As an avid user of mobile apps currently working in Emergency
Medicine, I enjoyed reading this article (and have since downloaded a
couple of apps!). I have found mobile apps are a useful adjunct to my work
in the Emergency Department, most commonly for checking drug doses using
the British National Formulary app or using a Snellen Chart app in a
departmental bay.
I do think, however, if mobile apps are to be in...
As an avid user of mobile apps currently working in Emergency
Medicine, I enjoyed reading this article (and have since downloaded a
couple of apps!). I have found mobile apps are a useful adjunct to my work
in the Emergency Department, most commonly for checking drug doses using
the British National Formulary app or using a Snellen Chart app in a
departmental bay.
I do think, however, if mobile apps are to be integrated into
clinical practice that there needs to be a regulatory and cultural
revolution. Authoritative signs dictating 'do not use your mobile phone'
litter many hospitals and, in my opinion, have contributed to patients
challenging my use of them. Additionally, there is the cultural perception
that if you are 'checking your phone' you are probably on a social media
site when in actual fact you could well be checking the hospital's
antibiotic guidelines for a septic patient.
From a regulatory point of view, I think at the moment we need to be
cautious when using these apps. Very few of these have approval of
regulatory bodies such as the Medicines and Healthcare products Regulatory
Agency (MHRA) in the case of the UK. If we are using these apps to
diagnose and manage patients, we need to view them as much of a medical
device as a pulse oximeter.
Emergency Medicine is incredibly varied and, for that reason, is
probably the most ideal specialty to embrace mobile apps. I cannot see a
future for the specialty without mobile apps but I think we need to be
careful and open about using them.
In a manikin study simulating cardiopulmonary resuscitation, Tandon et al.1 showed that intubation time was shorter for GlideScope?? videolaryngoscope than direct laryngoscope. This result agrees with the findings of Shin et al2 and Xanthos et al3 in manikin studies simulating cardiopulmonary resuscitation. However, in other similar manikin studies, GlideScope?? videolaryngoscope was not superior to direct laryngoscope with r...
In a manikin study simulating cardiopulmonary resuscitation, Tandon et al.1 showed that intubation time was shorter for GlideScope?? videolaryngoscope than direct laryngoscope. This result agrees with the findings of Shin et al2 and Xanthos et al3 in manikin studies simulating cardiopulmonary resuscitation. However, in other similar manikin studies, GlideScope?? videolaryngoscope was not superior to direct laryngoscope with regard to intubation time.4,5 In all these manikin studies,1-5 the authors suggest that further clinical trials are required to evaluate the effectiveness of the studied devices in patients. One of important reasons for this statement is that the manikin cannot precisely reproduce the intubation conditions of real patients. Also, the airway scenarios simulated in manikin studies cannot represent real clinical situations. Despite numerous manikin comparing GlideScope?? videolaryngoscope and direct laryngoscope for tracheal intubation during cardiopulmonary resuscitation, it is really unclear what these contradictory results can tell us for clinical decision-marking.
Rai and Popat6 have pointed out that manikin studies often reveal results that are impossible to interpret or even contradictory to subsequent human studies. An example of this is a recent randomized controlled clinical trial by Arima et al7 comparing the Airwayscope and direct laryngoscope for tracheal intubation in prehospital patients primarily with cardiac arrest. In manikin studies simulating cardiopulmonary resuscitation, the Airwayscope has been demonstrated to be superior to direct laryngoscope for tracheal intubation.8,9 However, when tracheal intubation was performed by experienced emergency physicians in the prehospital cardiopulmonary resuscitation patients, the Airwayscope did not show superior efficacy to direct laryngoscope in relation to intubation time, success rate, and difficulty of intubation. Moreover, initial intubation with the Airwayscope failed in 20 cases but was followed by successful intubation with the direct laryngoscope. A major cause of failed first intubation attempt with the Airwayscope was oral vomitus or secretion contamination, which was found in 45 of the total 109 cases (41%) in this clinical study.7 Simple or even sophisticated manikins cannot model vomitus or secretions regurgitated from the esophagus or trachea due to increased intra-thoracic pressure from chest compressions.8 Here, we would like to echo Behringer and Kristensen10 that manikin studies may be warranted in the evaluation of new intubation equipment as a means to teach a technique, maintain safety and oversee conduct of an ensuing clinical study, but they are of negligible value as sole predictors of any given airway device's value in the clinical realm. Thus, to obtain robust evidence regarding exact role of videolaryngoscopes in airway management of cardiopulmonary resuscitation patients, randomized controlled trials comparing each videolaryngoscope against an established alternative (for example, direct laryngoscope) in actual clinical settings are still needed.
