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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.
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical gradua...
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical graduates have knowledge of twenty first century management of emergencies in the pre-hospital situation. However in this area of medicine, where any medical practitioner can unexpectedly be required to help, it is important to ensure all medical graduates have knowledge of what interventions should not be undertaken as well as these that should be undertaken.
With a new GMC recognised sub-speciality of Pre-Hospital Emergency Medicine it is timely that the teaching of undergraduate of pre-hospital emergency medicine is standardised within the undergraduate curriculum.
Yours sincerely
Dr Colville Laird,
Chairman of The Faculty of Pre-hospital Care RCSEd
Email: claird@basics-scotland.org.uk
Mobile: 07768855798
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was...
Your article on ED patients' suffering came to me only this week
through Medscape.com. I would like to thank you for your analysis and for
bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in
the scientific literature. When I started practice in 1983 in a busy urban
academic Emergency Department in Baltimore, Maryland, and for the next
twenty-five years, THIS was the main driver of my practice style. It was
very rewarding and I am thrilled to see it championed so.
An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation...
An alternative to the use of a bite guard in conjunction with the LMA
would be to employ the intubating laryngeal mask airway (iLMA), since the
single-use version of the iLMA has a rigid plastic airway tube which
resists occlusion by biting, as does the silicone-coated stainless steel
tube with the reusable version. Additional benefits would be that the iLMA
can facilitate seamless progression to blind tracheal intubation without
any interruption in oxygenation or ventilation, and the fact that there is
no separate bite guard to become dislodged and obstruct the patient's
airway.
Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that...
Skrobo and Kelleher rightly stress the importance of accurate, rapid
weight estimation in children when the situation precludes actual
measurement of their weight.[1] They also rightly emphasise the need for
estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of
weight estimates using the Luscombe formula (3xage+7) is much smaller than
that for the old APLS formula (2xage+8). Interestingly, this was true for
1-5 year olds too, which suggests that it might be better to use the
Luscombe formula in all children, rather than just in 6-12 year olds as
recommended in the latest APLS manual.
However, the authors have not provided any results for the precision
of these methods, although they suggest that estimates should be within
15% of actual weight. The ISO standard for accuracy of measurement methods
defines both trueness and precision.[2] Trueness is the closeness of
agreement between the arithmetic mean of a large number of test results
and the true or accepted reference value. This is what the CORKSCREW study
has presented. Precision refers to the closeness of agreement between test
results. It is quite easy for a method to have very good trueness (for
example, using the median weight for a given age, as found on standard age
-weight curves), but have such an imprecision that it is clinically
useless. One commonly used method to describe trueness and precision is
described by Bland Altman.[3] The bias reflects trueness, and the limits
of agreement (LOA) reflect precision. For a given weight estimate, LOA
indicate the range of actual weights within which 95% of subjects will
fall.
Of the published methods of paediatric weight estimation, age-based
methods have the worst precision, deteriorating with increasing age.[4] We
would be particularly wary of using age-based weight estimation in
teenagers, as the range of weights for a given age is far too broad to
allow meaningful estimates in individuals. In comparison, the Broselow
tape is a very precise method in children, but not useful in over 10s.[5]
Newer methods of estimation based on mid-arm circumference (MAC) appear to
be at least as precise as the Broselow tape in older children and
adolescents.[6,7]
Of course, tape-based methods require the presence of the child, and
age-based methods might still have a role to play during preparation for a
child's arrival in the resuscitation room. A MAC tape could be readily
available pre-hospital as well as in the emergency department, and useful
when the condition of the patient precludes objective measurement of their
weight.
Sincerely,
Giles N Cattermole
Colin A Graham
Timothy H Rainer
References:
[1] Skrobo D, Kelleher G. CORKSCREW 2013 CORK study of children's
realistic estimation of weight. Emerg Med J 2015;32:32-5
[2] ISO 5725-1:1994. https://www.iso.org/obp/ui/#iso:std:iso:5725:-1:ed-
1:v1:en
[3] Bland JM, Altman DG. Statistical methods for assessing agreement
between two methods of clinical measurement. Lancet. 1986 Feb
8;1(8476):307-10.
[4] Cattermole GN, Leung MPY, So HK, Mak PSK, Graham CA, Rainer TH. Age-
based formulae to estimate children's weight in the emergency department.
