I thank the authors for an interesting article.
The article states that none of the other 13 GP co-ops are located on
hospital grounds close to an ED. This is factually incorrect. The North
East Doctor on call service has 2 co-located sites on hospital grounds,
Cavan and Navan. In the case of the Cavan centre the GPs are located in
the hospital building. In Navan, the site is on the hospital grounds. In
both cases, unlik...
I thank the authors for an interesting article.
The article states that none of the other 13 GP co-ops are located on
hospital grounds close to an ED. This is factually incorrect. The North
East Doctor on call service has 2 co-located sites on hospital grounds,
Cavan and Navan. In the case of the Cavan centre the GPs are located in
the hospital building. In Navan, the site is on the hospital grounds. In
both cases, unlike DubDoc, the service extends from 6pm to 8am and both
day and night at weekends and public holidays.
The article draws our attention on the necessity of the correct
procedures during the interhospital transfers, which demand 1) the
stabilization of the patient before the transfer 2) an appropriate
decision of the transfer and communication between referring and receiving
teams 3) an adequate level of care during the critical moment of the
transfer.
Many guidelines of the scientific societies supp...
The article draws our attention on the necessity of the correct
procedures during the interhospital transfers, which demand 1) the
stabilization of the patient before the transfer 2) an appropriate
decision of the transfer and communication between referring and receiving
teams 3) an adequate level of care during the critical moment of the
transfer.
Many guidelines of the scientific societies support these procedures.
Probably, at least in Italy, the problem is not yet perceived in its
complexity.
Exist as well here “guidelines for the clinical-organization criteria of
the transfer of a patient in critical conditions” (A.S.P. – Agenzia di
Sanità Pubblica- Lazio, 2002) which reflect perfectly the ones mentioned
in the article and which are applied only partially.
Our relative experience in the Department of Emergency (D.E.) of the 2nd
level of the Policlinic Umberto 1st in Rome is following: from 1st of
January until June 30th, 2006, 861 accesses to the Emergency unit,
(1,1%, out of 77.597) were transferred from other hospitals to D.E. of
Policlinic.
Out of those 861, 361 (41,92%) were transferred in the critical clinical
conditions of these patients (according to the Kellermann’s criterions):
the transfer was considered appropriate (first criterion of the guidelines
of A.S.P.).
Other 500 patients out of 861 (58,07 %) were transferred in non-critical
clinical conditions, but with the request of consultancy or/and specialist
therapy (eg. neurosurgery, heartsurgery ); the necessity of competence was
confirmed for 230 patients (46%): the transfer was considered appropriate
(second criterion of the A.S.P. guidelines).
The specialist competence was excluded in 270 cases (54%) and the transfer
was considered inappropriate because of the presence of at least one of
following characteristics: the case was not particularly complex or the
resources and competences required for the adequate care were present in
the sending hospital. If the trasfert is inappropriate, it will involve
risk during the transport for the patient and the staff.
These data are an anticipation of our research; the elaboration of all
the data is taking place right now.
I could not resist replying, even though time has passed since
publication, as I will be conducting continuing education based in part on
the classic text, first in the reference list, "Langa's Relative Analgesia
in Dental Practice."
In this text's preface, Langa makes the statement, "The term
'relative analgesia' was introduced by the author many years ago." This
would seem to be a credible...
I could not resist replying, even though time has passed since
publication, as I will be conducting continuing education based in part on
the classic text, first in the reference list, "Langa's Relative Analgesia
in Dental Practice."
In this text's preface, Langa makes the statement, "The term
'relative analgesia' was introduced by the author many years ago." This
would seem to be a credible statement, given the length of time he had
been teaching.
In Chapter 4, section subtitle "The Planes of Analgesia," Langa lists
the four stages of anesthesia and has divided Stage 1 into three planes:
the first two being degrees of Relative Analgesia, and the third being the
plane of Total Analgesia. Langa provides clinical signs to determine
which plane the patient is experiencing.
