We applaud Newton et al[1] in their efforts developing the Paramedic Pathfinder tools. We feel that supporting paramedics in decision making regarding non-conveyance and use of alternative referral pathways is vital in meeting the challenges facing modern pre-hospital care, and appreciate their efforts in empowering pre-hospital staff to safely make decisions regarding such patients. However we remained unconvinced that protocolis...
We applaud Newton et al[1] in their efforts developing the Paramedic Pathfinder tools. We feel that supporting paramedics in decision making regarding non-conveyance and use of alternative referral pathways is vital in meeting the challenges facing modern pre-hospital care, and appreciate their efforts in empowering pre-hospital staff to safely make decisions regarding such patients. However we remained unconvinced that protocolising the decision making process alone will improve the ability of pre-hospital clinicians to make the best use available resources to provide optimal clinical outcomes.
Protocolising referral decisions is not a new concept. Snooks et al[2] investigated a protocolised approach to patients being diverted to a minor injury unit over the emergency department, and discovered no increase in the number of patients referred to an alternative point of care. Conversley, Mason et al[3] and Gray and Walker[4] identified that paramedics when given extended training in assessment, treatment and diagnostic skills were able to safely reduce attendance at the emergency department, while Clesham et al[5] showed that ambulance staff are able to correctly identify most patients that could be diverted away from the emergency department, without the need for a strict protocolised approach, if sufficient governance is in place to support them in making these decisions.
We commend the safe approach taken by the authors in retrospectively applying the tool to patients seen by North West Ambulance Service staff. However we are concerned that this may not be generalisable to ambulance staff in other areas of the country. Recent performance data[6] demonstrated that as of April 2014 NWAS were the poorest performing Trust in the country for emergency department conveyance and calls closed via telephone triage. We would like to see the Pathfinder tools retrospectively applied to patients seen by pre-hospital clinicians in other areas of the country before stating that they categorically reduce hospital admissions, as the effect of the tools may be weakened - or even detrimental - when applied to Trusts performing stronger against these metrics. Additionally, where the patient had not been conveyed or referred to another agency, there was no follow up in the study to determine if this was a safe and appropriate thing to do. It would seem vital to ensure that the patients that the tool recommends for non-conveyance were not discharged in error.
In attempting to be easily applied by all front-line staff, the tools also fail to account for the grade of clinician making the clinical decision. As already stated, improved training allows paramedics to avoid ED admissions more often[3-5], so it would be important to establish if this triage tool performs equally well for each grade of clinician. One would presume that the sensitivity and specificity of a clinician making the same decision without the tool should increase as their clinical grade becomes more senior, but this increased experience and knowledge risks being over-ridden by the use of a rigid protocol unless some flexibility is built in. Additionally, the tool makes use of the Pre-Hospital Early Warning Score (PHEWS) to filter out patients at risk. As with similar track-and-trigger protocols, this fails to consider patients with baseline "abnormal" physiology, nor does it allow for normal paediatric physiology, despite Paramedic Pathfinder being recommended for use in anyone over the age of five. Strictly applying PHEWS further reduces the clinician's autonomy in deciding what they feel is best for their patient.
Although we welcome the efforts of Newton et al in developing a tool to assist paramedics in making such clinical decisions, we are concerned that the Paramedic Pathfinder tool risks reducing highly trained and experienced pre-hospital professionals to a flowchart, with no scope to take account of a patient's holistic needs or wishes. When providing increased training and skills to front-line staff has been shown to just as effectively reduce ED attendance safely, this paper provides no compelling evidence that increased reliance on rigid and inflexible protocols instead will achieve a better outcome for patients. We feel that Paramedic Pathfinder will become a useful tool in providing clinicians with a safety net when making decisions regarding use of alternative referral pathways, especially when used by less qualified pre-hospital practitioners, but this can only be achieved in concert with improved training and increased clinical autonomy for pre-hospital practitioners, and the tool needs to be validated in a national setting before widespread implementation can be supported.
James Goulding, Paramedic, Yorkshire Ambulance Service NHS Trust.
Dr Nick Plummer, Academic foundation doctor, Lancashire Teaching Hospitals NHS Foundation Trust.
[1] Newton, M., Tunn, E., Moses, I., et al. 2013. Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder. Emerg Med J Published Online First: 7 October 2013.
[2] Snooks, H., Foster, T., et al. 2004. Results of an evaluation of the effectiveness of triage and direct transportation to minor injuries units by ambulance crews. Emerg Med J , 21(1), 105-111
[3] Mason, S., Knowles, E., et al. 2007. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial. Brit Med J, 335(7626), 919.
[4] Gray, J. T. and Walker, A. (2008). Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire. Emerg Med J , 25(3), 168-171.
