In response to this article it is important to highlight that this system is not used by any ambulance services or EMS systems in the UK or the world - it is over 8 years old and has been replaced multiple times. Also, a later version of the system has demonstrated a sensitivity of 83% for Emergency Medical Dispatchers using MPDS stroke protocol (http://www.prioritydispatch.co.uk/uk/San_Diego_Accuracy_of_Stroke.pdf). A response...
In response to this article it is important to highlight that this system is not used by any ambulance services or EMS systems in the UK or the world - it is over 8 years old and has been replaced multiple times. Also, a later version of the system has demonstrated a sensitivity of 83% for Emergency Medical Dispatchers using MPDS stroke protocol (http://www.prioritydispatch.co.uk/uk/San_Diego_Accuracy_of_Stroke.pdf). A response by the International Academies of Emergency Dispatch to this EMJ article can be viewed at http://www.prioritydispatch.co.uk/uk/documents/StrokeStudyAMPDS.pdf
Whilst we feel that Lindford et al(1)’s work has many admirable
points, we also feel it important to point out minor areas about the study
which detract from its overall impact.
Whilst details of the subgroups in the sample size of 50 assessors is
given, unfortunately there is no similar breakdown in the information
about their answer regarding size of burn requiring resuscitation in
adults and chi...
Whilst we feel that Lindford et al(1)’s work has many admirable
points, we also feel it important to point out minor areas about the study
which detract from its overall impact.
Whilst details of the subgroups in the sample size of 50 assessors is
given, unfortunately there is no similar breakdown in the information
about their answer regarding size of burn requiring resuscitation in
adults and children, about the fluid used, or about the identity of the
Parkland Formula. As burns nurses are not routinely involved in the
prescription of fluid for burns resuscitation their inclusion as part of
the sample group is questionable.
In the calculations of the correct value of resuscitation fluid, no
information is given about who was incorrect in their calculations. Whilst
it is stated that 72% correctly assessed the size of the burn we do not
know if the 28% who did not were excluded from the assessment of correct
fluid resuscitation values.
A separate chart is given for use in children under the weight of
36kg, including maintenance fluids, this does not specify a proportion to
be given as Dextrose Saline, which would constitute a deviation from the
normal Parkland formula. Whether this would result in clinically
significant hypoglycaemia is debatable(2), but concerns have been raised
in the management of infants undergoing fluid resuscitation for septic
shock(3). It may be possible to include this weight-related value within
the chart in each weight based row.
The chart makes it easy to select the correct amount of resuscitation
fluid to infuse per hour if the patient proceeds directly from injury to
Emergency Department with no pause, this is often not the case. Delay in
commencement of resuscitation and inadequate initial management may result
in a deficit which needs to be calculated and the infusion rate adjusted
compared to the value derived from the table, as the authors acknowledge.
This is an area where information technology in the form of a web based
application hosted on the burns centre website would be ideal.
T.H. McKinnell, MB ChB, MSc, MRCS (Ed)*$
A. Hartley, MB BS, BSc$
K. Allison MB ChB, MD, FRCS (Plast)$
*Royal Victoria Infirmary, Newcastle
$James Cook University Hospital, Middlesbrough
1 Lindford AJ, Lim P, Klass B, Mackey S, Dheansa BS, Gilbert PM
(2009) Resuscitation tables: a useful tool in calculating pre-burns unit
fluid requirements Emerg Med J;26:245-249
2 Murat I and Dubois MC (2008) Perioperative fluid therapy in
pediatrics. Pediatric Anesthesia 18: 363–370
3 Parker, MM; Hazelzet, JA; Carcillo, JA (2004) Pediatric
considerations. Crit Care Med; 32[Suppl.]:S591–S594)
One major shortcoming of this comparison of monophasic and biphasic
defibrillators for the treatment of out-of-hospital cardiac arrest, which
was not fully addressed by the authors, concerns the fact that the
defibrillators used were programmed to analyse and deliver up to three
stacked shocks in accordance with the AHA guidelines of 2000. Guidelines
2005 revolutionised the treatment of VF cardiac arrest by emphasising t...