The reader is warned to avoid the third plane because of its
proximity to Stage 2 of Anesthesia, the Excitement/Delerium Stage. Langa
notes that attempts to maintain Total Analgesia often result in the
patient drifting in-and-out of the Excitement stage, causing undesirable
lapses in patient co-operation.
While individuals vary considerably in their response to varying
concentrations of nitrous oxide, given the doses reported in the original
article, it is likely that many, if not all, of the subjects were, in
fact, quite beyond the stage of Relative Analgesia.
This is not to be critical of the practice described, as the safety
of the technique was amply documented. Apparently it enabled needed
treatment to proceed. It is furthermore likely the procedures performed
did not require patient co-operation, and the patient was not expected to
look forward to experiencing repeated sessions with nitrous oxide,
administered in this manner.
In summary, using Langa's technique and definitions, the procedure
used for the children was probably not equivalent to Relative Analgesia in
its classical sense, as is administered in an outpatient dental setting by
a trained operator. I believe it was within this context, however, that
Langa was speaking, when he originally defined the term.
I do like the last two sentences of the author's reply and would like
to use it verbatim with credit, in my continuing education presentation:
"Nitrous oxide provides analgesia, anxiolysis, and mild amnesia obtained
with maintenance of verbal contact and predominantly intact laryngeal
reflexes. No other single agent does this."
We welcome our Edinburgh colleagues' further contribution1 to the
emergency medicine literature regarding procedural sedation for relocating
hip prostheses. Their work raises a number of points worthy of debate.
The number of patients in their study is unlikely to accurately
determine a relationship between ASA grade and complication rates. This is
particularly so for (meaningful) sentinel adverse events and outc...
We welcome our Edinburgh colleagues' further contribution1 to the
emergency medicine literature regarding procedural sedation for relocating
hip prostheses. Their work raises a number of points worthy of debate.
The number of patients in their study is unlikely to accurately
determine a relationship between ASA grade and complication rates. This is
particularly so for (meaningful) sentinel adverse events and outcomes
since we have demonstrated that these are rare2, occurring in only about
1% of patients sedated with propofol. The notion that ASA grade has no
influence on complication rate defies logic. Since the Edinburgh paper was
submitted, a consensus working party adverse event reporting tool has been
published3 allowing meaningful comparison of data between studies. Dawson
and colleagues' work would be more helpful if re-analysed using these
parameters, rather than (undefined) apnoea (as opposed to apnoea >60s)
and desaturation <90% at any time (as opposed to <75% at any time or
<90% for >60s).
The successful relocation rate of 78% is poor and likely reflects the
limited use of propofol in their study - 87 of 204 patients (30%). Our
work has previously demonstrated success rates of about 95% with this
agent (their references five and six). It is our opinion that a deep level
of sedation is required to enable relocation of a joint on which such
large muscle groups act. Propofol reliably allows this, as indeed does
larger doses of midazolam; it is the short duration of action of the
former that is its key advantage. We applaud their cautious approach to
the sedation of this elderly patient group. An updated version of our
protocol which they quote is available (www.enlightenme.org/); notable
features include the use of nasal capnography and an emphasis on a smaller
(0.5mg/kg) bolus and top- up for this age group.
Refs
1. Dawson N, Dewar A, Gray A, et al. Association between ASA grade
and complication rate in patients receiving procedural sedation for
relocation of dislocated hip prostheses in a UK emergency department.
Emerg Med J 2014;31:207-209
2. Newstead B, Bradburn S, Appelboam A, et al. Propofol for adult
procedural sedation in a UK emergency department: Safety profile in 1008
cases. BJA 2013;111(4):651-5
3. Mason K, Green S, Placevoli, et al. Adverse event reporting tool to
standardize the reporting and tracking of adverse events during procedural
sedation: a consensus document from the World SIVA International Sedations
Task Force. BJA 2012;108(1):13-20
Conflict of Interest:
We have published in this clinical arena in this and another journal.
