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Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's
Slipper
Lillitos et al are to be congratulated on a most helpful paper
clarifying whether disease severity and the need for hospital admission
can be predicted using two similar PEWS systems (Brighton PEWS and COAST -
the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric
Earl...
Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's
Slipper
Lillitos et al are to be congratulated on a most helpful paper
clarifying whether disease severity and the need for hospital admission
can be predicted using two similar PEWS systems (Brighton PEWS and COAST -
the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric
Early Warning Scores (PEWS) in recent years, as part of the patient safety
agenda. Their original (dare I say, intended) purpose was to detect early
deterioration in hospitalised children, prompting timely interventions and
predicting the need for possible Paediatric Intensive Care admission
whereas increasingly, PEWS are being employed generically in paediatric
practice in the UK. Like Cinderella's slipper (following the spirit of
this season), Early Warning systems are attractive, colourful and
everybody wants to claim them for their own, with Ambulance Call
Response/Prioritisations, Hospital Admissions, ED Triage Systems,
Telephone Triage and Decision Making algorithms, Minor Injury/Walk-in
centres (to name but a few potential suitors) all seeking to shoe-horn
their patient's demographics into one of the currently available scoring
systems, in some situations avoiding the need for proper face-to-face
clinical assessment.
Of particular importance was the author's subdivision of presenting
complaints into both minor and significant "Medical" and "Surgical"
conditions which highlights some of the limitations of Early Warning
Scores.
It is reassuring to find that both the Brighton and COAST scores were
good at detecting significant respiratory illnesses, (Brighton and COAST
ROC scores yielding AUCs of 0.9 and 0.87, respectively). Whilst intended
to be universally applicable, both these scores have an inherent
respiratory design-bias, measuring multiple respiratory parameters
(respiratory rate, moderate-severe respiratory distress, supplemental
oxygen (Brighton), hypoxia (saturations ?92% in air (COAST))), both
expected and desirable qualities given the prevalence of respiratory
illness encountered in acute "paediatric practice" (asthma/wheeze,
bronchiolitis, croup, URTI, LRTI etc.)
Importantly, both local and regional experience and reviews of
adverse incidents, morbidity and mortality have anecdotally found PEWS
scores to be less reliable in the early detection of neurological
conditions, surgical conditions and blunt and penetrating trauma (where
compensatory mechanisms delay physiological abnormalities until disease
progression has advanced) and again the authors should be thanked for
quantifying these reported observations (they describe AUC's of i)
0.48AVERAGED for significant neurology, 0.56 for general surgical
conditions, 0.65 for significant trauma and 0.7 for head injury; Table 3).
(I suspect that in major trauma, simple descriptors such as "fall from
height", "ejected through windscreen" might well outperform medical
COAST/PEWS systems).
The study also validates what has been termed the "currency of COAST"
- that a high COAST score (a score ?3) must be taken seriously. (Due to
the score's poor specificity, the converse is not true - a low score does
not exclude significant illness/the need for admission). By choosing to
use the PEWS/COAST score at Triage, the authors were reliant solely on
abnormal physiological findings at one isolated point in time (influenced
by external factors such as crying and fever etc.) whereas tracking scores
over a period of observation or on an admissions/inpatient wards may have
revealed the trends of deterioration described in the early papers that
supported the introduction of PEWS systems (1). Even so, like other
clinical descriptors (e.g. haemorrhagic rash, shock, unresponsive,
fitting) the chosen individual trigger parameters would be expected to
prompt an appropriate nursing/medical response e.g. this child's heart
rate is abnormally high, their respiratory rate is depressed, their
conscious level diminished etc. (Previous authors have discussed the
possible merits of using aggregate weighted scores rather than single
clinical parameters but neither approach has been found to be superior to
the other (2); aggregate scores are certainly more complex, less user-
friendly and suggest a knowledge and appreciation of disease processes
that - if universal- is at best, currently poorly understood i.e. what
happens to "normal" heart rates in an unwell/injured 5-year old as their
condition progresses).
