The "Sepsis Six" resuscitation bundle is now common in UK hospitals,
and endorsed by the College of Emergency Medicine, SIGN guidelines, and
the Royal College of Physicians.1-3 However, the evidence behind it
remains limited and must be re-evaluated as new data emerges - especially
since the results of the PRoCESS and ARiSE trials on Early Goal Directed
Therapy (EGDT) were published this year.4,5...
The "Sepsis Six" resuscitation bundle is now common in UK hospitals,
and endorsed by the College of Emergency Medicine, SIGN guidelines, and
the Royal College of Physicians.1-3 However, the evidence behind it
remains limited and must be re-evaluated as new data emerges - especially
since the results of the PRoCESS and ARiSE trials on Early Goal Directed
Therapy (EGDT) were published this year.4,5
The paper supporting Sepsis Six was originally published in 2010 in
this Journal, and remains (as far as we are aware) the only published
evidence on Sepsis Six.6 We believe this trial is internally flawed, and
unable to provide convincing evidence of the benefit of Sepsis Six.
We have two main criticisms of this sepsis 6 trial - firstly, it is
inconsistent. Given that two large randomised controlled trials this year
have shown EGDT to have negligible effect on mortality, it is hard to
interpret the results of this trial - which showed a relative risk
reduction of 91% (mortality dropped from 90.3% without EGDT to 7.5% with
it). Also, the subgroup of patients who were shocked shows internal
inconsistencies. The worst performing group - with a staggering 97.1%
mortality were the shocked patients who received Sepsis 6 - yet if they
received EGDT alone, their mortality was 8%. However, the combination of
Sepsis 6 and EGDT in shocked patients performed best of all - with a 4.7%
mortality!
It seems inconceivable that in septic shock Sepsis 6 would increase
mortality to 97.1% if performed alone, but reduce it to 4.7% if performed
in combination with EGDT (which we know from RCT data has a negligible
effect).
The only possible explanation is that of confounding effects -
younger, fitter people were receiving EGDT and Sepsis 6- who had a low
mortality rate and survived, and less fit people did not receive it This
leads to our second criticism - lack of co-variate analysis. Although the
authors comment on the difference in age between some of the cohorts, they
did not perform a multivariate logistic regression (or similar) that could
have included age, MEWS score, source of infection. Given the complexity
and difference between the subgroups, it is impossible to compare them
without covariate statistical analysis.
It is very hard to draw causality from observational trials (and the
authors do not try here), but given the significant problems with this
trial, we do not feel it can be interpreted as supporting evidence for
Sepsis 6 either.
Although we do not aim to be unnecessary critical of what may be seen
as 'common sense practice', we have three main concerns. Firstly, the
claim that sepsis 6 in unlikely to be harmful is not a sufficient basis
for it's continued use. 'Common sense' medicine has repeatedly been proven
to be harmful on numerous occasions. Secondly, emergency departments and
wards are busy and under huge time pressure, and protocols that might tie
up staff for an hour or more must be scrutinised. Thirdly, sepsis 6 is
likely to lead to the greater use of stat doses of antibiotics in any
febrile patient, given the impetus to administer them within the first
hour for any unconfirmed sepsis diagnosis. We do not know the long-term
impact of this on antibiotic resistance - which is rapidly increasing.
Sepsis 6 means well, but is unproven, and should be treated as such.
Fergus Hamilton
Bryony Lewis
1. SIGN. Care of deteriorating patients: Guideline 139. 2014.
Available at: http://www.sign.ac.uk/pdf/SIGN139.pdf. Accessed October 14,
2014.
2. RCP. Acute Care Toolkit 9: Sepsis.; 2014.
3. College of Emergency Medicine. Clinical Standards for Emergency
Departments. 2013. Available at: http://www.collemergencymed.ac.uk/Shop-
Floor/Clinical Standards. Accessed October 14, 2014.
4. The ARISE Investigators and the ANZICS Clinical Trials Group.
Goal-Directed Resuscitation for Patients with Early Septic Shock. N. Engl.