We read with interest the article by Duncan et al (1) making us aware
about the increasingly common household hazard of contact burns due to
hair straighteners particularly in children. We would also like to share
similar experience in our department of 2 cases who presented with contact
burns from hair straighteners.
Case 1: 18 month old boy with superficial partial thickness burn over
the palmar aspect of his l...
We read with interest the article by Duncan et al (1) making us aware
about the increasingly common household hazard of contact burns due to
hair straighteners particularly in children. We would also like to share
similar experience in our department of 2 cases who presented with contact
burns from hair straighteners.
Case 1: 18 month old boy with superficial partial thickness burn over
the palmar aspect of his left middle finger extending form the proximal
interphalangeal crease till the pulp of the finger.
Case 2: 24 month old boy with superficial partial thickness burns
over the palmar aspect of his left little finger from proximal
interphalangeal crease till middle interphalangeal crease; ring finger
from proximal interphalangeal crease till middle interphalangeal crease
and hypothenar eminence of the same hand measuring 1cm× 1.2cm along with 2
large blisters.
In both the cases the mechanism was accidental contact and
possibility of non-accidental injury was ruled out. Both of the cases were
managed conservatively, the blisters were left intact (2) and the wounds
were covered with chlorhexidine acetate 0.5% (Bactigrass®) dressing. The
burns in both the cases healed spontaneously without any residual
scarring.
We completely agree with the authors that hair straighteners are
becoming increasingly common potential hazard as more and more of such
cases are reported. This preventable cause of childhood morbidity has not
been well recognised. Since these burns are potentially avoidable the
public need to be made aware by education and the manufacturing companies
should compulsorily add a word of caution to “keep away from children” by
legislation.
References:
1) Duncan RA, Waterson S, Beattie TF, Stewart K. Contact burns from
hair straighteners: a new hazard in the home. Emerg. Med. J 2006;23;e21
2) Swain, AH, Azadian, BS, Wakeley, CJ, Shakespeare, PG. Management
of blisters in minor burns; British Medical Journal 1987;295(6591);181
In our practice this vagally-mediated response to sublingual GTN is
not uncommon, and perhaps occurs more frequently in nitrate-naive
patients. Indeed this is the basis for its use in head-up tilt testing,
where it increases the sensitivity of the procedure to induce vaso-vagal
syncope. The traditional attribution of this response to the 'Bezold-
Jarish' reflex is now considered unlikely, although c...
In our practice this vagally-mediated response to sublingual GTN is
not uncommon, and perhaps occurs more frequently in nitrate-naive
patients. Indeed this is the basis for its use in head-up tilt testing,
where it increases the sensitivity of the procedure to induce vaso-vagal
syncope. The traditional attribution of this response to the 'Bezold-
Jarish' reflex is now considered unlikely, although credible alternative
explanations are few! The apparent use of aspirin to treat this patient's
hypertension is also worthy of comment.
We read with interest the article written by Freshwater et. al. (1)
'Extending access to specialist services: the impact of an onsite helipad
and analysis of the first 100 flights' and were very impressed with the
findings and at the outset we would like to congratulate the authors on
this innovative analysis. This paper demonstrates the great impact
retrievals and transfers can have on the referred hospital, however we...
We read with interest the article written by Freshwater et. al. (1)
'Extending access to specialist services: the impact of an onsite helipad
and analysis of the first 100 flights' and were very impressed with the
findings and at the outset we would like to congratulate the authors on
this innovative analysis. This paper demonstrates the great impact
retrievals and transfers can have on the referred hospital, however we
provide some constructive criticism on the article below.
