previous angiography or history of claudication).
In our patient group the percentage of positive troponin results did not increase in line with the number of Framlingham risk factors present, however these patients were highly likely to receive further in-patient investigation. Conversely, while past medical history of cardiac or vascular disease did not appear to have a bearing on the emergency physician’s decision to admit a patient for investigation, those patients with 1-3 conditions appeared to form the majority of patients with positive troponin results (this group made up 55.9% of patients with positive troponin results, but only contributed 36.9% of those with negative troponins).
This data supports a number of other studies on this topic 2,3, and we believe that physicians should consider treating chest pain patients with significant cardiovascular history with a higher index of suspicion that is currently the case. We also believe that further research into the use of past medical history in the assessment and risk stratification of acute chest pain is required.
References:
Manini AF, Ilgen J, Noble VE et al.. Derivation and validation of a sensitive IMA cutpoint to predict cardiac events in patients with chest pain. Emerg Med J 2009;26:791-796.
Body R, McDowell G, Carley S et al.. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation 2008;79:41-5.
Cakir B, Blue K. How to Improve the Management of Chest Pain: Hospitalists and Use of Prediction Rules. South Med J 2007;100:242-7.
This case appears to be describing the Pellegrini-Stieda
syndrome/lesion. This is, in fact, a well-known and fairly common finding,
generally felt to reflect a post-traumatic ectopic ossification, either
acute or chronic. MR is a useful test, as the signal void from the
calcification can be seen in relation to the MCL. It may also uncover bone
bruising from an associated avulsion fracture (the so-called Stieda
fracture)....
This case appears to be describing the Pellegrini-Stieda
syndrome/lesion. This is, in fact, a well-known and fairly common finding,
generally felt to reflect a post-traumatic ectopic ossification, either
acute or chronic. MR is a useful test, as the signal void from the
calcification can be seen in relation to the MCL. It may also uncover bone
bruising from an associated avulsion fracture (the so-called Stieda
fracture). As an academic exercise, MR can also subclassify the lesion
into 4 different types, dependent on the exact pattern of ossification
(although this has limited, if any, clinical importance).
Reference: Mendes et al. Skeletal Radiology (2006) 35(12):916-22.
Dear Editor,
I understand that it is very important to log roll and carefully evaluate the whole spine of the patient.
By reading this article, I understand the importance of complete spinal evaluation but there are situations in which spinal injuries are missed as a result of incomplete evaluation or not adhering to systematic approach.
I want to share one of the clinical cases in the management of which I was involved.
A pa...
Dear Editor,
I understand that it is very important to log roll and carefully evaluate the whole spine of the patient.
By reading this article, I understand the importance of complete spinal evaluation but there are situations in which spinal injuries are missed as a result of incomplete evaluation or not adhering to systematic approach.
I want to share one of the clinical cases in the management of which I was involved.
A patient presented with hypotension, abdominal distension, bradycardia and unconsciouness in A&E after being involved in a high speed motor vehicle crash. The patient was taken for emergency laparotomy which proved negative.
Despite that patient remained hypotensive and cervical spine x-rays were obtained which revealed atlanto-occipital dislocation.
The patient died 2 days later but the lesson is to firmly adhere to A,B,C,D and E protocol of ATLS and don’t cut short corners. Unnecessary operations can be avoided and those who are unlikely to survive symptomatic treatment
can be decided from the point of presentation.
I was disturbed to read the article by Body and Foex [1] advocating
the embrace of Utilitarian values in medicine. I hope it was merely a
misuse of words. All penguins are birds, but not all birds are penguins.
Utilitarianism is a form of consequentialism, but not all ethical thinking
that considers the consequences of one’s actions is Utilitarian. The
authors of the article correctly make a clear c...
I was disturbed to read the article by Body and Foex [1] advocating
the embrace of Utilitarian values in medicine. I hope it was merely a
misuse of words. All penguins are birds, but not all birds are penguins.
Utilitarianism is a form of consequentialism, but not all ethical thinking
that considers the consequences of one’s actions is Utilitarian. The
authors of the article correctly make a clear case for efficiency and risk
-benefit “consequential” thinking in medicine, and in particular in
decision analysis. However, this is not Utilitarianism.