Emerg Med J 2011;28:390-6.
[5] Cattermole GN, Leung PYM,Graham CA, Rainer TH. Too tall for the tape:
the weight of schoolchildren who do not fit the Broselow tape. Emerg Med J
2014;31:541-544.
[6] Cattermole GN, Leung PYM, Mak PSK, Graham CA, Rainer TH. Mid-arm
circumference can be used to estimate children's weights. Resuscitation
2010;81:1105-10.
[7] Abdel-Rahman SM, Ridge AL. An improved pediatric weight estimation
strategy. Open Med Devices J 2012;4:87-97.
We read with interest the article by Rashid et al (1) documenting current UK practice with regards to hip fractures (HF) and regional analgesia (RA); only 44% of their respondents reported local use of RA for this indication. The two main reasons highlighted were lack of equipment availability and lack of staff training; they therefore suggest that an appropriate protocol, a "Hip Block Box", audit and staff training may i...
We read with interest the article by Rashid et al (1) documenting current UK practice with regards to hip fractures (HF) and regional analgesia (RA); only 44% of their respondents reported local use of RA for this indication. The two main reasons highlighted were lack of equipment availability and lack of staff training; they therefore suggest that an appropriate protocol, a "Hip Block Box", audit and staff training may improve RA utilisation. They also highlight the utility of the Fascia Iliaca Compartment Block (FICB) in an emergency department setting.
Our local guidance advises the use of the FICB in all patients with HF unless contraindicated. An audit of 100 consecutive hip fracture presentations in 2012 demonstrated disappointing performance with only 40% managed appropriately. Following a local survey of clinicians, the main reasons cited for limited utilisation of the FICB were:
1) Lack of familiarity with the technique
2) Lack of awareness of the protocol
3) Difficulty locating equipment
These findings mirror those of Rashid et al (1).
In order to address this we undertook an education programme with middle grade doctors in the department; they were then encouraged to disseminate their knowledge to the junior team. The survey identified that consultant awareness of, and familiarity with, the procedure was already adequate. A simplified dosing regime was developed in consultation with the anaesthetic team; this facilitated the introduction of a simplified protocol. We also introduced "Block Boxes" to relevant clinical areas containing all the equipment necessary to perform the block.
The audit cycle was completed approximately a year later and demonstrated appropriate management in 76% of patients. This represents an absolute improvement of 36% and a relative improvement of 90%.
Our local findings demonstrate the efficacy of simple changes in generating significant improvements in the management of this cohort of patients. The changes implemented mirror those advocated by Rashid et al and we lend our support both to their utility and to the ease with which they can be introduced.
References
1. Rashid A, Beswick E, Galitzine S, Fitton L. Regional analgesia in the emergency department for hip fractures: survey of current UK practice and its impact on services in a teaching hospital. Emerg Med J 2014;31(11):909-13; doi:10.1136/emermed-2013-202794
I was interested to read the paper by Castle & Naguran describing
use of the intubating laryngeal mask airway (iLMA) in an entrapped patient
[1]. The authors might be interested to know that I have also used the
iLMA in the treatment of trapped trauma patients [2][3], and their case
bears striking similarities to the ones that I encountered. Their report
provides further evidence of the efficacy of the iLMA in trapped...
I was interested to read the paper by Castle & Naguran describing
use of the intubating laryngeal mask airway (iLMA) in an entrapped patient
[1]. The authors might be interested to know that I have also used the
iLMA in the treatment of trapped trauma patients [2][3], and their case
bears striking similarities to the ones that I encountered. Their report
provides further evidence of the efficacy of the iLMA in trapped trauma
situations, both as a primary airway rescue device and as a bridge to
tracheal intubation. Their report was encouraging, but I felt that there
were a number of important questions left unanswered, and I would like to
draw attention to these and offer some observations of my own.
The first important issue concerns the use of drugs. The authors
failed to say if an anaesthetic or sedative agent was used to assist with
insertion of the iLMA, and whether or not a neuro-muscular blocking agent
(NMBA) was used to facilitate intubation via the device. In my own small
case series involving five hypoxaemic trapped trauma patients, four of the
patients who went on to survive to discharge from hospital required the
administration of a dose of midazolam to facilitate insertion of the iLMA,
and the single patient who accepted the iLMA without the need for
medication was the only non-survivor. Although it has been shown that
there is no statistical difference in the success rates for intubation via
the iLMA between chemically paralysed and non-paralysed patients [4], the
incidence of reflex coughing is likely to be higher in non-paralysed
individuals, and the possible implications of coughing in the presence of
brain injury and raised intracranial pressure clearly need to be borne in
mind. Consequently, I would be interested to know if any drugs were used.