J. Med. 2014:141001063014008. doi:10.1056/NEJMoa1404380.
5. Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of
protocol-based care for early septic shock. N. Engl. J. Med.
2014;370(18):1683-93. doi:10.1056/NEJMoa1401602.
6. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and
the severe sepsis resuscitation bundle: a prospective observational cohort
study. Emerg. Med. J. 2011;28(6):507-12. doi:10.1136/emj.2010.095067.
Sir
I find the methodology for this paper to contain a significant flaw in
that the triage criteria used to determine suitability for the GP unit
contain a requirement that the patient will need minimal additional
resources for them to be processed. It is hardly surprising therefore that
the post intervention analysis sees fewer additional resources
subsequently spent on this group with the associated savings.
Sir
I find the methodology for this paper to contain a significant flaw in
that the triage criteria used to determine suitability for the GP unit
contain a requirement that the patient will need minimal additional
resources for them to be processed. It is hardly surprising therefore that
the post intervention analysis sees fewer additional resources
subsequently spent on this group with the associated savings.
In addition, it is contradictory to say that under the cost data the
ED cost per patient went up due to "some shift in patient mix after
triage" but in the discussion to claim that it was unlikely that the cost
differences were explained by differences between the two populations.
Finally, the rise in patient numbers of around 60% in 5 years
represents a phenomenal failure to contain the overall cost of emergency
care provision, despite the quoted lower costs per patient for the GP
unit. The conclusion that such a model represents "dominance" is therefore
quite extraordinary.
Sincerely
Wright and colleagues1 discuss some interesting issues around blood
cultures and sepsis outcome measurement. We agree that evaluating and
tracking sepsis associated mortality over time is important. It would
facilitate assessment of the impact of changes in practice, both intended
effects of sepsis improvement interventions and unintended consequences of
other initiatives, e.g. restrictive antibiotic policies, as well a...
Wright and colleagues1 discuss some interesting issues around blood
cultures and sepsis outcome measurement. We agree that evaluating and
tracking sepsis associated mortality over time is important. It would
facilitate assessment of the impact of changes in practice, both intended
effects of sepsis improvement interventions and unintended consequences of
other initiatives, e.g. restrictive antibiotic policies, as well as
epidemiological changes in populations. An ideal outcome measure would be
"simple, objective, clinically meaningful, resistant to ascertainment
bias, and, ideally, suitable for automation using data routinely stored in
electronic health records"2. Unfortunately, there is no such perfect
measure to track sepsis associated mortality.
Analysis of recorded International Classification of Diseases, Tenth
Revision (ICD-10) codes is frequently utilised for tracking trends in
healthcare, including mortality3. At first, this seems appealing as ICD-
10 codes should be simple and clinically meaningful and are available from
routinely collected data. However, inconsistency in assignment of codes
and changes in coding patterns make this susceptible to ascertainment bias
thereby compromising the validity and reliability of applying this as a
standalone measure2. Where remuneration and penalisation in healthcare is
linked to coding, there is also potential for gaming and coding trends to
emerge which do not reflect a real change in the population2,3.
Additionally, due to the presence of a range of appropriate codes that
could be applied to patients with sepsis, analysis of coding is complex4.
Both primary and secondary discharge codes require interrogation and organ
-specific infection codes, such as community-acquired pneumonia (ICD- 10
code J18.9), do not indicate whether the patient had sepsis, thereby
reducing the sensitivity of this as a measure. All-cause mortality is
also utilised within the literature. It is simple, objective and
routinely collected, however, it lacks sensitivity to detect the impact of
improvement interventions in clinical practice.
We agree with Wright et al that blood cultures should only be drawn
where appropriate. As advocated as part of the Sepsis Six5, when patients
fulfil two or more Systemic Inflammatory Response Syndrome (SIRS) criteria
(see Box 1) and have a suspected or confirmed source of infection blood
cultures should be obtained7.