Utilitarianism is an ethical theory in which the “right” action is
that which maximises the aggregate “good” outcome across a population. The
“good” can variously be defined as pleasure, or preference satisfaction,
or as in this article, health benefit. There are practical problems with
the theory which are common to any consequential thinking: the
difficulties of making predictions and calculating relative risk-benefits
for people with different perceptions of what is good for them. However,
the big problem with utilitarianism itself is that it justifies any
action, so long as there is an aggregate net increase in what is
considered good. Plagiarism, falsified research data, dishonest job
applications, unfair discrimination - could all in some situations be
justified. And so could bribery, theft, or murder. Of course, doctors
would never be involved in inhuman human experiments, forced
sterilisations, “eugenic” murder, or torture for the “greater good”… but
they would, and they were, and it didn’t stop with Nazi Germany or
Tuskegee. And why should it, if you accept Utilitarianism? Why not kill an
unwilling patient in order to harvest his healthy organs to save five
others who would otherwise die?
If we seek to do net good in medicine, the command to “do no harm” is
a helpful warning against the evil of imposing a centrally defined,
collective “good”, on vulnerable individuals. As such, it is good that
Hippocrates is said to have made it a priority. Bentham might have
considered rights to be “nonsense upon stilts”,[2] but it is because
consequence-based ethical thinking is so inherently dangerous, that we
need human rights, and aphorisms such as “first, do no harm”.
No-one outside the extreme wing of the health-and –safety lobby would
suggest that “do no harm” means that one must never perform an action that
might be painful. Foex and Body are setting up a “straw man” by using
examples such as venous cannulation to argue against the importance of non
-maleficence. Patients consent to undergo discomfort or risk in order to
achieve a later benefit: this expresses their right to choose for
themselves (autonomy), and is a balance of good and harm (beneficence and
non-maleficence). If the patient cannot consent, then we have to weigh up
very carefully what is in the patient’s best interests (risk-benefit) –
not primarily the interests of the State.
Utilitarianism can impose deliberate involuntary harm on an
individual for others’ benefit. By reminding ourselves of the importance
of autonomy and doing no harm, we would remember that the good we seek is
that of the patient we are treating, that the harm that may ensue is
accidental, and the risks agreed by the one facing them.
Consequence-based reasoning and good medicine are of course
“inescapably intertwined”.[1] But for goodness’ sake, do not call this
“Utilitarianism”.
Sincerely,
Giles N Cattermole.
[1]Body R, Foex B. On the philosophy of diagnosis: is doing more good
than harm better than “primum non nocere”? Emerg Med J 2009;26:238-40.
[2] Bentham J. Anarchical fallacies. In Bowring J (editor): The Works
of Jeremy Bentham (Vol 2). Edinburgh, Wm Tait. 1843, p501. Viewed 26 May
2009. http://books.google.co.uk.
University Department of Anaesthetics
Level 2, University Block
Glasgow Royal Infirmary
10 Alexandra Parade
Glasgow G31 2ER
19 February 2009
Dear Sir,
We read with interest the clinically based study, on the use of
propofol to sedate patients for relocation of hip prostheses in the
emergency department.[1] The authors rightly point out that there are
problems with the safety and efficacy of us...
University Department of Anaesthetics
Level 2, University Block
Glasgow Royal Infirmary
10 Alexandra Parade
Glasgow G31 2ER
19 February 2009
Dear Sir,
We read with interest the clinically based study, on the use of
propofol to sedate patients for relocation of hip prostheses in the
emergency department.[1] The authors rightly point out that there are
problems with the safety and efficacy of using midazolam, and conclude
that the described technique is both effective and safe. In another paper
by the same authors they demonstrate this technique of “sedation” has a
better success than midazolam, reduces the delay in these patients going
to theatre, and therefore the patients discomfort (although there is no
mention of pain scores of these patients).[2] However we disagree strongly
with the conclusions that adverse effects were acceptably uncommon, and
argue that the authors have not demonstrated the safety of this technique.
First, we would like to comment on the sedation protocol.