One major shortcoming of this comparison of monophasic and biphasic
defibrillators for the treatment of out-of-hospital cardiac arrest, which
was not fully addressed by the authors, concerns the fact that the
defibrillators used were programmed to analyse and deliver up to three
stacked shocks in accordance with the AHA guidelines of 2000. Guidelines
2005 revolutionised the treatment of VF cardiac arrest by emphasising the
importance of the application of early chest compressions with minimal
interruption to these compressions, together with the delivery of an
initial single shock instead of stacked shocks. Guidelines 2005 also
advised that the energy level for the initial shock from a monophasic
defibrillator should be raised to 360 Joules, as opposed to the
200/300/360-Joule pattern used in the study.
Consequently, this study probably poses more questions than it
answers. For example, there is no way of knowing if the use of the
currently recommended higher energy level for the initial shock from a
monophasic defibrillator might have elevated the first-time success rate
for monophasic defibrillation in the study to that (or, for that matter,
above that) demonstrated by the biphasic units. Therefore, it may be
premature to scrap all monophasic defibrillators based on the findings of
this study, although it may have driven one more nail into their communal
coffin.
CONFLICT OF INTEREST STATEMENT: This author still carries his trusty
manual monophasic defibrillator with its integral cardiac pacing facility,
and has been reluctant to ditch it until there is clear evidence of the
superiority of biphasic AEDs.
I found the article by Deakin et al interesting but have to feel that
the article seems to dwell on whether the Advanced Medical Priority
Dispatch system (AMPDS) correctly identifies stroke when the emphasis
should have been on whether it can correctly prioritise patients to a
catagory A or B who are later found to have suffered a stroke.
The authors themselves identify the fact that ambulance
prioritisation is...
I found the article by Deakin et al interesting but have to feel that
the article seems to dwell on whether the Advanced Medical Priority
Dispatch system (AMPDS) correctly identifies stroke when the emphasis
should have been on whether it can correctly prioritise patients to a
catagory A or B who are later found to have suffered a stroke.
The authors themselves identify the fact that ambulance
prioritisation is more important for the patient than the actual
categorisation made by the AMPDS software. Certainly any system that
relies upon information supplied by a lay person cannot expect to make a
"diagnosis" of stroke in all cases. If the patient has collapsed and is
unconcious use of the appropriate AMPDS algorithm for this is more
appropriate in ensuring that the correct response is sent. Based on this
the underprioritisation of only 2.9% is not entirely unacceptable and
further review could be done to look for any triggers in these calls to
indicate a higher likelihood of stroke.
Given that the DH has acute stroke response time set at Catagory B
(19 minutes) these patients are getting an appropriate priority of
response 97.1% of the time which is the most important thing.
It would be interesting to know how many of these cases were
diagnosed as a stroke by the ambulance staff on their arrival and
subsequently handed over at the ED.
We read with great interest the excellent article in the September
2008 issue
of the journal by Ulahannan et al entitled “Benefits of CT Urography in
patients presenting to the emergency department with suspected ureteric
colic”[1]. They employed a test designated a “non-contrast CT Urogram” and
concluded that CT is the preferred test of choice for patients over 40
with
suspected ureteric coli...
We read with great interest the excellent article in the September
2008 issue
of the journal by Ulahannan et al entitled “Benefits of CT Urography in
patients presenting to the emergency department with suspected ureteric
colic”[1]. They employed a test designated a “non-contrast CT Urogram” and
concluded that CT is the preferred test of choice for patients over 40
with
suspected ureteric colic. We understand the authors aim, methods and fully
agree with the conclusion. However we feel the title and nomenclature are
incorrect and potentially misleading to practitioners.
Advanced 3D CT can now offer a number of distinct studies of the
urinary
tract with specific protocols which are designed around various clinical
questions (e.g. Routine CT, Urinary Stone CT, Renal CT Angiography (CTA),
Dynamic Renal Mass CT and CT Urography (CTU). Much has been written in
the literature regarding CTU[2, 3], and there is more than one way to
perform
this test[4]. There is however one common theme: in a CT Urogram, contrast
material must be administered to demonstrate the urothelium-lined tract.
The CT Urography working group of the European Society of Urogenital
Radiologists has recently provided very comprehensive and most welcome
guidelines on CT Urography[5]. They define a CTU as “a diagnostic
examination optimized for imaging the kidney, ureters and bladder. The
examination involves the use of multidetector CT with thin-slice imaging,
intravenous administration of a contrast medium and imaging in the
excretory phase”. ‘Direct’ CTU is performed by administering contrast
through nephrostomy, urostomy or bladder catheter. Urinary stone CT
performed for detection of renal, ureteric or bladder stones is a non-
contrast
study and should not be referred to as “non-contrast CT Urography”, as the
authors repeatedly do in their article. Most institutions do not give
intravenous contrast routinely to patients for investigation of acute
ureteric
colic.
