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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
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effective...
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding
us of what is our primary objective as healthcare providers -- to relieve
pain and suffering; and for providing the evidence that suggests that we
often are failing in this objective. As medical crewmembers in helicopter
EMS, we appreciate the need to elicit accurately, and to relay
effectively, information about a patient's pain and suffering. We believe
that the PENS tool is effective in meeting these objectives.
The authors remind us that managing a patient's pain and suffering
requires that healthcare providers be aware of the constellation of
unpleasant sensations experienced by the patient. These sensations may be
caused by illness or injury (i.e., their pain). Their pain, a distinct
entity, may be associated with both mental and emotional distress, such as
fear, anxiety, and uncertainty; and with physical sensations caused by
hunger, thirst, nausea, dizziness, fatigue, and the unpleasant features of
ambient light, temperature, and noise (i.e., their suffering).
Managing pain and suffering begins with asking the right questions.
PENS, an acronym pronounced as a word, is an abbreviation for the elements
of Pain/Discomfort; Emotions/Expectations; Nausea/Nutrition (Elimination);
and Sensory-Stimuli/Sleep. The "PENS assessment" begins with asking the
patient: "Are you in pain?" It ends with asking: "Is there anything else
that I can do for you?"
We use PENS in transport medicine as a prompt to ask questions that
allow us to mitigate pain and suffering in both initial and subsequent
patient assessments. We use the "E" for "Expectations" in PENS as a prompt
for asking the patient questions such as: "Do you understand what our
plans are?" because such questions provide the means for initial creation
and ongoing modification of healthcare plans, and are the basis for shared
decision-making. We have found that during transitions of care
("handoffs") the information that we elicited from PENS assessments is the
type of information that other healthcare providers often find most
useful. Finally, we have found the PENS tool to be easy to remember, and
simple to apply.
Mark J. Greenwood, DO, JD, FAAEM, FCLM;
Emily J. Bennett, MSN, APRN-BC, EMT-P.
Grand Rapids, MI, USA.
mkjhgd@aol.com
I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidi...
I read with interest the study by Bloch and Bloch demonstrating the
effectiveness of observation-based simulation training. As they discussed,
simulation training not only improves attendees' knowledge and skills but
can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on
a departmental basis. However, increasingly emergency medicine involves a
multidisciplinary team. In the particular case of paediatric
resuscitation, in many hospitals the paediatric cardiac arrest team may
comprise emergency physicians, paediatricians and anaesthetists, as well
of course as emergency and paediatric nursing staff, all of whom may train
separately in their own departments. This can lead to incongruities in the
approach that is taught, and is a missed opportunity to foster better
teamwork and communication between the doctors and allied health
professionals playing these different roles during the management of time-
critical emergencies.
Just as there is a drive for conformity in the design and
availability of equipment for emergencies, which has been identified as an
important factor in increasing the efficacy and efficiency of care for
critically ill patients[2], perhaps the need for better conformity of
training also needs to be recognised. As this paper demonstrates the
effectiveness of observation-based simulation training, this may open a
way for multiple departments to train jointly, so that the
multidisciplinary team managing paediatric emergencies develop a cohesive
approach with stronger interdisciplinary communication and and teamwork.
References
1 Simulation training based on observation with minimal participation
improves paediatric emergency medicine knowledge, skills and confidence.
Scott A Bloch, and Amy J Bloch. Emerg. Med. J. 2015 32:195-202
2 Timing and teamwork--An observational pilot study of patients referred
to a Rapid Response Team with the aim of identifying factors amenable to
re-design of a Rapid Response System. Peebles, Emma et al. Resuscitation,
83(6):782-787
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realis...
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre-
Hospital Training should be included in all Undergraduate Medical
Curriculums. They will be pleased to hear that a nationwide Faculty of Pre
-Hospital Care Undergraduate Committee has been set-up, aiming to
springboard ideas and information about events, funding and training in
pre-hospital care, to all healthcare students.
Antrum and Ho quite rightly realise that some form of compulsory pre-
hospital training in all medical curriculums is only likely to happen if
the General Medical Council specifically requests it.
However at present, evidence to illustrate to the GMC the real value of
such training is lacking. This must change if it is to be a credible
competitor for precious curriculum time.
The Undergraduate Pre-Hospital Care Committee hopes that through co-
ordination of student pre-hospital care events, sharing of information and
literary review, as well as a now standardised and followed-up feedback
system for pre-hospital training, the evidence-base will grow. I urge
anyone involved in student pre-hospital care activities throughout the UK,
to get in touch with the Committee and together let's make sure the
necessary evidence for such vital training actually exists.
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...
Communicating Pain and Suffering: The PENS Acronym.
We would like to thank the authors of this study both for reminding us of what is our primary objective as healthcare providers -- to relieve pain and suffering; and for providing the evidence that suggests that we often are failing in this objective. As medical crewmembers in helicopter EMS, we appreciate the need to elicit accurately, and to relay effective...
I read with interest the study by Bloch and Bloch demonstrating the effectiveness of observation-based simulation training. As they discussed, simulation training not only improves attendees' knowledge and skills but can also improve teamwork and communication[1].
As reflected in this article, simulation training is typically run on a departmental basis. However, increasingly emergency medicine involves a multidi...
I agree with Antrum and Ho (EMJ 2015;32:171-172) that formal Pre- Hospital Training should be included in all Undergraduate Medical Curriculums. They will be pleased to hear that a nationwide Faculty of Pre -Hospital Care Undergraduate Committee has been set-up, aiming to springboard ideas and information about events, funding and training in pre-hospital care, to all healthcare students. Antrum and Ho quite rightly realis...
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