[5] Clesham K, Mason S, Gray J et al. 2008. Can emergency medical service staff predict the disposition of patients they are transporting? Emerg Med J 25(10): 691-4
[6] AACE (2014) Measuring Patient Outcomes: Clinical Quality Indicators [online at: http://aace.org.uk/national-performance/ accessed 19/06/2014]
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven tha...
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven that nail polish effects the accuracy of pulse oximeters [1]. However, several randomized,
controlled trials with both healthy persons and critically ill patients report on the effect of nail polish on oxygen saturation measured by pulse
oximetry [2, 3, 4]. Interestingly, some of these studies have been cited by the authors themselves.
Sample size calculation prior to beginning of a trial is obligate to determine the significance of results. Unfortunately, in this trial an adequate mathematical sample size calculation was obviously waived.
Therefore, results of the present study cannot be interpreted regarding both the statistical significance and the clinical relevance.
To determine pulse oximetry accuracy, intermittent arterial blood gas analyses (ABGA) are essential [3]. However, accuracy in the present study was only determined by consecutive pulse oximeter measurements over a specific duration, which may alter pulse oximetry readings. A major limitation of the present study is that accuracy is not analyzed in the
present study although it is most important in patients who have nail polish applied, e.g. to identify hypoxia. The authors only report on mean
values (given in percent) but omit to verify their measurements, e.g. with ABGA.
Additionally, the presented results also lack standard deviation
(SD). Independently, one may assume that the presented differences (max. 1,25%) are not clinically relevant, which is in congruency to other publications [2, 3, 4].
In the present trial one may therefore speculate the differences identified might be due to slightly alternating oxygen saturation values in spontaneously breathing persons.
In conclusion, the present study does not add significant new data for nail polish to the present knowledge.
References:
[1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E, Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen saturation determined by pulse oximetry in healthy young adult females. Emerg Med J. 2010 Oct 5. [Epub ahead of print]
[2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail polish on pulse oximetry. Anesth Analg 1988;67:683
[3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007 Jan;72(1):82-91
[4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish affect pulse oximeter readings? Intensive Crit Care Nurs. 2007 Feb;23(1):51-5.
We appreciate Dr Plutarco E Chiquito for his interest and comments
about our recently published study of Intra-articular lidocaine versus
intravenous meperidine/diazepam in anterior shoulder dislocation [1]. This
letter is in response to his comments; however, it should be noted that
not many studies are performed in this field, many of them have similar
methods and limitations, suggesting that further studies are needed....
We appreciate Dr Plutarco E Chiquito for his interest and comments
about our recently published study of Intra-articular lidocaine versus
intravenous meperidine/diazepam in anterior shoulder dislocation [1]. This
letter is in response to his comments; however, it should be noted that
not many studies are performed in this field, many of them have similar
methods and limitations, suggesting that further studies are needed.
Chiquito has indicated that the successful reduction rate in our study is
surprisingly high, referring to his study (unpublished data) that has
reported a lower success rate; it should be noted that our study was
performed in a hospital with a high load of trauma patients admitted in
the center each day, many of which suffer from shoulder dislocations. As a
result, our team has a long experience in performing such procedures.
Chiquito has also suggested in his letter that we have prescribed
subtherapeutic doses of intravenous drugs (25 mg mepiridine, 5 mg
diazepam) in our study, mentioning the high pain scores in the group
receiving this type of sedation. The reason is obvious, the study was
performed in the emergency department setting, where there are not enough
personnel and monitoring devices to take care of the patients in case any
complication develops. Five out of 24 patients receiving intravenous
sedation developed respiratory depression in our study, suggesting that we
should have been prepared for managing complicated cases if we had used
higher doses. In other words, looking after a complicated case in such a
setting would be not only costly and time consuming but also dangerous and
life threatening, which suggests the very dose as an appropriate value for
our emergency setting.
In addition, previous similar studies had also used similar doses compared
to the amount prescribed in our study: The doses prescribed in the study
performed by Matthew et al was 10 mg morphine and 2 mg midazolam [2], and
in the Miller et al’s study was 100 mcg fentanyl and 2 mg midazolam [3].
However, in view of the fact that fixed doses may lead to complications in
certain patients such as elderly individuals with a low cardiac and
respiratory reserve, and pregnant women, particularly in a setting which
lacks necessary therapeutic drug monitoring devices, prescribing such
drugs using weight based doses rather than the fixed ones would be more
appropriate. But none of the previous studies performed in this field nor
our study has used such a system.
Chiquito has also suggested that Etomidate alone is a safe and effective
agent in patients looking forward for the procedure [4]. It should be
noted that despite the fact that the very drug is commonly used for short-
term orthopedic procedures, Etomidate does not have any analgesic
properties.