Disappointingly there is no attempt to describe the depth of sedation
provided. The report of the Academy of Royal Colleges on Safe Sedation
Practice states clearly that “verbal contact with the patient is
maintained throughout the period of sedation”.[3] To us, 1mg.kg-1 of
propofol in this age group is a dose close to that required for induction
of anaesthesia [4], and without documentation of the maintenance of verbal
contact it cannot be termed sedation. By your own admission, many of the
patients in this study were, in fact, anaesthetised. The Academy of Royal
Colleges document (to which the Faculty of Accident and Emergency Medicine
were party) again is quite clear that “provision of sedation deeper than
this (verbal contact)… is bordering on anaesthesia. As such, this depth of
sedation must be supervised by those with the same level of training and
skills necessary to provide general anaesthesia”.[4] Given that many of
these patients may have been anaesthetised, we have several concerns
regarding this protocol pertaining to training, monitoring, and fasting:
Training: the staff responsible for this procedure had only undergone
one hour of in-house training. The Royal College of Anaesthetists mandate
to its own trainees that they should undergo an initial assessment of
competency before being allowed to give any anaesthetic not directly
supervised. This assessment is usually after a full three months.[5]
Monitoring: the level of monitoring recommended for patients undergoing
general anaesthesia should include capnography.[6]
Fasting: we find it incredible that in emergency patients suffering pain
(and consequently at higher risk of pulmonary aspiration) that you stated
that fasting guidelines were used “as a guide and not a rule”. Evidence
on the necessity of fasting for elective procedures are clear after almost
40 years of evidence.[7] Guidelines are less clear for emergency cases as
normal fasting times may be insufficient, necessitating protection of the
patients’ airway.
More worryingly we refute the interpretation of these data as
evidencing safety. It would have been useful to present the incidence of
adverse events with confidence intervals (CI). This allows one to estimate
the true population incidence of a rare event, which could be as much as
the upper level of the 95% CI.[8] We have taken the liberty of doing this
for you: 8% (95% CI 2.6 to 13.4) of patients suffered arterial oxygen
desaturation, 4% (95%CI 0.2-8) required bag-valve-mask ventilation and 4%
(95%CI 0.2 to 2.8) required vasopressors. Therefore your actual population
rate may be anywhere between 2.6% and 13.4%. This rate of
airway/respiratory events equates to 80/1000 (but could be anywhere
between 26 and 134/1000 patients). This compares very unfavourably with
those of other non anaesthetic groups (Australian GPs) of 4.1 (95%CI 3.3
to 4.9) /1000 and even less favourably with anaesthetists of 2.6 (95%CI
1.6 to 4.2) /1000. 9 Our department has trained non-medical sedationists
to provide true conscious sedation for a different painful procedure
(oocyte retrieval for assisted conception), and have audited experience of
3000 patients with an adverse incidence rate of 0.3 (95%CI -0.3 to +0.9)
/1000patients. In this context your described results cannot be remotely
construed as demonstrating safety. We would also point out that a sample
size of thousands not hundreds would be necessary to convince us of the
safety of this non-standard technique.[10]
In conclusion we are not surprised that the hip relocation rate is
higher with your technique as you have compared propofol anaesthesia with
midazolam sedation. We can entirely understand the desire to reduce delays
for your patients waiting in pain for hip relocation in theatre. However,
our answer to the title of your article “Is propofol a safe and effective
sedative for relocating hip protheses?” is a resounding no. It is our
interpretation that this technique has not been demonstrated as safe, and
would be difficult to justify in the event of a permanent serious
complication.
Yours sincerely,
Dr A Puxty, Dr M Sim, Dr KJ Anderson, Professor J Kinsella
References
1. Mathieu N, Jones L, Harris A, et al. Is propofol a safe and effective
sedative for relocating hip prostheses? Emerg Med J 2009;26:37–38.
2. Gagg J, Jones L, Shingler G, et al. Door to relocation time for
dislocated hip prosthesis: multicentre comparison of emergency department
procedural sedation versus theatre-based general anaesthesia. Emerg Med J
2009;26:39–40.
3. UK Academy of Medical Royal Colleges and their Faculties. Implementing
and ensuring Safe Sedation Practise for healthcare procedures in adults.
Report of an Intercollegiate working party chaired by the Royal College of
Anaesthetists. November 2001.
http://www.rcoa.ac.uk/docs/safesedationpractice.pdf
4. Dundee JW, Robinson FP, McCollum JSC, Patterson CC. Sensitivity to
propofol in the elderly. Anaesthesia 1986;41:482 – 485.
5. http://www.rcoa.ac.uk/docs/CCTptii.pdf
6.
http://www.aagbi.org/publications/guidelines/docs/standardsofmonitoring07.pdf
7. Practice guidelines for preoperative fasting and the use of
pharmacological agents for the prevention of pulmonary aspiration:
application to healthy patients undergoing elective procedures.
Anesthesiology 1999; 90; 896-905.