Shi Yu Wang, Fu Shan Xue, Rui Ping Li
Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, People's
Republic of China.
Correspondence to Fu Shan Xue, Department of Anesthesiology, Plastic
Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union
Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing
100144,China. Email: xuefushan@aliyun.com; fushan.xue@gmail.com
References
1. Tandon N, McCarthy M, Forehand B, et al. Comparison of intubation
modalities in a simulated cardiac arrest with uninterrupted chest
compressions. Emerg Med J 2013; In Press. doi:10.1136/emermed2013-202783.
2. Shin DH, Choi PC, Han SK. Tracheal intubation during chest compressions
using Pentax-AWS?, GlideScope?, and Macintosh laryngoscope: a randomized
crossover trial using a mannequin. Can J Anesth 2011; 58:733-9.
3. Xanthos T, Stroumpoulis K, Bassiakou E, et al. Glidescope?
videolaryngoscope improves intubation success rate in cardiac arrest
scenarios without chest compressions interruption: a randomized cross-over
manikin study. Resuscitation 2011; 82:464-7.
4. Kim YM, Kang HG, Kim JH, et al. Direct versus video laryngoscopic
intubation by novice prehospital intubators with and without chest
compressions: A pilot manikin study. Prehosp Emerg Care 2011; 15:98-103.
5. Kim YM, Kim JH, Kang HG, et al. Tracheal intubation using Macintosh and
2 video laryngoscopes with and without chest compressions. Am J Emerg Med
2011; 29:682-6.
6. Rai MR, Popat MT. Evaluation of airway equipment: man or manikin?
Anaesthesia 2011; 66:1-3.
7. Arima T, Nagata O, Miura T, et al. Comparative analysis of airway scope
and Macintosh laryngoscope for intubation primarily for cardiac arrest in
prehospital setting. Am J Emerg Med 2014; 32:40-3.
8. Komasawa N, Ueki R, Itani M, et al. Validation of the Pentax-AWS
Airwayscope utility as an intubation device during cardiopulmonary
resuscitation on the ground. J Anesth 2010; 24:582-6.
9. Komasawa N, Ueki R, Kohama H, et al. Comparison of Pentax-AWS
Airwayscope video laryngoscope, Airtraq optic laryngoscope, and Macintosh
laryngoscope during cardiopulmonary resuscitation under cervical
stabilization: a manikin study. J Anesth 2011; 25:898-903.
10. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new
intubation equipment. Anaesthesia 2011; 66 Suppl 2:57-64.
We read the article "AP pelvis and frog lateral for a limping
child"(1) with some concern for radiation safety. The AP pelvis radiograph
at presentation does not show merely slight irregularity of the articular
surface as stated in the article, but a reduction of height of 50% of the
left femoral capital epiphysis, increased density projected across the
growth plate, loss of clarity and contour of the growth plate and
la...
We read the article "AP pelvis and frog lateral for a limping
child"(1) with some concern for radiation safety. The AP pelvis radiograph
at presentation does not show merely slight irregularity of the articular
surface as stated in the article, but a reduction of height of 50% of the
left femoral capital epiphysis, increased density projected across the
growth plate, loss of clarity and contour of the growth plate and
lateralisation of the left hip - all classical signs of slipped epiphysis.
In our hospital we performed a study by which we reviewed all cases where
an AP and lateral pelvis had been performed over a period of 2 years (2).
This showed that the AP view very rarely demonstrated abnormality not seen
on the lateral view, whereas the converse is not true. Our protocol since
2008 is frog lateral only for painful hip except where there is a history
of trauma. To our knowledge there have been no missed diagnoses as a
result of this policy.
If any further investigation is required we prefer MRI to CT, which
delivers high dose to the gonads in hip examinations.
1.Sultan J, Ali F. Emerg Med J Published online first. 13th January
2014 doi 10.1136/ememed-2013 203366
2. Is a single radiograph adequate screening for possible slipped
upper femoral epiphysis? Gummow A, McGurk SF, WilkinsonAG. Pediatr Radiol
(2008) 38 (Suppl 3) S537
COMMENTS ON: "BET 3: Evaluation of intra-aortic balloon support in
cardiogenic shock"
Maria Cristina Acconcia(a), MD, Flavia Chiarotti(b), DStat, Francesco
Romeo(c), MD, Quintilio Caretta(d*), MD.