One of the study's shortcomings was to "wrongly" assign each child
with a universal score of "1" for parental concern, "on the basis that
parents/carers, by bringing their child to the ED, were by default
concerned". Parents do sometimes make uninformed choices when presenting
to ED; 60% of parents whose children had ATS (Australasian Triage System)
category 4 and 5 scores described the severity of their child's illness as
the primary (or secondary) reason for ED attendance (3). The intension
behind the "Doctor/Nurse/Family concern" trigger was to appreciate the
importance of gut feelings - something subjective, often unquantifiable
and unmeasurable - to prompt an appropriate clinical response. (Van den
Bruel, A et al's paper helpfully supports this approach (4)). [Within the
confines of a retrospective study, the authors can legitimately claim that
they unfortunately had no alternative].
As an advocate of PEWS scores (I adapted and designed the COAST chart,
with permission, from the original NHS Institute for Innovation &
Improvement's PEWS chart, in 2010), I do question how often these scoring
systems have identified a child that would not otherwise have been
identified and am concerned that, in the headlong rush to employ a PEWS
system in any and every clinical setting, their value has been overstated
at the expense of comprehensive nursing observations and medical
assessments. They do most certainly i) have an important role to play in
ensuring deteriorating trends are appreciated, communicated and acted upon
by nursing and medical teams and ii) can be useful when used as a safety
netting tool but, paraphrasing social media, might I suggest that we....
"Don't confuse my early warning score for years of clinical training and
experience!"
Dr Julian Sandell, Consultant in Paediatric Emergency Medicine, Poole
Hospital NHS Foundation Trust, and author of the Children's Observation
And Severity Tool (COAST), 2010
REFERENCES:
(1) Detecting and managing deterioration in children. Monaghan A.
Paediatric Nursing. 2005 Feb;17(1):32-35
(2) "Systematic review of paediatric alert criteria for identifying
hospitalised children at risk of critical deterioration". Chapman SM et
al. Intensive Care Med. 2010 Apr;36(4):600-11. Epub 2009 Nov 26.
(3)Why parents present to ED for non-urgent care. Williams A et al. ADC
2009;94:817-820
(4)Clinicians' gut feeling about serious infections in children:
observational study. Van den Bruel, A et al. BMJ 2012;345:e6144
Conflict of Interest:
I adapted and designed the COAST chart, with permission, from the original NHS Institute for Innovation & Improvement's PEWS chart, in 2010
We wish to thank Wilmer et al for their recent article "Air ambulance
tasking: mechanism of injury, telephone interrogation or ambulance crew
assessment", which we read with interest. As researchers in the field of
triage we feel it raises a number of interesting questions. We believe
that there are considerable similarities between triaging for enhanced
trauma team despatch (eg LAA) and effective triage for direct trans...
We wish to thank Wilmer et al for their recent article "Air ambulance
tasking: mechanism of injury, telephone interrogation or ambulance crew
assessment", which we read with interest. As researchers in the field of
triage we feel it raises a number of interesting questions. We believe
that there are considerable similarities between triaging for enhanced
trauma team despatch (eg LAA) and effective triage for direct transfer to
a Major Trauma Centre (MTC). It could be reasonably suggested that those
requiring treatment at a MTC would benefit from a LAA response and indeed
be the target population.
We would welcome some further clarification which we feel would
strengthen this work and assist with further research in the field.
Although MOI has historically been used as a dispatch criterion due
to "a high rate of serious injury", the authors conclude that it is the
least accurate method of tasking. We wonder if it is possible to clarify
the injury patterns amongst patients identified via MOI, particularly
injury severity and life-saving interventions performed by LAA.Are the
authors able to identify whether any of the six MOI criteria are more
accurately predictive than others? We are not aware of any such study in
the literature and this could greatly benefit the MOI criteria for MTC
triage.