Chiquito has also recommended that asking the patients upon their pain
during the procedure is a more accurate manner compared to the data
gathered after the procedure similar to what was performed in our study.
His hypothesis is completely true, however, not feasible; traction-counter
traction is a uncomfortable procedure; as a result it is hard to receive
an appropriate answer from the patient during the procedure.
In closing, it should be noted that all the available data [2, 3, 5-10]
indicate the method as an effective alternative in the emergency setting.
References
1. Moharari RS, Khademhosseini P, Espandar R, Asl Soleymani H, Talebian
MT, Khashayar P, et al. Intra-articular lidocaine versus intravenous
meperidine/diazepam in anterior shoulder dislocation: a randomised
clinical trial. Emergency Medicine Journal 2008; 25: 262-4.
2. Matthews DE, Roberts T. Intraarticular lidocaine versus
intravenous analgesic for reduction of acute anterior shoulder
dislocations. A prospective randomized study. American Journal of Sports
Medicine 1995;23:54-8.
3. Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-
articular lidocaine and intravenous sedation for reduction of shoulder
dislocations: a randomized prospective study. Journal of Bone and Joint
Surgery (American) 2002; 84-A: 2135-9.
4. Burton JH, Bock AJ, Strout TD, et al. Etomidate and midazolam for
reduction of anterior shoulder dislocation: a randomized controlled trial.
Ann Emerg Med 2002; 40: 496-504.
5. Kosnik J, Shamsa F, Raphael E, Huang R, Malachias Z, Georgiadis
GM. Anesthetic methods for reduction of acute shoulder dislocations: a
prospective randomized study comparing intraarticular lidocaine with
intravenous analgesia and sedation. American Journal of Emergency Medicine
1999;17:566-70.
6. Orlinsky M, Shon S, Chiang C, Chan L, Carter P. Comparative study
of intra-articular lidocaine and intravenous meperidine/diazepam for
shoulder dislocations. Journal of Emergency Medicine 2002;22:241- 5.
7. Paudel K, Pradhan RL, Rijal KP. Reduction of acute anterior
shoulder dislocations under local anaesthesia - a prospective study.
Kathmandu University Medical Journal 2004;2:13-7.
8. Pradhan RL, Lakhey S, Pandey BK, Rijal KP. Reduction of acute
anterior shoulder dislocations: comparing intra- articular lignocaine with
intravenous analgesia. Journal of the Nepal Medical Association 2006; 45:
223- 7.
9. Suder PA, Mikkelsen JB, Hougaard K, Jensen PE. Reduction of
traumatic secondary dislocations with lidocaine. Archives of Orthopaedic
and Trauma Surgery 1995; 114: 233-6.
10. Suder PA, Mikkelsen JB, Hougaard K, Jensen PE. Reduction of
traumatic primary anterior shoulder dislocation under local analgesia.
Ugeskrift-for-laeger 1995; 157: 3625-9.
Hunter and colleagues gives a good method to distinguish COPD and
heart failure in a dyspnoeic patient. May i politely suggest an easier,
clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent,
bulging veins has COPD as the predominant cause for the breathlessness
compared to the patient with heart failure who has collapsed, thready
veins. The therapy...
Hunter and colleagues gives a good method to distinguish COPD and
heart failure in a dyspnoeic patient. May i politely suggest an easier,
clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent,
bulging veins has COPD as the predominant cause for the breathlessness
compared to the patient with heart failure who has collapsed, thready
veins. The therapy can be directed accordingly and early benefits achieved
using this clinical marker of distinction. Of course, this venous
distension could reflect higher CO2 levels in the COPD patients. As a
junior doctor, i found it much easier to cannulate these patients in
emergency department compared to the congestive heart failure patients
where cannulation was much more difficult.
So, the quick clue for the acute on chronic breathless patient is
bulging veins = worsening COPD, thready veins = worsening heart failure
We have read the original contribution by Sutcu Cicek et al. [1] with
high interest regarding the effect of nail polish and henna on pulse
oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is
interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not pro...
We have read the original contribution by Sutcu Cicek et al. [1] with
high interest regarding the effect of nail polish and henna on pulse
oximetry readings. In their study, these authors report on the influence
of both factors in 33 normoxic healthy females. Although the study is
interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven that nail polish
effects the accuracy of pulse oximeters [1]. However, several randomized,
controlled trials with both healthy persons and critically ill patients
report on the effect of nail polish on oxygen saturation measured by pulse
oximetry [2, 3, 4]. Interestingly, some of these studies have been cited
by the authors themselves.
Sample size calculation prior to beginning of a trial is obligate to
determine the significance of results. Unfortunately, in this trial an
adequate mathematical sample size calculation was obviously waived.