(a)Department of Cardiovascular Disease, University of Rome - La
Sapienza, Rome, Italy
(b)Department of Cell Biology and Neuroscience, Italian National Institute
of Health, Rome, Italy
(c)Department of Cardio...
COMMENTS ON: "BET 3: Evaluation of intra-aortic balloon support in
cardiogenic shock"
Maria Cristina Acconcia(a), MD, Flavia Chiarotti(b), DStat, Francesco
Romeo(c), MD, Quintilio Caretta(d*), MD.
(a)Department of Cardiovascular Disease, University of Rome - La
Sapienza, Rome, Italy
(b)Department of Cell Biology and Neuroscience, Italian National Institute
of Health, Rome, Italy
(c)Department of Cardiovascular Disease, University of Rome - Tor Vergata,
Rome, Italy
(d) Department of Clinical and Experimental Medicine, University of
Florence, Florence, Italy
*Corresponding author at: Quintilio Caretta, MD, Clinical and
Experimental Medicine, University of Florence, Largo Brambilla, 3 - 50134
Florence, Italy. Tel: 0039-3487809379; Fax: 0039-06-20904008;E-mail:
qcaretta@unifi.it.
In the meta-analysis "The outcome of intra-aortic balloon pump
support in acute myocardial infarction complicated by cardiogenic shock
according to the type of revascularization" by Romeo et al (2013), we
assessed the impact of intra-aortic balloon pump (IABP) on in-hospital
mortality, safety end points (stroke, severe bleeding) and long-term
survival, using risk ratio (RR) and risk difference (RD) estimates(1). We
found that IABP support did not significantly affected the risk of death
in patients who did not undergo reperfusion, while it reduced
significantly in the Thrombolysis (TT) subgroup and significantly
increased in the percutaneous coronary intervention (PCI) subgroup the
in-hospital mortality.
Humphrey et al (2013) recently performed a short-cut review to
establish whether IABP improves mortality in cardiogenic shock after acute
myocardial infarction (2) including our meta-analysis(1) . In Table 3 they
stated that the use of the observational studies and the different
mortality rates among the three subgroups (83.9% for the no reperfusion
subgroup, 66.9% for the TT subgroup, and 38.4% for the PCI subgroup),
suggested a weakness of the study. They concluded that "the role of IABP
support in patients with cardiogenic shock from myocardial infarction
remains unclear, without evidence of clear confirmed benefit compared to
conventional therapy, especially when PCI is available".
With respect to these remarks we would like to make some comments.
First, the statement on the observational studies is formally correct, but
in the scientific literature the evidence of IABP support in cardiogenic
shock is mainly based on registry data, due to feasibility; indeed, in our
meta-analysis the inhospital mortality was analyzed on 14186 patients from
16 studies, 13 observational, including 13526 patients, and 3 randomised
controlled trials, contributing with 22, 40, and 598 patients,
respectively. Furthermore in our meta-analysis we adopted the more
conservative random effect model to take into account heterogeneity among
studies. In adjunct Benson and Hartz (2000) performed meta-analyses of
randomised clinical trials and observational studies and found that
treatment effect estimates from observational studies reported after 1984
were similar to those obtained in randomised controlled trials(3). Also,
in their meta-analyses based on randomised clinical trials and
observational studies on identical clinical topics, Concato et al (2000)
found that the average results of well-designed observational studies
(with either a cohort or a case-control design) were markedly similar to
those of the randomised controlled trials(4). Finally, an integrated
approach is advisable because "Discarding observational evidence when
randomised trials are available is missing an opportunity. Conversely,
abandoning plans for randomised trials in favour of quick and dirty
observational designs is poor science"(5).
Second, we think that the authors did not take into appropriate account
the role of reperfusion strategies as confounding factor in the meta-
analysis. Indeed, from a clinical point of view it is quite different to
support patients affected by cardiogenic shock with IABP alone, or with
IABP in combination with TT or PCI. This is clearly demonstrated in our
meta-analysis by the fact that the three groups of patients who did not
receive IABP support (control groups) had significantly different in-
hospital mortality rates due to the clinical treatment (83.9%, 66.9%,
38.4%, for no reperfusion, TT and PCI, respectively) (see Figure 4 in
Romeo et al, 2013)(1). Thus the actual impact of IABP support could be
assessed only if the subgroups were stratified according to clinical
treatment. And this must not be interpreted as a gap, but as correct
application of the statistical method.