8. Eypasch E, Lefering R,Kum CK, Troidl H. Education and debate.
Probability of adverse events that have not yet occurred: a statistical
reminder. BMJ 1995;311:619-620
9. Clarke AC, Chiragakis l, HillmanLC, Kaye GL. Sedation for endoscopy:
the safe use of propofol by general practitioner sedationists. Med J of
Aust 2002;176:158-61
10. Craig DC, Wildsmith JA. Conscious sedation for dentistry: an update.
Br Dent J 2007; 203(11): 629-31
I commend the work of Geelhoed and MacDonald in their sentinel dose-
finding studies regarding the minimum effective dose of dexamethasone for
croup, it does seem to suggest a 'ceiling' effect. This work has been
recently followed by a descriptive paper (accepted for publication, not
yet published) outlining the experience over 27 years at their
institution, clearly demonstrating the real-world effect...
I commend the work of Geelhoed and MacDonald in their sentinel dose-
finding studies regarding the minimum effective dose of dexamethasone for
croup, it does seem to suggest a 'ceiling' effect. This work has been
recently followed by a descriptive paper (accepted for publication, not
yet published) outlining the experience over 27 years at their
institution, clearly demonstrating the real-world effectiveness of the
lower dose (0.15mg/kg), which became local policy more than two decades
ago.
Unfortunately, every Systematic Review by the Cochrane Collaboration has
found the numbers of patients enrolled in the initial RCTs of Geelhoed and
MacDonald too small to rigorously prove the efficacy of the lower dose of
dexamethasone in croup.
It is with this background that we have recently started recruiting
subjects for a large RCT, the ToPDoG Study: Trial of Prednisolone /
Dexamethasone oral Glucocorticoid. This trial aims to settle the question
of dexamethasone dose (0.6 vs 0.15mg/kg), and compare the efficacy of
prednisolone (1mg/kg)in a three-armed equivalence study. Details can be
found at:
http://www.anzctr.org.au/trial_view.aspx?ID=83722
References:
Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3
mg/kg versus 0.6 mg/kg.
Geelhoed GC, Macdonald WB.
Pediatr Pulmonol. 1995 Dec;20(6):362-8.
PMID: 8649915
Sixteen years of croup in a Western Australian teaching hospital:
effects of routine steroid treatment.
Geelhoed GC.
Ann Emerg Med. 1996 Dec;28(6):621-6.
PMID: 8953950
Glucocorticoids for croup.
Russell K, Wiebe N, Saenz A, Ausejo SM, Johnson D, Hartling L, Klassen TP.
Cochrane Database Syst Rev. 2004;(1):CD001955. Review.
PMID: 14973975
Although the definition of Basic Life Support (BLS) does vary between
sources, it is probably best regarded as, "a level of medical care that
can be used to treat patients with life-threatening illness or injury
without the use of any advanced or invasive medical procedures or
intravenous access". It should be possible for any rescuer in any
situation to render BLS simply by using hands and lungs, although simple
improvi...
Although the definition of Basic Life Support (BLS) does vary between
sources, it is probably best regarded as, "a level of medical care that
can be used to treat patients with life-threatening illness or injury
without the use of any advanced or invasive medical procedures or
intravenous access". It should be possible for any rescuer in any
situation to render BLS simply by using hands and lungs, although simple
improvised items (such as a handkerchief plus necktie or tights to apply
local pressure to a bleeding wound) should also be allowed. Some would
extend the list of permitted adjuncts to include a face shield/pocket mask
or even an oropharyngeal airway. However, to stretch the concept of BLS to
include the use of a bag-valve-mask device (BVMD), laryngeal mask airway
(LMA) or laryngeal tube (LT) probably strays too far into the realms of
advanced life support. If this is the case, then the title of the paper by
Dixon et al.[1] was inaccurately worded.
In reality, the BVMD is probably one of the trickiest items to use
correctly in prehospital care, and some would say its use requires two
persons – one to hold the mask securely against the patient’s face and the
other to squeeze the bag. Certainly, to ventilate the lungs correctly with
a BVMD without inflating the stomach requires considerable skill.