Although this article is a first in investigating the success of a
new helipad at the University Hospital Southampton (UHS), we feel that the
authors have overlooked more updated and recent data on the number of
missions flown annually in the UK. The Association of Air Ambulances'
website, under the document '2013 Framework for A High Performing Air
Ambulance(2)', states that 19 charity air ambulances flew approximately
25500 missions in 2012. This is considerably more than the 19,000 stated
within the article. Following this, additional numbers of charities have
been established, thus we feel that the total figures until the time this
article was published will be far greater. This updated information would
have only strengthened the findings of this study.
On a similar note, regarding 'blue-light' times vs normal speed drive
times, a more recent article by McKeekin et. al. (3) states that whilst
the software used is appropriate to estimate 'blue-light' times from
normal speed drive times (as stated by the authors in the article), more
importantly there needs to be adjustments made in the software to account
for population density, traffic and other factors involved. This again is
more recent evidence than that quoted by the authors in this paper (4)
(5).
Due to the nature of this type of study, the results are quite
subjective because it is human decision whether to send the patient via
air to the hospital. That human is not always the same and changes per
shift, and therefore there may be some times where patients were sent to
UHS or alternative sites when others would not have made that decision.
This can alter the results, and therefore for future studies, it is
important to address this issue to ensure results are as accurate as
possible. We appreciate that the sample size was small because the service
was new, however we would suggest that in future, the data would be more
accurate if a larger sample size is analysed over a greater period, by
comparing with other trauma centres which have helipads. Also it is
important to compare results internationally to better understand the
findings in a national and international context. Finally, a discussion
into the implications on the staff, resources and wards of the hospital
since the introduction of the helipad would be equally important.
Once again, we commend the authors on a brilliant piece of work, and
look forward to reading further articles exploring into this topic
further.
1. Freshwater ES, Dickinson P, Crouch R, Deakin CD, Eynon CA.
Extending access to specialist services: the impact of an onsite helipad
and analysis of the first 100 flights. Emergency Medicine Journal.
2014;31:121-5.
2. Association of Air Ambulances. Framework for A High Performing Air
Ambulance. 2013:9. Available from:
http://www.associationofairambulances.co.uk/resources/events/AOAA-
Framework%202013-OCT13-%20Final%20Document.pdf [Accessed on 13.04.2014]
3. McMeekin P, Gray J, Ford GA, Duckett J, Price CI. A comparison of
actual versus predicted emergency ambulance journey times using generic
Geographic Information System software. 2013;0:1-5.
4. Lerner EB, Billittier AS. Delay in ED arrival resulting from a
remote helipad at a trauma center. Air Med J. 2000;19(4):134-6.
5. Hunt RC, Brown LH, Cabinum ES, Whitley TW, Prasad NH, Owens CF,
Jr., et al. Is ambulance transport time with lights and siren faster than
that without? Ann Emerg Med. 1995;25(4):507-11.
Best BETS are based on specific clinical scenarios and aim to provide
a clinical bottom line which should indicate, in the light of the
evidence, what the clinician would do if faced with the same scenario
again.[1] The article by Sen and Nechani (EMJ 2005;22:887-889) serves to
remind us that unless Best BETS are rigorously conducted their conclusions
may be inappropriate.
Best BETS are based on specific clinical scenarios and aim to provide
a clinical bottom line which should indicate, in the light of the
evidence, what the clinician would do if faced with the same scenario
again.[1] The article by Sen and Nechani (EMJ 2005;22:887-889) serves to
remind us that unless Best BETS are rigorously conducted their conclusions
may be inappropriate.
Sen and Nechani wonder if pre-hospital intubation was of benefit to
the major trauma patient they describe. They conclude that pre-hospital
intubation is associated with increased mortality and imply that this
intervention should not be undertaken.
There are two main problems with this. Firstly, evidence based
medicine is the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients.[2]
Accumulating bad evidence does not make it good. Good evidence answers a
highly specific question and the results are similarly specific to the
circumstances. Sen and Nechani ask a poorly focused question and do not
define the circumstances surrounding pre-hospital intubation in the
studies they review – especially whether anaesthetic drugs were used. Even
a cursory glance at these studies reveals major differences in quality,
study design, patient populations, the experience and training of the
operator, the use of anaesthetic drugs and the operational environment.