Finally, we performed a trial sequential analysis (TSA) using TSA program
(The Copenhagen Trial Unit, Center for Clinical Intervention Research CTU,
Denmark; version 0.9 beta; available at www.ctu.dk/tsa)(6,7) to settle any
further doubt. TSA provides the required information size, a threshold for
a statistical significant treatment effect and a threshold for futility.
We calculated the relative risk reduction (RRR) both for RR and RD, using
the event proportion observed in the control group (i.e. the basal risk)
and the actual difference in risks between the experimental and control
group observed in our meta-analysis. TSA performed on TT and on PCI
subgroups demonstrated that the sample sizes were adequate to verify the
hypotheses. The required number of participants was reached in both
subgroups of patients (TT: RR, n=1646 and RD, n=1287, RRR=26.6%; PCI: RR,
n=2671 and RD, n=2523, RRR=-18.2%). The monitoring boundaries constructed
to detect significance were crossed by the z-curves. Thus, our meta-
analysis can be considered as conclusive in contrast with the final
statement by Humphrey et al (2013)(2).
References
1. Romeo F, Acconcia MC, Sergi D, et al. The outcome of intra-aortic
balloon pump support in acute myocardial infarction complicated by
cardiogenic shock according to the type of revascularization: A
comprehensive meta-analysis. Am Heart J 2013:165:679-92.
2. BET 3: Evaluation of intra-aortic balloon support in cardiogenic shock.
Emerg Med J 2013;30:1063-4.
3. Benson K, Hartz AJ. A comparison of observational studies and
randomized, controlled trials. N Engl J Med 2000;342:1878-86.
4. Concato J, Shah N, Horwitz RI. Randomized, controlled trials,
observational studies, and the hierarchy of research designs. N Engl J Med
2000;342:1887-92.
5. Ioannidis JPA, Haidich A-B, Lau J. Any casualties in the clash of
randomised and observational evidence? No--recent comparisons have studied
selected questions, but we do need more data. 2001;322:879-80.
6. Thorlund K, Engstr?m J, Wetterslev J, et al. User manual for trial
sequential analysis (TSA). Copenhagen Trial Unit, Centre for Clinical
Intervention Research, Copenhagen, Denmark. 2011. p. 1-115. Available from
www.ctu.dk/tsa
7. Wetterslev J, Thorlund K, Brok J, et al. Estimating required
information size by quantifying diversity in a random-effects meta-
analysis. BMC Medical Research Methodology 2009;9:86.
I thoroughly enjoyed reading this honest perspective from an
experienced colleague. Like most junior doctors, my career to this point
has been littered with examples of unpleasant exchanges. As unpleasant as
they are, at my level being put in ones place seems to have some value. As
an example I remember when the on call general surgical registrar informed
me that she was "not the only one in the hospital with effing finger...
I thoroughly enjoyed reading this honest perspective from an
experienced colleague. Like most junior doctors, my career to this point
has been littered with examples of unpleasant exchanges. As unpleasant as
they are, at my level being put in ones place seems to have some value. As
an example I remember when the on call general surgical registrar informed
me that she was "not the only one in the hospital with effing fingers." I
was embarrassed, but in the year since this incident I have never
attempted to refer a patient with potential small bowel obstruction
without first completing my examination. The unforgiving tone of this
remark will likely stay with me for the rest of my career. Perhaps a
gentler delivery would not have had the same impact.
I was interested to read the papers by Jobe J and colleagues
published in Feb 2014 issue of Emerg Med J.1 The authors aimed to
investigate the validity and efficiency of a specific French-language
triage system named Echelle Liegeoise d'Index de Severite a l'Admission
(ELISA). 1
As the authors pointed out validity was estimated by studying the
correlations between the triage ranking assigned by the nurse and actual
reso...