CT Urography is reserved for those patients in whom it is important
to define
the urothelial tract with contrast (e.g. investigation of hematuria,
urothelial
neoplasms, differentiating parapelvic cysts and assessment of ileal
diversion).
In summary, CT performed for the evaluation of urolithiasis in the setting
of
acute renal colic is a renal or urinary stone CT and is not a CT Urogram.
Labelling it as a CT Urogram is a patient safety issue under current
guidelines. If a contrast-enhanced scan is performed instead of a urinary
stone CT it is a reportable event as it involves a misadministration of a
drug,
radiation exposure for the wrong test and a possible needless IV access.
While we welcome this paper, we also feel that nomenclature is important
for
all readers and hope this clarifies any confusion.
References:
1. Ulahannan D, Blakeley CJ, Jeyadevan N, Hashemi K. Benefits of CT
urography in patients presenting to the emergency department with
suspected ureteric colic. Emerg Med J, 2008. 25(9): p. 569-71.
2. McNicholas MM, Raptopoulos VD, Schwartz RK, Sheiman RG, Zormpala A,
Prassopoulos PK et al., Excretory phase CT urography for opacification of
the
urinary collecting system. AJR Am J Roentgenol, 1998. 170(5): p. 1261-7.
3. Kawashima A, Vrtiska TJ, LeRoy AJ, Hartman RP, McCollough CH, King BF
Jr. CT urography. Radiographics, 2004. 24 Suppl 1: p. S35-54; discussion
S55-8.
4. Nolte-Ernsting C, Cowan N. Understanding multislice CT urography
techniques: Many roads lead to Rome. Eur Radiol, 2006. 16(12): p. 2670-86.
5. Van Der Molen AJ, Cowan NC, Mueller-Lisse UG, Nolte-Ernsting CC,
Takahashi S, Cohan RH. CT urography: definition, indications and
techniques.
A guideline for clinical practice. Eur Radiol, 2008. 18(1): p. 4-17.
Sibbald and colleagues raise the important point that sedation often
verges on the edge of general anaesthesia during emergency department
sedation in response to Vardy et al’s audit of ED sedation practice(1,2).
They do, however, make the false assumption that a GCS of 8 or less is
equivalent to the loss of airway reflexes.
Moulton et al(3,4), in two papers describing the relationship between
the GCS and gag a...
Sibbald and colleagues raise the important point that sedation often
verges on the edge of general anaesthesia during emergency department
sedation in response to Vardy et al’s audit of ED sedation practice(1,2).
They do, however, make the false assumption that a GCS of 8 or less is
equivalent to the loss of airway reflexes.
Moulton et al(3,4), in two papers describing the relationship between
the GCS and gag and cough reflexes in the same institution as Vardy’s
study, showed that even in conscious patients with a GCS>8 who had been
given narcotics, the gag reflex was suppressed in 64% compared to 8% of
similar head injury patients. Even patients who had a GCS of 14 or 15 and
were exposed to ‘tranquilisers’ (not defined) had an impaired gag reflex.
Airway reflexes should be reassessed independently of the GCS as the GCS
alone is unable to indicate a loss of airway reflexes.
The significance of present airway reflexes may be an indication of a
reduced risk of aspiration, although even that is not completely
assured(3). Duncan et al showed that even in poisoned patients with a
decreased GCS, endotracheal intubation was not necessarily required(5).
The definition of coma as a GCS of 8 or less does not include any
reference to airway reflexes. The assumption that comatose patients
require intubation after head injury is not unreasonable, but this
practice has often been uncritically extended to other conditions such as
poisoning, in addition to head injured patients. It may be that we should
be considering intubation for patients with a GCS of 12 or less, in
specific situations such as poisoning, or avoiding it is other specific
patient populations with impaired consciousness.
Much more basic research is needed to unravel the complex
relationships between GCS, airway reflexes and the subsequent incidence of
aspiration and intubation.