Secondly, although the SpO2 and EtCO2 readings suggested that there
was a significant improvement in the casualty's condition after insertion
of the device, we were not told if the patient went on to survive to
discharge from hospital - an important test of the efficacy and safety of
any prehospital intervention.
Finally, the authors omitted to mention the size and type of ET tube
that they used, and it would be interesting to know if the iLMA's
dedicated atraumatic wire-reinforced tube was employed, or simply a
standard ETT rotated through 180-degrees, as some authors have recommended
[5].
I agree with the authors that it is probably wise to leave the iLMA
in situ during transportation to hospital, even when tracheal intubation
via the iLMA has been undertaken in the prehospital phase, since
manipulation to remove the device from around the tracheal tube could
cause the tube to become accidentally dislodged. It should be noted,
however, that when the iLMA is left in situ after intubation, the
manufacturer recommends reducing the volume of air in the cuff of the iLMA
by 50%. This reduces pressure on the hypopharyngeal mucosa with the aim of
preventing possible ischaemic damage to tissues.
Castle & Naguran report that the first attempt to intubate via
the iLMA was unsuccessful, with resistance felt at the point where the ETT
should have entered the larynx, but that a second attempt at intubation
was successful after the iLMA was repositioned and forward traction
applied. Early studies suggested that a learning curve of approximately
twenty cases existed for proficiency in tracheal intubation via the iLMA
[6]. However, subsequent refinements to the recommended insertion
technique have managed to improve first-time intubation success rates
significantly [7].
The recommended technique for intubation via the iLMA is sometimes
called the 'Chandy' manoeuvre, named after the UK anaesthetist, Dr Chandy
Verghese. The first part of the Chandy manoeuvre involves grasping the
iLMA by its handle and moving it back-and-forth in the sagittal plane
while noting the rise-and-fall of the chest (tidal volume) together with
the resistance to manual ventilation. This optimises ventilation through
the device which occurs when the distal airway aperture in bowl of the
mask is directly opposite the laryngeal inlet. The second part of the
manoeuvre involves lifting the handle of the iLMA at 45% to the horizontal
plane of the patient's chest. This helps to align the angled ramp at the
distal end of the airway aperture with the longitudinal axis of the upper
trachea, so facilitating direct and unhindered passage of the tip of the
tube into the upper trachea. Use of the Chandy manoeuvre can be expected
to improve first-time intubation rates with the iLMA to levels approaching
100%.
Castle and Maguran's case report shows the potential value of the
iLMA as a device for rapid control of the airway in the prehospital
setting, particularly when there is restricted access to a trapped
casualty. They also show the value of the device as a bridge to blind
intubation of the trachea.
I believe that the iLMA is a much underrated and underused
supraglottic airway device which is particularly suitable in a trapped
trauma situation where there is limited access to the casualty. Its
benefits include:
1. Insertion and ventilation can be achieved easily by persons with
minimal training [8][9][10][11][12]
2. Functions as an initial rescue airway device in its own right
3. Laryngoscopy unnecessary
4. Neutral alignment of head & neck is a pre-requisite for
insertion, rendering manipulation of a potentially injured cervical spine
unnecessary
5. Insertion requires an interdental gap of only 20mm
6. Neuromuscular blockade not essential for insertion of the iLMA or
subsequent intubation via the device
7. Can be introduced blindly with one hand from any position
8. No need to insert a finger into patient's mouth
9. Rigid airway tube resists occlusion by biting
10. When the cuff is inflated, this provides protection of the airway
from bleeding arising above
11. Facilitates seamless progression to tracheal intubation
12. Permits ventilation between and even during intubation attempts
13. Available as a disposable single-use device.
With regard to the iLMA as a suitable rescue ventilation device for
prehospital trauma care, one is tempted to ask, 'What is there not to
like?'