I was interested to read the papers by Jobe J and colleagues
published in Feb 2014 issue of Emerg Med J.1 The authors aimed to
investigate the validity and efficiency of a specific French-language
triage system named Echelle Liegeoise d'Index de Severite a l'Admission
(ELISA). 1
As the authors pointed out validity was estimated by studying the
correlations between the triage ranking assigned by the nurse and actual
resource consumption and patient outcome.1 Why did the authors not used
well known test for validity analysis such as sensitivity, specificity,
positive predictive value (PPV), negative predictive value (NPV),
likelihood ratio positive and likelihood ratio negative as well as odds
ratio (true results\false results - preferably more than 50)? 2-9
Regarding reliability or agreement, it is good to know that ICC should be
used for quantitative variables and weighted kappa (not simple Cohen's ?
coefficient because kappa has its own limitations too) for qualitative
ones. 2-9
It is crucial to know that there is no value of kappa that can be regarded
universally as indication good agreement. Two important weaknesses of k
value to assess agreement of a qualitative variable are as follow: It
depends upon the prevalence in each category and also depends upon the
number of categories.
Moreover, statistics cannot provide a simple substitute for clinical
judgment. 2-9
As the authors pointed out in their conclusion, ELISA is a valid triage
tool with high interrater and intra rater agreement. Such a conclusion is
a misinterpretation due to inappropriate use of statistical test to assess
validity and reliability and should really be avoided by researchers.
As a take home message, for reliability and validity analysis,
appropriate tests should be applied.
References:
1- Job? J, Ghuysen A, G?rard P, Hartstein G, D'Orio D, Reliability and
validity of a new French-language triage algorithm: the ELISA scale. Emerg
Med J, 2014 Feb;31(2):115-20. doi: 10.1136/emermed-2012-201927. Epub 2013
Jan 23
2- Jeckel. J.F, Katz. D.L, Elmore, J.G, Wild, D.M.G, Epidemiology,
Biostatistics and Preventive Medicine, 3rd edition. 2007, SAUNDERS,
Elsevier, Philadelphia, PA, United State
3- Kenneth J. Rothman, Sander Greenland, Timothy L. Lash. Modern
Epidemiology, 4th edition. 2010. Lippincott Williams & Wilkins,
Baltimore, United States
4- Sabour S, Dastjerdi EV. Reliability of four different computerized
cephalometric analysis programs: a methodological
error.Eur J Orthod. 2013 Dec;35(6):848. doi: 10.1093/ejo/cjs074. Epub 2013
Oct 16.
5- Sabour S. Single slice vs. volumetric MR assessment of visceral adipose
tissue: reliability and validity among the
overweight and obese. Obesity (Silver Spring). 2013 Jan;21(1):6-7. doi:
10.1002/oby.20093.
6- Sabour S, Dastjerdi EV. Reliability of assessment of nasal flow rate
for nostril selection during nasotracheal intubation:
common mistakes in reliability analysis. J Clin Anesth. 2013
Mar;25(2):162. doi: 10.1016/j.jclinane.2012.10.006. Epub
2013 Jan 16.
7- Sabour S, Ghassemi F. Accuracy, validity, and reliability of the
infrared optical head tracker (IOHT), Invest Ophthalmol Vis Sci. 2012 Jul
13;53(8):4776. doi: 10.1167/iovs.12-10324.
8- Sabour S, Ghassemi F. Reliability and validity of conjunctival
ultraviolet autofluorescence measurement. Br J Ophthalmol.
2012 Sep;96(9):1271; author reply 1271. doi: 10.1136/bjophthalmol-2012-
302087. Epub 2012 Jun 13.
9- Sabour S, Ghassemi F. The reproducibility of measurements of
differential renal function in paediatric 99mTc-MAG3
renography: is this correct? Nucl Med Commun. 2012 Dec;33(12):1311; author
reply 1311-2.
doi:10.1097/MNM.0b013e328359453a
We read with interest the PALM consensus statement (1). This is an
airway rescue technique for comatose hypoxaemic patients in the pre-
hospital environment. The PALM procedure could also apply to the general
practitioner (GP) run community hospital environment since the facilities
of a metropolitan hospital, specifically rapid sequence induction of
anaesthesia (RSI), are not available.
We read with interest the PALM consensus statement (1). This is an
airway rescue technique for comatose hypoxaemic patients in the pre-
hospital environment. The PALM procedure could also apply to the general
practitioner (GP) run community hospital environment since the facilities
of a metropolitan hospital, specifically rapid sequence induction of
anaesthesia (RSI), are not available.
The islands of the west coast of Scotland are served by such
hospitals. The catchment population of these hospitals is clearly defined
and almost all patients will present to, or be initially transported to,
these hospitals. Since these hospitals do not have facilities for ongoing
management of intubated patients, critically ill or injured patients are
retrieved for ongoing care in metropolitan hospitals. These three
circumstances provides for a unique opportunity to estimate the RSI
incidence per head of population. It should then be possible to examine
these cases to assess if a PALM procedure by the island GP would have been
indicated as an initial procedure.