We note that the authors' findings of 31% overtriage and 19%
undertriage are amongst the closest described to the US field triage
guidelines tolerance for over and under triage (up to 35% and 5%
respectively)1. . Clearly a decision must always be made as to the trade-
off between minimising either over or under triage. The authors describe
a number of risks of over triage and this is indeed correct, a linear
relationship between over triage and critical mortality has indeed been
shown2. This is often over looked, with the harmful effects of under
triage being the most obvious. With that in mind, we would be interested
to see more information on those patients who were under triaged in this
study, particularly their MOI. Can the automatic despatch criteria be
further refined by looking at these under triaged patients?
We welcome the authors' response and their views on using this work
as a foundation to optimise MTC triage decisions.
1American College of Surgeons. Resources for the optimal care of the
injured patient: 2014. Chicago, IL: American College of Surgeons; 2014.
2Frykberg ER. Medical Management of Disasters and Mass Casualties From
Terrorist Bombings: How Can We Cope? J Trauma 2002; 53(2):201-12
Conflict of Interest:
A PICO research suggestion on MTC triage has been submitted by the author (JV) for the James Lind/RCEM Research priorities
We read with interest the article by Seligman and colleagues (1)
which evaluated a novel first responder scheme for medical students as a
collaborative venture between a medical school and the local ambulance
service. Previous authors have advocated the early introduction of
Emergency Medical Technician teaching in an undergraduate medical
curriculum in the United States.(2) We would like to report...
We read with interest the article by Seligman and colleagues (1)
which evaluated a novel first responder scheme for medical students as a
collaborative venture between a medical school and the local ambulance
service. Previous authors have advocated the early introduction of
Emergency Medical Technician teaching in an undergraduate medical
curriculum in the United States.(2) We would like to report our
experiences in delivering an innovative special study module (SSM) in pre-
hospital emergency care (PHEC), which has consistently been one of the
most popular elective modules offered to the preclinical medical students
at our institution.
The PHEC SSM was designed by senior medical educators in partnership
with paramedics and advanced paramedics at our local hospital. Our
university has conferred honorary clinical fellowships on the paramedic
supervisors involved. Second year students complete the SSM over a 10-week
period in small groups of 12 students as part of their core medical
professionalism module. Participants actively shadow ambulance crews on
emergency calls and assist in patient assessment, monitoring and hand-over
in the emergency department, under the supervision of experienced
paramedics. Students have the opportunity to consolidate their theoretical
knowledge and practise procedural skills such as blood pressure
measurement, capillary blood glucometry, electrocardiography and oxygen
administration in an authentic clinical environment. They also become
familiar with standardised emergency management, first aid, and patient
safety protocols. Students maintain a reflective log of their emergency
calls and are debriefed in the case of traumatic incidents. Assessment
involves a combination of supervisor-led student evaluation, and
submission of a written assignment based on a contemporary emergency
medicine topic. Students also deliver a group presentation in which they
are required to critically analyse the efficiency of the ambulance service
and compare it to international best practice.
The PHEC SSM provides a formative early introduction to immediate
care and emergency medicine and it focuses students' attention on the
realities of clinical practice outside of a hospital setting. SSMs such as
this are a useful vehicle for fostering greater inter-professional
learning opportunities and improving communication between members of a
multidisciplinary clinical team, as well as promoting a deeper
appreciation for team-working and the ethical dilemmas of patient care.
Some medical students will also benefit from being motivated towards a
future career in emergency medicine. This educational intervention has
greatly facilitated collaboration between the ambulance service, emergency
department and the medical school, and we propose that it may serve as a
model of good practice for other higher educational institutions.
Consideration should be given to ultimately integrating this clinical
placement into the core undergraduate medical curriculum.
Ben Murphy, Craig Joyce, Barry Hannagen, Michael Smith, Gerard
Flaherty
School of Medicine, National University of Ireland, Galway, Ireland
Correspondence to Dr. Gerard Flaherty, School of Medicine, National
University of Ireland, Galway, Ireland; gerard.flaherty@nuigalway.ie
REFERENCES
1 Seligman WH, Ganatra S, England D, et al. Initial experience in
setting up a medical student first responder scheme in South Central
England. Emerg Med J 2015;0:1-4. Doi:10.1136/emermed-2015-204638.