Box 1:
SIRS criteria6
SIRS present when two or more of the following measured:
* Temperature <36oC or >38oC
* Heart Rate >90 beats/min
* Respiratory Rate >20 breaths/min OR PaCO2 <4.3kPa
* White blood cell count <4000/?L or >12000/?L
One concern which we share with Wright et al is that blood cultures
are often taken from patients who do not meet SIRS criteria, as found in
an audit of patients with cellulitis presenting to an Acute Medical Unit8,
but this is not encouraged if the Sepsis Six is implemented correctly.
Such snapshot audits are limited to the clinical observations available at
the time of data collection and this is likely to result in an
underestimation of the prevalence of sepsis at any time during a hospital
admission among patients who have a blood culture taken. With the
exception of immunocompromised patients or those with suspected
endocarditis, blood cultures should only be taken from patients who have
two or more SIRS criteria otherwise there is potential to waste resources
and cause patient harm7.
Wright et al reported a rise in blood culture sampling within NHS
Forth Valley. This should not necessarily be interpreted as a negative
development. The Scottish Trauma Audit Group9 reported that 39% (n=251)
of patients fulfilling criteria for severe sepsis in the emergency
department had no blood cultures sampled during the first 48 hours
following presentation. From this baseline the number of blood cultures
being drawn should rise initially if the Sepsis Six is being implemented
reliably. Interestingly the beginning of NHS Forth Valley's rise in blood
culture sampling appears to pre-date the beginning of the Scottish Patient
Safety Programme (SPSP) national Sepsis Collaborative in January 2012.
This apparently crude rate may reflect an already increasing awareness of
sepsis but may also have been influenced by the increasing number of
inpatient discharges in NHS Forth Valley in the period 2010-201310.
Wright et al suggest that the measurement of mortality among patients
with a positive blood culture would be more useful than blood cultures
alone. However, the proportion of patients with a positive blood culture
is a small subset of the wider sepsis population with one cohort reporting
that only 21% of patients with sepsis had a bacteraemia11. Therefore, to
restrict the measurement of sepsis associated mortality to this population
would significantly underestimate the true incidence of sepsis.
Additionally, the presence of a positive blood culture has not been
demonstrated to be independently associated with higher mortality once
adjusted for age, sex and comorbidity11,12. These considerations limit
the clinical meaningfulness of this as a measure, and negate Wright et
al's concern about "treating culture-negative sepsis with broad spectrum
antibiotics". This concern is not consistent with the objective of the
Sepsis Six, which is to ensure that patients with clinical signs of sepsis
receive prompt, appropriate and timely antibiotic treatment.
The proxy outcome measure for the SPSP national Sepsis Collaborative
examines the thirty day mortality among adult inpatients in acute
hospitals who have had a blood culture sampled. Utilising the existing
Scottish Hospital Standardised Mortality Ratio (HSMR) model, the data will
be adjusted for changes in clinical activity and acuity of care. However,
even crudely adjusted (e.g. for age, sex and occupied bed days or
admissions) blood culture mortality is a superior outcome measure compared
to the other currently proposed options. We accept that it is not perfect,
and are undertaking further work to validate its scope and applicability,
including investigating combining blood culture sampling with other
routinely available data. Improving the selection of patients for blood
culture sampling, as discussed above, would improve the performance of
this measure. However, even as it stands, it is simple, relatively
objective, clinically meaningful and more resistant to ascertainment bias
than most other options, and is suitable for automation using data
routinely stored in electronic health records.