[1] Castle N, Naguran S. Reflection: on the use of the ILMA in an
entrapped patient. Emerg Med J 2014; 31(12): 1014-1015
[2] Mason AM. Use of the intubating laryngeal mask airway in pre-
hospital care: a case report. Resuscitation 2001 Oct; 51(1): 91-5
[3] Mason AM. Prehospital use of the intubating laryngeal mask airway
in patients with severe polytrauma: a case series. Case Rep Med 2009;
2009:938531. doi: 10.1155/2009/938531. Available for free download at:
http://www.hindawi.com/journals/crim/2009/938531/
[4] Ambulkar R, Tan AYH, Chia NCH, Low TC. Comparison between use of
neuromuscular blocking
agent and placebo with the intubating laryngeal mask airway. Singapore Med
J. 2008; 49(6): 462-465
[5] Shah VR, Bhosale GP, Mehta T, Parikh GP. A comparison of
conventional endotracheal tube with silicone wire-reinforced tracheal tube
for intubation through intubating laryngeal mask airway. Saudi J Anaesth
2014; doi:10.4103/1658-354X.130702
[6] Baskett PJF, Parr MJA, Nolan JP, et al. The intubating laryngeal
mask. Results of a multicentre trial with experience of 500 cases.
Anaesthesia 1998; 53(12): 1174-1179
[7] Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A.
Use of the intubating LMA-Fastrach in 254 patients with difficult-to-
manage airways. Anesthesiology 2001; 95(5): 1175-1181
[8] Levitan RM, Ochroch EA, Stuart S, Hollander JE. Use of the
intubating laryngeal mask airway by medical and nonmedical personnel. Am J
Emerg Med 2000; 18(1): 12-16
[9] Reeves MD, Skinner MW, Ginifer CJ. Evaluation of the intubating
laryngeal mask airway used by occasional intubators in simulated trauma.
Anaesth Intens Care 2004; 32(1): 73-76
[10] Menzies R, Manj H. The intubating laryngeal mask: is there a
role for paramedics. Emerg Med J 2007; 24(3): 198-199
[11] Timmermann A, Russo SG, Crozier TA, et al. Laryngoscopic versus
intubating LMA guided tracheal intubation by novice users - a manikin
study. Resuscitation 2007; 73(3): 412-416
[12] McCall MJ, Reeves M, Skinner M, Ginifer C, Myles P, Dalwood N.
Paramedic tracheal intubation using the intubating laryngeal mask airway.
Prehosp Emerg Care 2008; 12(1): 30-34.
Conflict of Interest:
AMM is a former adviser in prehospital care to both Intavent Direct and the Laryngeal Mask Company, former distributors of the iLMA. Opinions expressed are purely those of AMM who has no connection with the current distributor(s) and no financial interest in sales of the iLMA.
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...
Dear Editor
ANTRUM AND HO (EMJ 2015;32:171-172)
Antrum and Ho (EMJ 2015;32:171-172) identify an important issue in identifying the deficiency in medical education due to the lack of formal training in pre-hospital medical care at most medical schools in the UK.
There are obvious benefits of increasing the number of trained professionals able to provide pre-hospital care it is important that all medical gradua...
Your article on ED patients' suffering came to me only this week through Medscape.com. I would like to thank you for your analysis and for bringing this topic to the surface.
I have been waiting thirty years for this concept to be treated in the scientific literature. When I started practice in 1983 in a busy urban academic Emergency Department in Baltimore, Maryland, and for the next twenty-five years, THIS was...
An alternative to the use of a bite guard in conjunction with the LMA would be to employ the intubating laryngeal mask airway (iLMA), since the single-use version of the iLMA has a rigid plastic airway tube which resists occlusion by biting, as does the silicone-coated stainless steel tube with the reusable version. Additional benefits would be that the iLMA can facilitate seamless progression to blind tracheal intubation...
Editor,
Skrobo and Kelleher rightly stress the importance of accurate, rapid weight estimation in children when the situation precludes actual measurement of their weight.[1] They also rightly emphasise the need for estimation tools to be validated locally.
The CORKSCREW study convincingly demonstrates that the mean bias of weight estimates using the Luscombe formula (3xage+7) is much smaller than that...
I was interested to read the paper by Castle & Naguran describing use of the intubating laryngeal mask airway (iLMA) in an entrapped patient [1]. The authors might be interested to know that I have also used the iLMA in the treatment of trapped trauma patients [2][3], and their case bears striking similarities to the ones that I encountered. Their report provides further evidence of the efficacy of the iLMA in trapped...
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