Dexter Y S Chan
Colin A Graham
Accident & Emergency Medicine Academic Unit
Chinese University of Hong Kong
Trauma & Emergency Centre, Prince of Wales Hospital
Shatin, New Territories, Hong Kong
References
1. Sibbald NM, Jackson MJ, Howie A. How deep is your sedation? Emerg
Med J 2009;26:389
2. Vardy JM, Dignon N, Mukherjee N, Sami Dm, Balachandran G, Taylor
S. Audit of the safety and effectiveness of ketamine for procedural
sedation in the emergency department. Emerg Med J 2008;25:579-582
3. Moulton C, Pennycook A, Makover R. Relation between Glasgow coma
scale and the gag reflex. BMJ 1991;303:1240-1241
4. Moulton C, Pennycook AG. Relation between Glasgow coma score and
cough reflex. Lancet 1994;343(8908):1261-2.
5. Duncan R, Thakore S. Decreased Glasgow coma scale score does not
mandate endotracheal intubation in the emergency department. J Emerg Med
2009 Mar 7 [Epub ahead of print].
Four years on from 7/7 I believe the issue of major incident
awareness has still not been properly addressed. Wong in 2006 highlighted
the inadequacy of Registrar awareness with their major incident
contingency plan and their role. This year I set out to establish Junior
Doctor’s (FY1 + FY2) awareness at Wrexham Maelor Hospital using a similar
questionnaire.
Greater than 90% of Junior Doctors did not know wh...
Four years on from 7/7 I believe the issue of major incident
awareness has still not been properly addressed. Wong in 2006 highlighted
the inadequacy of Registrar awareness with their major incident
contingency plan and their role. This year I set out to establish Junior
Doctor’s (FY1 + FY2) awareness at Wrexham Maelor Hospital using a similar
questionnaire.
Greater than 90% of Junior Doctors did not know what would be
expected of them during a major incident.
No Junior Doctor knew what to do if bleeped about a major incident.
No medical or surgical Junior Doctor would attend to their ward first, 13%
of FY1’s and 38% of FY2’s would report to A+E. Switchboard would receive
calls from 17% of FY1’s and 6% of FY2’s, and A+E 13%, 19% respectfully.
12.5% of FY1’s believed their role would be triage. 17%, 25% of ward
FY1’s, FY2’s believed they would be working in A+E.
Of all the Junior Doctors, only 12% of surgical FY1’s and 25% of
medical FY2’s would attend to existing patients, only 25% of the surgical
FY2’s would shortlist patients for discharge.
These findings, 2 years on from Wong’s report still show a dangerous
lack of awareness by doctors on major incidents. Not only did our Junior
Doctors not know what to do, their choices on the day would be highly
detrimental. However, after organised teaching, all Junior Doctors knew
who to ring, where to go and what to do during a major incident.
It could seem ‘it’ll never happen to us’ is the line that keeps major
incident training off the induction programme. Can we afford this
innocence? Staff unaware of their roles and responsibilities will turn a
major incident into a major disaster.
Body and Foëx are to be congratulated on their thoughtful analysis of
the philosophy of diagnosis in emergency medicine(1). They raise some
issues which would bear further examination.
The philosophy of truth
As Body and Foëx point out, our continued use of “gnosis” in
diagnosis implies an ongoing assumption of an inherent knowledge and a
positivist paradigm briefly expressed as “reality exists”. Thei...
Body and Foëx are to be congratulated on their thoughtful analysis of
the philosophy of diagnosis in emergency medicine(1). They raise some
issues which would bear further examination.
The philosophy of truth
As Body and Foëx point out, our continued use of “gnosis” in
diagnosis implies an ongoing assumption of an inherent knowledge and a
positivist paradigm briefly expressed as “reality exists”. Their
discussion of the post-positivist paradigm quite justifiably highlights
the flaws of applying this to medical practice; any “reality” is
interpreted by the subjectivity of observers. However, even post-
positivism has its limitations; it still relies on the premise that
reality exists, merely that human imperfections render it effectively
undetectable; therefore we continue to hunt for the “square ROC curve”.
The multitude of scientific papers presenting sensitivities,
specificities, confidence intervals and all the other components of our
statistical arsenal all take as a given that a “true” population mean, or
a “gold standard” diagnosis is in fact there to be identified or made if
only we as physicians could make our trial or our test good enough.
Outside the medicoscientific sphere, however, such post-positivism
does not necessarily hold sway. As Huxley recognised:
“It is the customary fate of new truths to begin as heresies and to end as
superstitions”(2).