References
1. Wright DJ, Beckett DJ, Cooke B. Use of sepsis 6 raises some
interesting questions. Emerg Med J Published Online First: 01.09.2014
2. Rhee C, Gohil S, Klompas M. Regulatory Mandates for Sepsis Care -
Reasons for Caution. N Engl J Med 2014; 370: 1673-1676
3. Vaughan Sarrazin MS, Rosenthal GE. Finding Pure and Simple Truths
with Administrative Data. JAMA 2012; 307(13):1433-1435
4. MacPherson D, Griffiths C, Williams M, Baker A, Klodawski E,
Jacobson B, Donaldson L. Sepsis-associated mortality in England: an
analysis of multiple cause of death data from 2001-2010. BMJ 2013;
3(8)e002586
5. Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the
severe sepsis resuscitation bundle: a prospective observational cohort
study. Emerg Med J 2011; 28:507-512
6. Jones GR, Lowes JA. The systematic inflammatory response syndrome
as a predictor of bacteremia and outcome from sepsis. Q J Med 1996; 89:7
7. Coburn B, Morris Am, Tomlinson G, Detsky AS. Does This Adult
Patient With Suspected Bacteremia require blood cultures? JAMA 2012;
308:5
8. Marwick C, Rae N, Irvine N, Davey P. Prospective study of severity
assessment and management of acute medical admissions with skin and soft
tissue infection. J Antimicrob Chemother 2012; 67:1016-9.
9. The Scottish Trauma Audit Group. Sepsis Management in Scotland.
2010.
11. Marwick CA, Guthrie B, Pringle JE. Identifying which septic
patients have increased mortality risk using severity scores: a cohort
study. BMC Anesthesiol 2014; 14:1
12. Phua J, Ngerng WJ, See KC, Tay CK, Kiong T, Lim HF, Chew MY, Yip
HS, Tan A, Khalizah J, Capistrano R, Lee KH, Mukhopadhyay A.
Characteristics and outcomes of culture-negative versus culture-positive
severe sepsis. Critical Care 2014; 17:R202
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and
Patricia E. Kern Center for the Science of Health Care Delivery,
Rochester, MN, USA
2Division of Hospital Internal Medicine, Department of Internal Medicine,
Mayo Clinic, Rochester, MN, USA
Correspondence to:
Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern
C...
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and
Patricia E. Kern Center for the Science of Health Care Delivery,
Rochester, MN, USA
2Division of Hospital Internal Medicine, Department of Internal Medicine,
Mayo Clinic, Rochester, MN, USA
Correspondence to:
Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern
Center for the Science of Health Care Delivery, 200 First Street SW,
Rochester, MN 55905; romerobrufau.santiago@mayo.edu
We have read with much interest the article by Corfield et al.
published in a recent issue of Emergency Medicine Journal.1 They describe
calculation of the National Early Warning Score (NEWS) in a cohort of
septic patients admitted to the Emergency Department (ED). Their results
look very promising at first sight, as they report a positive predictive
value of 27% and 72% sensitivity for the combined outcome of in-hospital
death or admission to the intensive care unit (ICU). With these results,
they argue that "Among patients who have sepsis, a single EWS of ?7 in the
ED indicates a 27% chance of requiring admission to the ICU within 48h
and/or death within 30 days. At this level, an argument can be made for
mandating senior ED clinical review for all these patients," and they also
argue for review by a critical care outreach team.
However, there are important limitations and observations to be made.
First, out of the 2,489 patients who fulfilled "sepsis" criteria prior to
leaving the ED, 486 (19.5%) were not included in the final cohort for
missing data, and the characteristics of these excluded patients are not
reported. This exclusion of a large number of patients could bias the
cohort, as it can be argued that more severe patients are more likely to
have a complete set of observations captured.
Second, and more importantly, their inclusion criteria included patients
who were hospitalized for more than 48 hours, yet they added in patients
who died, regardless of their length of stay. This, in turn, has two
important consequences: it means that, to be able to know that a patient
has a certain probability, one has to know that the patient will have a
length of stay of more than 2 days, which requires data from the future
that is obviously not available on admission. But, more importantly, this
decision artificially increases the baseline outcome rate in the study's
cohort. The final cohort used in the analysis has an overall mortality
rate of 15%, and a combined outcome rate of 18%. This means that a
patient, just for meeting the study's eligibility criteria, has a 15% risk
of dying during the hospitalization. In the light of this finding, the
increased risk for a patient that has a NEWS ?7 is only 1.4 above the
average patient in their cohort.