2 Kwiatkowski T, Rennie W, Fornari A, et al. Medical students as
EMTs: skill building, confidence and professional formation. Med Educ
Online 2014;19:24829. Doi: 10.3402/meo.v19.24829.
This article by Howlett et al. makes for interesting reading as a
junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to
maintain successful, long, enjoyable and fruitful careers, and avoid
'burnout', we should develop 'task-orientated coping' mechanisms.
Currently one may argue that this is encouraged via personal ref...
This article by Howlett et al. makes for interesting reading as a
junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to
maintain successful, long, enjoyable and fruitful careers, and avoid
'burnout', we should develop 'task-orientated coping' mechanisms.
Currently one may argue that this is encouraged via personal reflection in
the e-portfolio, may I suggest that a more collective approach is called
for.
The Emergency Medicine training programme dictates that one must
learn to reflect regularly and use this reflection to direct self-learning
and 'learn from our experiences'. The e-portfolio is relatively rigid in
how one must reflect: 'What you did', 'What would you do differently and
why', 'what have you learnt', and does not necessarily encourage timely
discussion with a senior colleague.
Trainees should be encouraged to discuss learning points from an
experience with their Clinical/Educational Supervisor or another senior
colleague. In the busy Emergency Department environment this cannot happen
as frequently as it may be required and one way to combat this may be
achieved through changing staff members' attitudes to the importance of
reflection.
Whilst our main focus is patient care, we must acknowledge that in
order to continue to provide excellent care for our patients, we need to
care for ourselves and ensure that we do address issues that arise in a
timely matter. All doctors will make mistakes over their career with
differing impacts on patient outcome. Open discussions regarding mistakes
made by clinicians at different levels will encourage all doctors to
reflect and discuss issues they have been involved with and improve
learning from these experiences.
Furthermore perhaps 'task-orientated coping' mechanisms should be
included in the Undergraduate medical curriculum to encourage this
practice from the outset for newly qualified doctors.
We read this article with interest, given the high prevalence of
penetrating chest trauma in South Africa and the fact that we and others
(1,2) have published on the challenges faced in high-volume systems with
errant tube placement. While we also advocate the "safe-triangle"
approach, we aim to place the tube rather in the 4th ICS to avoid the risk
of trans-diaphragmatic injury. We are also adamant that the "finger-sweep...
We read this article with interest, given the high prevalence of
penetrating chest trauma in South Africa and the fact that we and others
(1,2) have published on the challenges faced in high-volume systems with
errant tube placement. While we also advocate the "safe-triangle"
approach, we aim to place the tube rather in the 4th ICS to avoid the risk
of trans-diaphragmatic injury. We are also adamant that the "finger-sweep"
be performed to gently displace any organ (lung or herniated viscus) away
from the chest tube during placement and to ensure placement within the
thoracic cavity. Directing all tubes apico-posteriorly is also advocated
strongly.
What has been clearly shown in previous studies is that senior
clinicians have much lower complication rates and that technical "errors
of execution", especially the continued use of trochars (3), are to blame
for many complications. The range of complication rates are listed between
10 and 30% across most of the studies. Indeed, it may be time for a "check
-list approach" for trauma chest tubes! (4)
Better training, under the watchful supervision of senior experienced
clinicians, could probably reduce the complication and misplacement rates
where often junior staff place these tubes initially1,2,3. In addition, a
return to the counting of the intercostal spaces and the use of the 4th
ICS rather than the 5th ICS may further reduce these misplacements.
Regards,
Dr TC Hardcastle, MMed(Chir), PhD, FCS(SA), Trauma Surgeon
Deputy Director: Trauma Services, and Trauma ICU, IALCH, and Head: Trauma
Training Unit, UKZN, Durban ZA
Dr MS Morris, MBBS, FCEM(UK), Emergency Medicine Specialist (ret)
Honorary Senior Lecturer, Emergency Medicine, Groote Schuur, UCT, Cape
Town, ZA
References
1) Maritz D, Wallis L, Hardcastle T. Complications of tube thoracostomy
for chest trauma. S Afr Med J, 2009;99:114-117.