The authors failed to state which versions of the selected
supraglottic airway devices (SADs) were used in the trial. The Laryngeal
Tube is available with both a single lumen (LT & LT-D) and dual lumens
(LTSII & LTS-D), the dual-lumen versions featuring a gastric drainage
channel in addition to the airway tube. With its distal balloon inflated
within the manikin’s upper oesophagus, it is hardly surprising that the
authors found a low incidence of gastric insufflation with the LT,
particularly if the device also featured a gastric drainage channel
opening beyond the distal balloon. Also, the authors failed to state which
type of LMA was used by way of comparison. If this was a basic LMA (e.g.,
the LMA Classic, LMA Unique, Ambu LM or Softseal LM) then a direct
comparison with any LT device was probably unfair with respect to the
rates of gastric insufflation. It would have been better to have compared
the LT with either the LMA Proseal or the disposable LMA Supreme or i-Gel
airways - all of which have gastric drainage channels like the LT-D. It
should also be noted that the correct sizing of a supraglottic airway
device is particularly important when attempting to ventilate manikins,
and the same size of airway does not always provide the optimum fit with a
particular manikin across the entire range of SADs from different
manufacturers. An ill-fitting basic LMA will never be a match for a
correctly-sized LT on any of its performance characteristics.
Bearing in mind all these points, the authors’ conclusions need to be
viewed with a degree of caution.
REFERENCE:
1. Dixon M, Carmody N, O’Donnell C. The effectiveness of supraglottic
airway devices in prehospital Basic Life Support airway management. Emerg
Med J 2009; 26: 4.
I would like to thank Body and Foex for their thought-provoking article, and also Cattermole and Challen for their replies. Too often in the culture of emergency medicine, the philosophical underpinnings of thought and action are neglected. When is there time to reflect?
One highlight of their discussion of utilitarianism is the inclusion of emotional factors into the weighing of what actions can be counted as...
The article by Higginson made me think about our specialty and whether we have got a missing link. However, it reminded me to look at the Way Ahead document produce by the UK College of Emergency Medicine in 2008. Surely this provides an excellent service concept for our specialty? The document provides clear guidance as to what our core and extended services should be and how we should consider delivering them. I wonder...
With great interest we read the recent article by Bevan and colleagues reporting how predictive ALT is for liver injury in children with blunt abdominal trauma. In the result section the authors describe the following: "The presence or absence of liver injury can be predicted with a sensitivity of 96% and a specificity of 80%". In their conclusion they reported: "a threshold of >104 IU/L gave a 96% specificity for t...
We read with interest Manini et al’s 1 recent paper suggesting ischaemia-modified albumin assays could assist in decreasing the rate of inappropriate discharges from the ED, and that further studies into diagnostic tools for use in chest pain are warranted.
We conducted an audit at Ealing Hospital that also supports the need for developing new diagnostic algorithms for chest pain. Medical histories of 14...
This case appears to be describing the Pellegrini-Stieda syndrome/lesion. This is, in fact, a well-known and fairly common finding, generally felt to reflect a post-traumatic ectopic ossification, either acute or chronic. MR is a useful test, as the signal void from the calcification can be seen in relation to the MCL. It may also uncover bone bruising from an associated avulsion fracture (the so-called Stieda fracture)....
Dear Editor, I understand that it is very important to log roll and carefully evaluate the whole spine of the patient. By reading this article, I understand the importance of complete spinal evaluation but there are situations in which spinal injuries are missed as a result of incomplete evaluation or not adhering to systematic approach. I want to share one of the clinical cases in the management of which I was involved. A pa...
Dear Editor,
I was disturbed to read the article by Body and Foex [1] advocating the embrace of Utilitarian values in medicine. I hope it was merely a misuse of words. All penguins are birds, but not all birds are penguins. Utilitarianism is a form of consequentialism, but not all ethical thinking that considers the consequences of one’s actions is Utilitarian. The authors of the article correctly make a clear c...
University Department of Anaesthetics Level 2, University Block Glasgow Royal Infirmary 10 Alexandra Parade Glasgow G31 2ER
19 February 2009
Dear Sir,
We read with interest the clinically based study, on the use of propofol to sedate patients for relocation of hip prostheses in the emergency department.[1] The authors rightly point out that there are problems with the safety and efficacy of us...
Dear Sirs
I commend the work of Geelhoed and MacDonald in their sentinel dose- finding studies regarding the minimum effective dose of dexamethasone for croup, it does seem to suggest a 'ceiling' effect. This work has been recently followed by a descriptive paper (accepted for publication, not yet published) outlining the experience over 27 years at their institution, clearly demonstrating the real-world effect...
Although the definition of Basic Life Support (BLS) does vary between sources, it is probably best regarded as, "a level of medical care that can be used to treat patients with life-threatening illness or injury without the use of any advanced or invasive medical procedures or intravenous access". It should be possible for any rescuer in any situation to render BLS simply by using hands and lungs, although simple improvi...
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