Even the group of patients with the lowest NEWS (0-4) has an 8% risk of
the combined outcome, and a 5% in-hospital mortality risk. It could be
argued that this, too, would merit an evaluation by a senior ED clinician,
regardless of their NEWS score.
References
1. Corfield AR, Lees F, Zealley I, et al. Utility of a single early
warning score in patients with sepsis in the emergency department. Emerg
Med J. Jun 2014;31(6):482-487.
However, they point out that her critique of their paper is largely
inconsistent with what was actually written and can only assume a
misunderstanding of the article.
The article does not state, nor even imply, that the GMC require
students to provide expert or definitive care as she asserted in her
response. Indeed the article talks about basic skills an...
However, they point out that her critique of their paper is largely
inconsistent with what was actually written and can only assume a
misunderstanding of the article.
The article does not state, nor even imply, that the GMC require
students to provide expert or definitive care as she asserted in her
response. Indeed the article talks about basic skills and basic
prehospital care verbatim, and as such is not culpable for the points
outlined in her comments.
Whilst BLS and first aid may be essential components of prehospital
care, the authors disagree that it is 'the best any practitioner (or
student) can offer'. As detailed in the article, other aspects of care
(and not just treatment) will benefit both the injured and those
assisting, not least in ensuring personal safety. Furthermore, whilst BLS
may be taught in medical schools, such teaching has been reported as
inadequate, and it is the authors' suggestion that its compulsory and
regulated integration into the undergraduate curriculum would ensure that
it is taught to the correct standard.
Finally, the authors thank Dr Clayton for pointing out the training
that paramedics receive. Nonetheless, they feel they must again emphasise
that the article has never once suggested that over-zealous students (and
junior doctors) should interfere with and hinder these paramedics, which
she wrongly implied in her response. Quite the opposite. As the article
states that ambulance response times have been reported as substandard,
i.e. are taking longer to reach an emergency than they should, its
emphasis is thus that of care prior to the arrival of these paramedics, a
time when a student is first on the scene and might improve patient
outcome. The authors had hoped that this could be understood from the
lines "transferring relevant and detailed information to a 999 operator"
i.e. what to say when calling 999, and "on-scene handovers to emergency
services" i.e. telling paramedics what has happened as they arrive and
take over.
The authors therefore do not agree with Dr Clayton's suggestion that
"everyone else should stand well back" as this implies that no care would
be given, the injured may deteriorate and the GMC guidelines are
disregarded.
Our previous study reported in your journal in 2012 found that 7.5%
of the transvaginal sonography (TVS) probe samples were human
papillomavirus (HPV) DNA positive in our Emergency Department, when a
barrier was applied along with low level disinfection using a quaternary
ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially
contaminated by HPV, C. trachomatis, mycoplasma...
Our previous study reported in your journal in 2012 found that 7.5%
of the transvaginal sonography (TVS) probe samples were human
papillomavirus (HPV) DNA positive in our Emergency Department, when a
barrier was applied along with low level disinfection using a quaternary
ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially
contaminated by HPV, C. trachomatis, mycoplasmas, Gram-positive and Gram-
negative bacteria with low level disinfection. (2)
According to the Centres for Disease Control and Prevention (CDC)
guidelines, transvaginal probes, as they have direct contact with mucosal
membranes, should be processed using a high level disinfection method. (3)
However, many suitable agents can potentially damage the transducer and
reduce its life span. Since the discovery of substantial HPV contamination
in 2011, our department has adopted high level disinfection techniques
using the Tristel TRIO wipes system [Tristel Solutions Ltd, U.K.], which
is a chlorine dioxide based agent specially designed for endocavity
ultrasound probes as well as certain endoscopes.
After implementation of the new disinfection method for 1 year, we
performed another surveillance sampling of the TVS probe. A total of 50
samples were collected daily over 50 consecutive days between March and
May 2013. All samples were HPV DNA negative by PCR performed as previously
described. (1)
Our latest results provide encouraging evidence that barrier methods
together with high level disinfection can successfully reduce HPV
contamination of the TVS probe. The associated increase in cost is
worthwhile to ensure a low risk of contamination.