2) Kong V, Oosthuizen GV, Sartorius B, Keene C, Clarke DL. An audit of the
complications of intercostal chest drain insertion in a high volume trauma
service in South Africa. Ann R Coll Surg Engl, 2014;96:609-613
3) Kong V, Clarke DL. The spectrum of visceral injuries secondary to
misplaced intercostal chest drains: experience from a high volume trauma
service in South Africa. Injury, 2014;45:1435-1439
4) Civil IDS. Tube thoracostomy in trauma: Is it time for a checklist for
chest tubes? Injury, 2013; 44:1143-1144
We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
m...
We were surprised by the EMJ decision to publish the study by Scotter
et al (1) A number of previous studies including those studied by Scotter
and colleagues have concluded that bilateral, fixed, dilated pupils in the
context of severe head injury are not universally predictive of poor
outcome. Performing a meta-analysis of five, retrospective, cohort
studies, one of which was conducted before 1988 does not change this
message. The results provided in the abstract are potentially misleading;
the overall mortality for patients with extradural haematomas should not
be reported as 29.7%, but rather that 25 of 82 patients died. Similarly,
for patients with subdural haematomas, the mortality was not 66.4% but
that 38 of 57 patients died. A favourable outcome was seen for 13 patients
with extradural haemorrhages and bilateral fixed pupils and 3 of those
with subdural haematomas.
The authors are correct regarding the limitations of their study -
there is considerable potential for selection bias in the published
reports, the age ranges of the study patients are unclear, the delays to
surgery are largely unreported and none reported the presence or absence
of co-morbidities. Whether a pupil of 4mm should be considered fixed and
dilated is also open to question. None of the studies addressed whether
there was any direct injury to the face that might have produced traumatic
mydriasis. There is also no mention in either Scotter's paper or those
reviewed, about the value of aggressive pre-hospital care including
intubation, ventilation and administration of hypertonic fluids. A young
patient with an extradural haematoma who is rapidly resuscitated, arrives
in a neurosurgical centre within minutes of the pupils becoming fixed and
dilated might have reasonable expectations of survival. Equally, a patient
with a subdural haematoma who has fixed and dilated pupils on arrival of
the paramedics, who is transported to a district general hospital for
intubation and who is on anticoagulation has no need to be referred for
consideration of neurosurgery but rather should be allowed to die with
comfort and dignity.
We would also take issue with the statement that patients should be
able to undergo surgery within an hour of arrival following the
introduction of major trauma networks in the U.K. Outside of London, many
patients with major trauma are initially managed in district general
hospitals. In Wessex, nearly 50% of patients with an injury severity score
of >15 (major trauma) were admitted to trauma units (Trauma Audit
Research Network, personal communication). For many patients with severe
head injuries, the initial admitting hospital remains distant from the
regional neurosurgical service. Only by altering the referral pathways
have we any hope of reducing the time to surgery for these patients (2,
3).
The motives for Scotter's paper are laudable but the messages should
be taken with a drop of (hypertonic) saline solution.
References:
1. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of
patients with bilateral fixed dilated pupils secondary to traumatic
extradural or subdural haematoma who undego surgery: a systematic review
and meta-analysis. Emerg Med J 2015; 32: 654-659
2. Trebilcock H. The impact of increasing the running time to the
major trauma centre (MTC) to 60 minutes in the south west. Emerg Med J
2015; 32: e17-e18 doi:10.1136/emermed-2015-204980.18
3. Dickinson P, Eynon CA. Improving the timeliness of time-critical
transfers: removing 'referral and acceptance' from the transfer pathway.
Journal of the Intensive Care Society 2014; 15: 104-108
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrig...
Just to clarify, they can be cut off using the same tool for cutting
off precious metal rings found in most high street jewellers. Probably the
only stipulation is that the blade is in new/really good condition and
lubrication is used e.g. Aquagel,(although a lubrication oil on the blade
such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with
irrigation is advisable. Ampoules or tap water dripped on whilst cutting
can aid here.