The brief conclusion is therefore completely inappropriate.
Secondly, good doctors use individual clinical expertise together
with the best available evidence: neither alone is enough.[2] Sen and
Nechani question whether pre-hospital emergency anaesthesia is indicated
in their patient. Such a question suggests that they do not appreciate the
reality of pre-hospital critical care practice. The decision to
anaesthetise and intubate an unconscious trauma patient is not
controversial.[3] The controversy relates to whether this critical care
intervention can be undertaken competently and safely. Are they really
suggesting that their potentially combative and physiologically
compromised patient should preferentially undergo bag-valve-mask
ventilation with an unsecured airway for a prolonged period (often greater
than half an hour) with no reliable measure of end tidal CO2? Would this
be acceptable in the hospital critical care environment?
The EMJ has a responsibility to ensure that Best BETS are properly
conducted and reviewed. This is not the first time that clinical bottom
lines with major implications have been questionable – perhaps it is time
to review the process again?
References
1. Mackway-Jones, K. Towards evidence based emergency medicine: Best
BETs from the Manchester Royal Infirmary. EMJ 2005;22:887.
2. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-72.
3. Mackenzie R, Lockey DJ. Pre-Hospital Emergency Anaesthesia. J R
Army Med Corps 2004;150:59-71.
The principle of 'primum non nocere' stems from the ancient world of
Plato. In the 'real' world it is immpossible to act without doing harm. An
examination or treatment takes always some time and money from the
patient. Taking time and money is the minimum harm that is done. In many
cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first
sight a better and more realistic...
The principle of 'primum non nocere' stems from the ancient world of
Plato. In the 'real' world it is immpossible to act without doing harm. An
examination or treatment takes always some time and money from the
patient. Taking time and money is the minimum harm that is done. In many
cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first
sight a better and more realistic principle but unfortunately what is
'more good than harm' cannot be easily defined. Indeed, what is considered
as more good than harm differs from individual to individual, from time to
time, from society to society.
A diagnosis is not only a matter of knowing. The more that is known
the more correct diagnoses will be made, but for an individual diagnosis
it is ultimately a decision based on less or more firm knowledge, not on
certainty. Who has the right (or the duty) to decide where uncertainty is
the rule? Perhaps it is (partly) dependent on the circumstances. For many
it will seem to be the first right of the well informed patient since
he/she will suffer from the potential harms or profit from the potential
benefits of the treatment. But even if this principle should be generally
accepted there is often lack of time in urgent situations to inform the
patient or the patient is not in the possibility to understand the
information. Moreover the government and/or insurance companies too will
influence the decision by less or more or no reimbursement for
examinations and treatments.
Since it can be assumed that diagnoses are more often accurate with
increasing knowledge it can perhaps be stated that doing more good than
harm can be defined by the duty of making efforts by the individual as
well as by the society to increase knowlegde.
We were interested to read Dr Oliphant et al’s paper on relocating
temporomandibular joint dislocations (1). In our practice we prefer the
Hippocratic method of reduction, but agree that this can be very worrying
to the clinician as their thumbs are placed directly in line of the bite!
To solve this problem we apply mallet splints to the examiners
thumbs. This acts as thumb protection, a...
We were interested to read Dr Oliphant et al’s paper on relocating
temporomandibular joint dislocations (1). In our practice we prefer the
Hippocratic method of reduction, but agree that this can be very worrying
to the clinician as their thumbs are placed directly in line of the bite!
To solve this problem we apply mallet splints to the examiners
thumbs. This acts as thumb protection, as illustrated in figure 1. Should
the patient bite down following reduction of the dislocation, there is now
a safeguard.
An additional tip is to place tape around the mallet splint,
improving purchase on the teeth and preventing displacement of the splint
into the oropharynx!