We examined our service database from 1st Jun 2008-1st December 2013
inclusively for ventilated patients retrieved from the islands of Arran,
Barra, Benbecula (and the Uists), Bute, Cumbrae, Coll, Colonsay, Islay,
Jura, Mull and Tiree. These islands are served by a GP hospital or
surgery. We could not assess deaths under medical care in the pre-hospital
setting thus there may be a survivor bias but we suspect this is small.
The total population of these islands is 25 204. Over a 4.5 year period,
68 ventilated patients were retrieved. Therefore we estimate that the "all
cause" RSI rate is 0.60 per 1000 of population per year.
We examined our service patient report forms for these 68 patients.
41 were comatose (an initial GCS of <9 either at referral to us or at
our initial assessment) and 17 were hypoxaemic (an initial SpO2 <90%).
13 patients were both comatose and hypoxaemic. Of these 13 patients, 4 had
airway management without drugs. Of the remaining 9 patients (a potential
PALM rate of 0.08 per 1000 per year), 5 had a primary neurological
diagnosis and 4 a primary respiratory diagnosis. Of the 13 patients there
was mention of an airway problem in 1.
We agree that PALM is likely to be a rare procedure. Our results,
within the clear limitations of our approach, may help inform that
opinion. We agree that the faculty should develop a robust registry to
inform discussion about this interesting development. We question if the
likely frequency of PALM for any one doctor is sufficient to maintain
currency unless very clear mechanisms are mandated.
References:
Moss R, Porter K, Greaves I. Pharmacologically assisted laryngeal mask
insertion: a consensus statement. Emerg Med J 2013; 30: 1073-1075.
As an avid user of mobile apps currently working in Emergency Medicine, I enjoyed reading this article (and have since downloaded a couple of apps!). I have found mobile apps are a useful adjunct to my work in the Emergency Department, most commonly for checking drug doses using the British National Formulary app or using a Snellen Chart app in a departmental bay.
I do think, however, if mobile apps are to be in...
In a manikin study simulating cardiopulmonary resuscitation, Tandon et al.1 showed that intubation time was shorter for GlideScope?? videolaryngoscope than direct laryngoscope. This result agrees with the findings of Shin et al2 and Xanthos et al3 in manikin studies simulating cardiopulmonary resuscitation. However, in other similar manikin studies, GlideScope?? videolaryngoscope was not superior to direct laryngoscope with r...
We read the article "AP pelvis and frog lateral for a limping child"(1) with some concern for radiation safety. The AP pelvis radiograph at presentation does not show merely slight irregularity of the articular surface as stated in the article, but a reduction of height of 50% of the left femoral capital epiphysis, increased density projected across the growth plate, loss of clarity and contour of the growth plate and la...
COMMENTS ON: "BET 3: Evaluation of intra-aortic balloon support in cardiogenic shock"
Maria Cristina Acconcia(a), MD, Flavia Chiarotti(b), DStat, Francesco Romeo(c), MD, Quintilio Caretta(d*), MD.
(a)Department of Cardiovascular Disease, University of Rome - La Sapienza, Rome, Italy (b)Department of Cell Biology and Neuroscience, Italian National Institute of Health, Rome, Italy (c)Department of Cardio...
I thoroughly enjoyed reading this honest perspective from an experienced colleague. Like most junior doctors, my career to this point has been littered with examples of unpleasant exchanges. As unpleasant as they are, at my level being put in ones place seems to have some value. As an example I remember when the on call general surgical registrar informed me that she was "not the only one in the hospital with effing finger...
I was interested to read the papers by Jobe J and colleagues published in Feb 2014 issue of Emerg Med J.1 The authors aimed to investigate the validity and efficiency of a specific French-language triage system named Echelle Liegeoise d'Index de Severite a l'Admission (ELISA). 1 As the authors pointed out validity was estimated by studying the correlations between the triage ranking assigned by the nurse and actual reso...
We read with interest the PALM consensus statement (1). This is an airway rescue technique for comatose hypoxaemic patients in the pre- hospital environment. The PALM procedure could also apply to the general practitioner (GP) run community hospital environment since the facilities of a metropolitan hospital, specifically rapid sequence induction of anaesthesia (RSI), are not available.
The islands of the west c...
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