For ease, it is advisable to cut the ring twice from both sides so
that the ring falls off making it a 'one man job'. Failing that, if the
ring is cut only once, a method will be needed to force the ring open
enough to be removed from the finger which could involve more staff, tools
and brute force.
As shown in the article, a method of forcing the ring open when it
has only been cut once would be to feed a couple of straightened
paperclips through each side of the cut and grip with pliers. It may be
only necessary to spring the ring open a short distance to remove it.
A single unused blade will cut off one or two titanium rings with
ease. New blades are available from specialist jewellery tool companies.
Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variable...
Dear Editor,
I read with interest this article by Keep et al. There is clearly growing interest in research aiming to identify patients with sepsis earlier in emergency departments, given evidence that early treatment seems to improve outcomes.
However, I am not sure of the usefulness of comparing one scoring system (NEWS) to another (Surviving Sepsis Campaign definitions). As both are composites of mostly physiological variables, it is not particularly surprising that they are closely related.
The major problem is that both scoring systems do not have a particularly strong relationship to mortality. Previous research on EWS in sepsis have shown AUC figures of around 0.6-0.7, much less than the figures presented here (1-3). A recent paper by Kaukonen et al (4) (published after this paper was submitted), has shown that the SIRS criteria are also not particularly ideal for defining 'cut off points' in patients with sepsis.
The authors suggest that using an EWS of >=3 has a NPV of 99.5% for 'severe sepsis', and a specificity of 77%. However, in Corfield et al's paper on sepsis mortality, the same cut off has an NPV of only 92.3% and a specificity of 11%(1)!
Subsequent data from that paper show that the mortality of patients with NEWS between 0-4 are almost identical (EWS =0, mortality 18.8%, EWS = 1, mortality 18.8%, EWS =2, mortality 19.3%, EWS=3, mortality = 20%, EWS =4, mortality = 21.3%).
Without presenting figures for mortality in this dataset, it is hard to know the relevance of using the cut off they suggest. Sepsis is clearly a condition which has a significant mortality attached, but this does not appear to be well related to either SSC definitions or EWS figures, apart from in extremes.
Did the authors collect any mortality or outcome data in this cohort?
Thanks,
Fergus Hamilton
1 )Corfield, A. R., Lees, F., Zealley, I., Houston, G., Dickie, S., Ward, K., & McGuffie, C. (2014). Utility of a single early warning score in patients with sepsis in the emergency department. Emergency Medicine Journal : EMJ, 31(6), 482-7. doi:10.1136/emermed-2012-202186
2) ??ld?r, E., Bulut, M., Akal?n, H., Kocaba?, E., Ocako?lu, G., & Ayd?n, ?. A. (2013). Evaluation of the modified MEDS, MEWS score and Charlson comorbidity index in patients with community acquired sepsis in the emergency department. Internal and Emergency Medicine, 8(3), 255-60. doi:10.1007/s11739-012-0890-x
3) Geier, F., Popp, S., Greve, Y., Achterberg, A., Gl?ckner, E., Ziegler, R., ... Christ, M. (2013). Severity illness scoring systems for early identification and prediction of in-hospital mortality in patients with suspected sepsis presenting to the emergency department. Wiener Klinische Wochenschrift, 125(17-18), 508-15. doi:10.1007/s00508-013-0407-2
4)Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D. J., & Bellomo, R. (2015). Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. New England Journal of Medicine, 372(17), 150317020036009. doi:10.1056/NEJMoa1415236
Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questi...
Dear editor
I wish to congratulate the authors of the HIRT trial on finally publishing
their results. Whilst a negative trial for primary outcomes, to me it
highlighted the major challenges in conducting high quality RCTs in
prehospital setting. Few countries have been able to perform this level of
prehospital research and it can only advance the future planning of
prehospital studies trying to examine the very same questions.In one
regard, I view this as a positive result in that it showed advanced ground
paramedic care in the Sydney region of New South Wales,provided quality
care to severe head injured patients that was not significantly improved
upon by addition of a prehospital HEMS physician led team.