We hope this modification will reduce the anxiety associated with the
Hippocratic technique, and perhaps save a few emergency physicians thumbs
in the process!
Yours
Gemma Mullen
ST1 ACCS (EM)
Simon Carley
Consultant in Emergency Medicine
References:
1. R Oliphant, B Key, C Dawson, and D Chung. Bilateral
temporomandibular joint dislocation following pulmonary function testing:
a case report and review of closed reduction techniques. Emerg. Med. J
Jul 2008; 25: 435 - 436.
I thank the authors for an interesting article. The article states that none of the other 13 GP co-ops are located on hospital grounds close to an ED. This is factually incorrect. The North East Doctor on call service has 2 co-located sites on hospital grounds, Cavan and Navan. In the case of the Cavan centre the GPs are located in the hospital building. In Navan, the site is on the hospital grounds. In both cases, unlik...
Dear Editor
The article draws our attention on the necessity of the correct procedures during the interhospital transfers, which demand 1) the stabilization of the patient before the transfer 2) an appropriate decision of the transfer and communication between referring and receiving teams 3) an adequate level of care during the critical moment of the transfer. Many guidelines of the scientific societies supp...
Dear Editor,
I could not resist replying, even though time has passed since publication, as I will be conducting continuing education based in part on the classic text, first in the reference list, "Langa's Relative Analgesia in Dental Practice."
In this text's preface, Langa makes the statement, "The term 'relative analgesia' was introduced by the author many years ago." This would seem to be a credible...
We welcome our Edinburgh colleagues' further contribution1 to the emergency medicine literature regarding procedural sedation for relocating hip prostheses. Their work raises a number of points worthy of debate.
The number of patients in their study is unlikely to accurately determine a relationship between ASA grade and complication rates. This is particularly so for (meaningful) sentinel adverse events and outc...
We read with interest the article by Duncan et al (1) making us aware about the increasingly common household hazard of contact burns due to hair straighteners particularly in children. We would also like to share similar experience in our department of 2 cases who presented with contact burns from hair straighteners.
Case 1: 18 month old boy with superficial partial thickness burn over the palmar aspect of his l...
Dear Editor,
In our practice this vagally-mediated response to sublingual GTN is not uncommon, and perhaps occurs more frequently in nitrate-naive patients. Indeed this is the basis for its use in head-up tilt testing, where it increases the sensitivity of the procedure to induce vaso-vagal syncope. The traditional attribution of this response to the 'Bezold- Jarish' reflex is now considered unlikely, although c...
We read with interest the article written by Freshwater et. al. (1) 'Extending access to specialist services: the impact of an onsite helipad and analysis of the first 100 flights' and were very impressed with the findings and at the outset we would like to congratulate the authors on this innovative analysis. This paper demonstrates the great impact retrievals and transfers can have on the referred hospital, however we...
Dear Editors,
Best BETS are based on specific clinical scenarios and aim to provide a clinical bottom line which should indicate, in the light of the evidence, what the clinician would do if faced with the same scenario again.[1] The article by Sen and Nechani (EMJ 2005;22:887-889) serves to remind us that unless Best BETS are rigorously conducted their conclusions may be inappropriate.
Sen and Nechani wond...
The principle of 'primum non nocere' stems from the ancient world of Plato. In the 'real' world it is immpossible to act without doing harm. An examination or treatment takes always some time and money from the patient. Taking time and money is the minimum harm that is done. In many cases ther is additional harm.
Therefore the principle 'doing more good than harm' seems at first sight a better and more realistic...
Dear Editor,
We were interested to read Dr Oliphant et al’s paper on relocating temporomandibular joint dislocations (1). In our practice we prefer the Hippocratic method of reduction, but agree that this can be very worrying to the clinician as their thumbs are placed directly in line of the bite!
To solve this problem we apply mallet splints to the examiners thumbs. This acts as thumb protection, a...
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