Medical historians and sociologists have repeatedly adopted a paradigm
wherein “illness” and “disease” are constructs of the society in which
they occur; as Brown argues “illness” and the diagnosis of such represents
an interaction between societal acceptance of condition and the biomedical
definition of the same. This includes the medicalisation of normality
(for example relabelling PMT as late luteal phase dysphoric disorder), and
the social acceptance of medically non-accepted conditions (Gulf War
syndrome)(3). Revisionist historians equally identify phases of
interaction between symptomatology, political and social institutions and
disease labelling(4). It is not therefore a given that an absolute reality
in fact exists.
If we accept that “truth” may at times be subjective, equally so must
be an acceptable level of inaccuracy; can we as physicians reasonably
decide what is an acceptable risk (whether of diagnostic error, potential
harm, or of a disease itself)? The use of decision analysis in evaluation
of diagnostic tests assumes a known (or identifiable) cost or utility for
each option; while this may be tenable on a population basis (certainly to
a post-positivist for whom the population will provide the requisite
confidence intervals), it is not intuitively applicable to each patient.
The philosophy of virtue
We are of course familiar with classical utilitarianism of the
Benthamite variety: “the greatest happiness for the greatest number” in
our emergency departments, in the form of the triage nurse. In no way can
it be of personal benefit to the patient with paper cut to wait 3 hours
but there is a clear population health benefit if the patient having an
acute MI is seen immediately.
I remain unconvinced that classical utilitarianism reflects
acceptable practice in diagnosis. The application of a test to a
population (in the manner of national screening programmes) is
utilitarian, trading off the negative aspects of an imperfect test (in
terms of false positives, anxiety and unnecessary further investigation)
against the benefits of early disease detection. It does not, however,
translate well to individual patient diagnostics. We recognise that
treatment decisions must be individualised, even where decision analysis
demonstrates a clear benefit of one particular option on a population
basis; why else do we insist on informed consent for surgery or
thrombolysis? Some diagnostics are already individualised; pre-test
counselling is mandated in clinical genetics and for HIV testing; what is
so different about the diagnostics we use in emergency medicine, other
than the timescale?
I would argue that good practice diagnostics would be more consistent
with reasonable consequentialism, whereby an action is considered to be
morally right if it has the best reasonably foreseeable consequences.
Thus siting an intravenous cannula, although inconsistent with primum non
nocere, can be the morally right action if by doing so the patient can
receive life-saving or health-enhancing therapy. Equally, performing a
contrast CT brain to identify the underlying lesion in a patient with
spontaneous intracranial haemorrhage would be considered morally
appropriate (assuming that the patient consents if able) even if the
patient then had a fatal anaphylactic reaction to the contrast medium
(unless, of course, their previous allergy was known to the physician!).
Clearly we are all aware that we work in a resource-constrained
environment and that a degree of utilitarianism is inevitable and in fact
justified; however it should not be used to justify the neglect of
individualised clinical reasoning in the management of each patient. I
would hope, as Body and Foëx have suggested, that by a closer analysis of
our philosophical paradigms we can, as they say, “move towards enhanced
understanding”.
1. Body R, Foex B. On the philosophy of diagnosis: is doing more good
than harm better than ‘‘primum non nocere’’? Emergency Medicine Journal
2009;26:238-40.
2. Huxley T. The coming of age of the Origin of Species. Science and
Culture and Other Essays. London: Methuen, 1881.
3. Brown P. Naming and framing: the social construction of diagnosis
and illness. Journal of Health and Social Behavior 1995;35(Extra):34-52.
4. Jordanova L. The Social Construction of Medical Knowledge. Social
History of Medicine 1995;8:361-81.
I fully endorse this notion and conclusion by the authors that we need to suspect and diagnose this pathology very early "when the patient is stable”, since diagnosing a ruptured AAA in an unstable patient usually, means that we have lost the battle already. Suspecting and diagnosing early and "then rushing for theaters" is the only way forward for saving all these lives and I strongly feel that we will save many lives.
Those...
I fully endorse this notion and conclusion by the authors that we need to suspect and diagnose this pathology very early "when the patient is stable”, since diagnosing a ruptured AAA in an unstable patient usually, means that we have lost the battle already. Suspecting and diagnosing early and "then rushing for theaters" is the only way forward for saving all these lives and I strongly feel that we will save many lives.