The other prehospital RCT of advanced interventions including RSI
for severe head injured patients was another Australian study by Bernard
et al in Melbourne, Victoria and this did show improved eGOS. It was a
paramedic delivered RSI intervention and therefore taken together HIRT and
the Melbourne MICA trial would suggest adding prehospital RSI to the NSW
paramedic skill set might in fact be the more EBM supported approach for
the severe head injured patient.
We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is...
We congratulate the authors on this excellent piece of work and are
particularly pleased to see method of arrival in their tool as a predictor
of admission. In a similar piece of work to predict surgical admissions
in our institution we found the same effect (1). At a time when it seems
to be politically expedient to scapegoat patients for the overcrowding in
our departments and lack of available beds on the wards it is helpful to
show that those who call 999 are found to be genuinely sicker!
(1) Who needs an expert? A tool for optimal triage of general
surgical patients in the Emergency Department. European Journal of Trauma
and Emergency Surgery
April 2014, Volume 40, Issue 1 Supplement, S76
Paediatric Early Warning Scores: Acute Paediatrics' Cinderella's Slipper
Lillitos et al are to be congratulated on a most helpful paper clarifying whether disease severity and the need for hospital admission can be predicted using two similar PEWS systems (Brighton PEWS and COAST - the Children's Observation And Severity Tool).
There has been a proliferation in the uptake and usage of Paediatric Earl...
We wish to thank Wilmer et al for their recent article "Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment", which we read with interest. As researchers in the field of triage we feel it raises a number of interesting questions. We believe that there are considerable similarities between triaging for enhanced trauma team despatch (eg LAA) and effective triage for direct trans...
Dear Editor,
We read with interest the article by Seligman and colleagues (1) which evaluated a novel first responder scheme for medical students as a collaborative venture between a medical school and the local ambulance service. Previous authors have advocated the early introduction of Emergency Medical Technician teaching in an undergraduate medical curriculum in the United States.(2) We would like to report...
Dear Editor,
This article by Howlett et al. makes for interesting reading as a junior doctor at the start of Emergency Medicine training.
This study suggests that in order for trainees (and Consultants) to maintain successful, long, enjoyable and fruitful careers, and avoid 'burnout', we should develop 'task-orientated coping' mechanisms. Currently one may argue that this is encouraged via personal ref...
We read this article with interest, given the high prevalence of penetrating chest trauma in South Africa and the fact that we and others (1,2) have published on the challenges faced in high-volume systems with errant tube placement. While we also advocate the "safe-triangle" approach, we aim to place the tube rather in the 4th ICS to avoid the risk of trans-diaphragmatic injury. We are also adamant that the "finger-sweep...
We were surprised by the EMJ decision to publish the study by Scotter et al (1) A number of previous studies including those studied by Scotter and colleagues have concluded that bilateral, fixed, dilated pupils in the context of severe head injury are not universally predictive of poor outcome. Performing a meta-analysis of five, retrospective, cohort studies, one of which was conducted before 1988 does not change this m...
Just to clarify, they can be cut off using the same tool for cutting off precious metal rings found in most high street jewellers. Probably the only stipulation is that the blade is in new/really good condition and lubrication is used e.g. Aquagel,(although a lubrication oil on the blade such as WD40 would be better for prolonging the blade life)
It can heat up quite rapidly as well so keeping it cool with irrig...
Dear editor I wish to congratulate the authors of the HIRT trial on finally publishing their results. Whilst a negative trial for primary outcomes, to me it highlighted the major challenges in conducting high quality RCTs in prehospital setting. Few countries have been able to perform this level of prehospital research and it can only advance the future planning of prehospital studies trying to examine the very same questi...
We congratulate the authors on this excellent piece of work and are particularly pleased to see method of arrival in their tool as a predictor of admission. In a similar piece of work to predict surgical admissions in our institution we found the same effect (1). At a time when it seems to be politically expedient to scapegoat patients for the overcrowding in our departments and lack of available beds on the wards it is...
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