Reference:
1. Ma ST, Yeung AC, Chan PK, Graham CA. Transvaginal ultrasound probe
contamination by the human papillomavirus in the emergency department.
Emerg Med J. 2013 Jun;30(6):472-5.
2. M'Zali F, Bounizra C, Leroy S, Mekki Y, Quentin-Noury C, Kann M.
Persistence of microbial contamination on transvaginal ultrasound probes
despite low-level disinfection procedure. PLoS One. 2014 Apr
2;9(4):e93368.
In Yeovil District Hospital (YDH), o2 alert cards are currently
issued by the respiratory nurse specialist. Patients are usually referred
by a doctor or the ward nurses for a respiratory nurse review to optimise
management of a respiratory disorder and arrange appropriate follow up in
the community. If a patient has a documented episode of type II
respiratory failure the respiratory nurse will issue an o2 alert card as...
In Yeovil District Hospital (YDH), o2 alert cards are currently
issued by the respiratory nurse specialist. Patients are usually referred
by a doctor or the ward nurses for a respiratory nurse review to optimise
management of a respiratory disorder and arrange appropriate follow up in
the community. If a patient has a documented episode of type II
respiratory failure the respiratory nurse will issue an o2 alert card as
recommended by BTS.
A retrospective audit was carried in Yeovil District Hospital in 2013 to
determine if oxygen alert cards are achieving their intended purpose. This
included assessing whether alert cards were issued correctly to at-risk
patients and to review the compliance of oxygen administration in both
ambulances and hospital with BTS guidance. 79 patients were issued o2
alert cards over the 12 month period; 63 notes were available and audited.
The results showed that all patients audited had a documented ABG
confirming an episode of hypercapnoea; the majority of which had a
diagnosis of COPD. Of those 63 patients audited, 19 patients were
readmitted with a total of 38 admissions. Therefore the average number of
re-admissions per patient was 2 (range: 1-5)
During 33 of these episodes the patient was brought to hospital via
ambulance. There were only 2 ( reports of alert cards being shown and
appropriate venturi masks being issued to the ambulance staff. Furthermore
on 76% of episodes, o2 administered in the ambulance was not appropriate
and oxygen saturations exceeded the targeted 88-92%.
On arrival to hospital there were no recordings of any alert cards being
shown to staff and issued with the appropriate venturi mask. On first
saturation measurement whilst in hospital only 29% were within the target
range and in over 50% these were not acted on appropriately.
During the admissions, there were 8 incidents where an ABG was not
preformed. However, in the remaining 30 admission episodes in which an ABG
was preformed, appropriate action and oxygen titration was carried out in
90% of the episodes.
It is clear from this audit that currently, in Yeovil District Hospital,
the o2 alert cards issued to patients are not being used. The audit has
also demonstrated that oxygen administration in both ambulatory services
and hospital setting are not following the current recommendations set by
BTS in regards to the administration of oxygen to patients at risk of
hypercapnoea. Patients are continuing to be inappropriately administered
oxygen and are being put at high risk of the potentially dangerous side-
effects of high-flow oxygen. It appears from the study that in the
majority of patients it is only after an ABG that oxygen administration
levels are appropriately titrated. However, worryingly not all patients
have an ABG on admission.
There are probably a number of reasons why the o2 alert cards are not
currently working. The alert cards are a relatively new scheme in Yeovil
District Hospital and therefore education will play a crucial role for
improving the use of o2 alert cards. Patient and carers will be targeted
as the main source of education and it is hoped that providing them with
BTS leaflets on oxygen administration will increase understanding.
Obviously education of health professionals will also be important to
raise awareness of the scheme and guidelines.
Communication between primary and secondary services is another area that
could possibly develop; one idea is that the home address and ideal oxygen
dose or target saturation ranges of at-risk patients could then be flagged
in the ambulance control systems and communicated to ambulance crews when
required.