Those who have worked in an Emergency Department (ED) for long enough are well aware of the usual course of events for the elderly patient presenting to the ED with back or flank pain, sometimes with a history of renal stones/colic decades ago. And it all stops there with the patient
getting labeled as renal colic-that is until the patient crashes and then the reality dawns to everyone, albeit too late. As the authors already have concluded (also supported by other previous studies) that once decompensation occurs there is a high mortality. For myself I can say that
I feel it is my “duty” to at least suspect and consider the possibility of a AAA in most elderly patients presenting with appropriate clinical scenario. In the Emergency Department where I am working, we have electronic records. There is a column titled "worst possible diagnosis" in
differential diagnosis list. Obviously for a flank/backache, one of the most serious diagnoses is AAA. This is one way of training and sensitizing
people to this ominous entity. There will be many others and it is up to medical community to do everything to prevent mortalities where possible.
The other approach proposed by the authors is to "get ahead of the disease" by initiating population based screening for the susceptible population. This can be effectively implemented in countries where there
is good primary healthcare infrastructure. Once the ball gets rolling, patients presenting to EDs will themselves alert all the ED staff that they have a AAA (Hopefully the ED staff will continue to retain the capacity to suspect this condition where patients may have slipped
through the safety net of screening).
This study has essentially reiterated what is already known but in the current scenario that this diagnosis is often missed with a fatal outcome, it is a good reminder that the medical profession needs to do more in this regard.
Sir,
Whilst we feel that Lindford et al(1)’s work has many admirable points, we also feel it important to point out minor areas about the study which detract from its overall impact.
Whilst details of the subgroups in the sample size of 50 assessors is given, unfortunately there is no similar breakdown in the information about their answer regarding size of burn requiring resuscitation in adults and chi...
One major shortcoming of this comparison of monophasic and biphasic defibrillators for the treatment of out-of-hospital cardiac arrest, which was not fully addressed by the authors, concerns the fact that the defibrillators used were programmed to analyse and deliver up to three stacked shocks in accordance with the AHA guidelines of 2000. Guidelines 2005 revolutionised the treatment of VF cardiac arrest by emphasising t...
Is this not "Pelligrini-Stieda" disease?
I found the article by Deakin et al interesting but have to feel that the article seems to dwell on whether the Advanced Medical Priority Dispatch system (AMPDS) correctly identifies stroke when the emphasis should have been on whether it can correctly prioritise patients to a catagory A or B who are later found to have suffered a stroke.
The authors themselves identify the fact that ambulance prioritisation is...
Dear Sir/Madam,
We read with great interest the excellent article in the September 2008 issue of the journal by Ulahannan et al entitled “Benefits of CT Urography in patients presenting to the emergency department with suspected ureteric colic”[1]. They employed a test designated a “non-contrast CT Urogram” and concluded that CT is the preferred test of choice for patients over 40 with suspected ureteric coli...
Sibbald and colleagues raise the important point that sedation often verges on the edge of general anaesthesia during emergency department sedation in response to Vardy et al’s audit of ED sedation practice(1,2). They do, however, make the false assumption that a GCS of 8 or less is equivalent to the loss of airway reflexes.
Moulton et al(3,4), in two papers describing the relationship between the GCS and gag a...
Four years on from 7/7 I believe the issue of major incident awareness has still not been properly addressed. Wong in 2006 highlighted the inadequacy of Registrar awareness with their major incident contingency plan and their role. This year I set out to establish Junior Doctor’s (FY1 + FY2) awareness at Wrexham Maelor Hospital using a similar questionnaire.
Greater than 90% of Junior Doctors did not know wh...
Body and Foëx are to be congratulated on their thoughtful analysis of the philosophy of diagnosis in emergency medicine(1). They raise some issues which would bear further examination.
The philosophy of truth
As Body and Foëx point out, our continued use of “gnosis” in diagnosis implies an ongoing assumption of an inherent knowledge and a positivist paradigm briefly expressed as “reality exists”. Thei...
I fully endorse this notion and conclusion by the authors that we need to suspect and diagnose this pathology very early "when the patient is stable”, since diagnosing a ruptured AAA in an unstable patient usually, means that we have lost the battle already. Suspecting and diagnosing early and "then rushing for theaters" is the only way forward for saving all these lives and I strongly feel that we will save many lives. Those...
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