A further idea is that the name of the o2 alert cards could be changed to
something which implies a more serious danger hopefully this would
encourage the use by patients similar to the reporting of drug allergies.
The very fact that the author has written this article at all
demonstrates to me a profound lack of understanding on his part of the
complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of
accidents is not a requirement to provide expert or definitive care - it
is simply a moral duty to provide what help one can given ones own skill
set and available resources. As the...
The very fact that the author has written this article at all
demonstrates to me a profound lack of understanding on his part of the
complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of
accidents is not a requirement to provide expert or definitive care - it
is simply a moral duty to provide what help one can given ones own skill
set and available resources. As the author rightly points out, opening an
airway or stabilising a cervical spine may indeed be life-saving.
Furthermore, the inability to provide expert or definitive
interventions does not reflect inadequacies on the part of medical school
curricula, but more the reality that, without equipment (which no-one
caries with them except BASICS doctors), the best any practitioner (or
student) can offer at the road side is basic life support/ first aid - and
this is already taught in medical schools.
Most importantly of all, there already exists a body of prehospital
care experts who spend on average of three years training to provide
assistance to accident victims - they are called paramedics, and trust me,
they do not appreciate over-enthusiastic medical students/ junior doctors
'helping' them on scene - whether or not their medical school has provided
them with prehospital care training.
Prehospital care is highly specialised, and those that practice
within the speciality have extensive experience within the critical care
domains and (assuming they have the right equipment available) can
sometimes offer the trauma victim an extra survival advantage. Everyone
else should stand well back and let the paramedics do what they do better
than anyone else.
Conflict of Interest:
I am a registrar in retrievals medicine, involving primary and secondary retrievals.
Much has been written about the current difficulties of recruiting
and retaining doctors in key specialities: most recently psychiatry (1)
and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of
doctors choosing to enter speciality training immediately upon finishing
their FY2 year: in 2013 only 64% of FY2's chose to enter speciality
training (3). Instead, many FY2's opt...
Much has been written about the current difficulties of recruiting
and retaining doctors in key specialities: most recently psychiatry (1)
and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of
doctors choosing to enter speciality training immediately upon finishing
their FY2 year: in 2013 only 64% of FY2's chose to enter speciality
training (3). Instead, many FY2's opt to work abroad, or to take trust
grade positions.
Currently, going "off-program" allows junior doctors the flexibility
to develop their own skills and interests, in a way that rigidly
structured training programs don't. It gives them a chance to take
ownership of their own training, and to see their personal and
professional development as their own responsibility, rather than an
exercise in "hoop-jumping". They have a chance to work abroad, pursue
additional qualifications or research, and to choose where they live and
how many hours they work. They can choose to work in specialities that
they didn't get to experience during the foundation program.
As a "sessional" speciality which requires a broad portfolio of
skills, and doesn't require continuity of care, emergency medicine could
capitalise on juniors doctors' apparent desire to have greater flexibility
and freedom in their training: trainees could be offered "half-time"
contracts, which would leave them 6 months a year free to pursue other
interests, degrees, or specialities.
Similarly, a more permissive approach to offering sabbaticals, and a
greater variety of less-than-full-time-training rotas would offer FY2's
the best of both worlds: the flexibility associated with trust-grade work,
and the support and development opportunities afforded by training jobs.
Emergency departments would benefit from having committed doctors on full-
time contracts, who would be guaranteed to return the following year to
continue training.
Svirko et al identified that one of the key factors repelling
trainees from emergency medicine is the perceived lack of a "work-life-
balance" (2): emergency departments can improve this by offering a wider
variety of training contracts, to suit the different lifestyles and
interests of the diverse group of doctors who are drawn to the emergency
department.
(1) Mukherjee, Psychiatric Bulletin (2013) 37: 210-214
(2) Svirko, Lambert et al Emerg. Med. J. 2014 31:556-561
(3) Foundation Programme Annual Report
http://www.foundationprogramme.nhs.uk/pages/home/keydocs
Hunter and colleagues gives a good method to distinguish COPD and
heart failure in a dyspnoeic patient. May i politely suggest an easier,
clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent,
bulging veins has COPD as the predominant cause for the breathlessness
compared to the patient with heart failure who has collapsed, thready
veins. The therapy...
Hunter and colleagues gives a good method to distinguish COPD and
heart failure in a dyspnoeic patient. May i politely suggest an easier,
clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent,
bulging veins has COPD as the predominant cause for the breathlessness
compared to the patient with heart failure who has collapsed, thready
veins. The therapy can be directed accordingly and early benefits achieved
using this clinical marker of distinction. Of course, this venous
distension could reflect higher CO2 levels in the COPD patients. As a
junior doctor, i found it much easier to cannulate these patients in
emergency department compared to the congestive heart failure patients
where cannulation was much more difficult.
So, the quick clue for the acute on chronic breathless patient is
bulging veins = worsening COPD, thready veins = worsening heart failure
Dear Editor,
The "Sepsis Six" resuscitation bundle is now common in UK hospitals, and endorsed by the College of Emergency Medicine, SIGN guidelines, and the Royal College of Physicians.1-3 However, the evidence behind it remains limited and must be re-evaluated as new data emerges - especially since the results of the PRoCESS and ARiSE trials on Early Goal Directed Therapy (EGDT) were published this year.4,5...
Sir I find the methodology for this paper to contain a significant flaw in that the triage criteria used to determine suitability for the GP unit contain a requirement that the patient will need minimal additional resources for them to be processed. It is hardly surprising therefore that the post intervention analysis sees fewer additional resources subsequently spent on this group with the associated savings.
...
Wright and colleagues1 discuss some interesting issues around blood cultures and sepsis outcome measurement. We agree that evaluating and tracking sepsis associated mortality over time is important. It would facilitate assessment of the impact of changes in practice, both intended effects of sepsis improvement interventions and unintended consequences of other initiatives, e.g. restrictive antibiotic policies, as well a...
Santiago Romero-Brufau, MD1; Jeanne M. Huddleston, MD1,2
1Healthcare Systems Engineering Program, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA 2Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
Correspondence to: Santiago Romero-Brufau, MD, Mayo Clinic Robert D. and Patricia E. Kern C...
The authors thank Dr Clayton for her comments.
However, they point out that her critique of their paper is largely inconsistent with what was actually written and can only assume a misunderstanding of the article.
The article does not state, nor even imply, that the GMC require students to provide expert or definitive care as she asserted in her response. Indeed the article talks about basic skills an...
Our previous study reported in your journal in 2012 found that 7.5% of the transvaginal sonography (TVS) probe samples were human papillomavirus (HPV) DNA positive in our Emergency Department, when a barrier was applied along with low level disinfection using a quaternary ammonia based agent. (1)
M'Zali et al also demonstrated that TVS probes remained substantially contaminated by HPV, C. trachomatis, mycoplasma...
In Yeovil District Hospital (YDH), o2 alert cards are currently issued by the respiratory nurse specialist. Patients are usually referred by a doctor or the ward nurses for a respiratory nurse review to optimise management of a respiratory disorder and arrange appropriate follow up in the community. If a patient has a documented episode of type II respiratory failure the respiratory nurse will issue an o2 alert card as...
The very fact that the author has written this article at all demonstrates to me a profound lack of understanding on his part of the complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of accidents is not a requirement to provide expert or definitive care - it is simply a moral duty to provide what help one can given ones own skill set and available resources. As the...
Much has been written about the current difficulties of recruiting and retaining doctors in key specialities: most recently psychiatry (1) and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of doctors choosing to enter speciality training immediately upon finishing their FY2 year: in 2013 only 64% of FY2's chose to enter speciality training (3). Instead, many FY2's opt...
Hunter and colleagues gives a good method to distinguish COPD and heart failure in a dyspnoeic patient. May i politely suggest an easier, clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent, bulging veins has COPD as the predominant cause for the breathlessness compared to the patient with heart failure who has collapsed, thready veins. The therapy...
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