Therefore, results of the present study cannot be interpreted regarding
both the statistical significance and the clinical relevance.
To determine pulse oximetry accuracy, intermittent arterial blood gas
analyses (ABGA) are essential [3]. However, accuracy in the present study
was only determined by consecutive pulse oximeter measurements over a
specific duration, which may alter pulse oximetry readings. A major
limitation of the present study is that accuracy is not analyzed in the
present study although it is most important in patients who have nail
polish applied, e.g. to identify hypoxia. The authors only report on mean
values (given in percent) but omit to verify their measurements, e.g. with
ABGA. Additionally, the presented results also lack standard deviation
(SD). Independently, one may assume that the presented differences (max.
1,25%) are not clinically relevant, which is in congruency to other
publications [2, 3, 4].
In the present trial one may therefore speculate the differences
identified might be due to slightly alternating oxygen saturation values
in spontaneously breathing persons.
In conclusion, the present study does not add significant new data for
nail polish to the present knowledge.
References:
[1] Sutcu Cicek H, Gumus S, Deniz O, Yildiz S, Acikel CH, Cakir E,
Tozkoparan E, Ucar E, Bilgic H. Effect of nail polish and henna on oxygen
saturation determined by pulse oximetry in healthy young adult females.
Emerg Med J. 2010 Oct 5. [Epub ahead of print]
[2] Cote CJ, Goldstein EA, Fuchsman WH, et al. The effect of nail
polish on pulse oximetry. Anesth Analg 1988;67:683
[3] Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail
polish on oxygen saturation determined by pulse oximetry in critically ill
patients. Resuscitation. 2007 Jan;72(1):82-91
[4] Rodden AM, Spicer L, Diaz VA, Steyer TE. Does fingernail polish
affect pulse oximeter readings? Intensive Crit Care Nurs. 2007
Feb;23(1):51-5.
We commend Dr. Baskerville for highlighted the important issue of
ionising radiation dose in the trauma patient population. The detail of
his commentary, however, could lead to a great deal of confusion. It seems
that the decision to use milligray in this commentary has been one of
expediency and not necessarily accuracy. Dr. Baskerville talks of the
average radiation exposure of his trauma patients, but then quotes a uni...
We commend Dr. Baskerville for highlighted the important issue of
ionising radiation dose in the trauma patient population. The detail of
his commentary, however, could lead to a great deal of confusion. It seems
that the decision to use milligray in this commentary has been one of
expediency and not necessarily accuracy. Dr. Baskerville talks of the
average radiation exposure of his trauma patients, but then quotes a unit
that represents maximal tissue absorption of the radiation that the body
is exposed to. To explain, a CT head dose of 70.42 mGy may well be true
for the dose absorbed by the cornea (if the eyes are within the CT beam),
but will not represent the average dose absorbed by the patients entire
head. That same CT head represents an ionising radiation exposure of
approximately 3 milli sievert (mSv). This is the amount of radiation
generated by the CT scanner. To quote an equivalence for mSv and mGy is
erroneus if there are tissues present in the beam that are more sensitive
to ionising radiation.
I read this work with interest ..indeed CT examination can determine
contrast material leakage to the lesser sac and different peritoneal
spaces ,but ultrasonography with proper oral contrast can do the same .
gstrosonography is indicated for several reasons . gastric masses, gastric
polyps, reduced gastric capacity , wall thickening ,gastroesophegeal
reflux ,gastrodudenal reflux and gastric perfor...
I read this work with interest ..indeed CT examination can determine
contrast material leakage to the lesser sac and different peritoneal
spaces ,but ultrasonography with proper oral contrast can do the same .
gstrosonography is indicated for several reasons . gastric masses, gastric
polyps, reduced gastric capacity , wall thickening ,gastroesophegeal
reflux ,gastrodudenal reflux and gastric perforation, all can be seen with
careful examination . with use of a gelatian as an oral contrast material
all gastric wall layers can easily seen . the gelatin can be prepared
from the gelatin capsules[ e.g. antibiotic capsules after their evacuation
] by boiling one of them in the water or from a hard gelatin used for
sweet production . a few drops aided to the water can produce a
hyperechoic fluid in its early phase . by rapid examination of the
traumatized patient any gastric leakage can be detected by seeing the
hyperechoic material out side the stomach . the late phase of the contrast
is hypoechoic in nature . pancreas is easily seen by using the full
stomach as a window pancras {head-body-tail - ] splenic hilum ,left renal
vein and artery all can be examined . gelatin is not harmful as we
already use it as a drug or food ,easily prepared , stored even at room
temperature, cheap and has two phases of echogenisty and long acting
[its action lasts for 25 minutes at least ]
Atkinson et al.[1] in their paper highlighted how catheterisation of
central
venous system for vascular access is an essential skill for emergency
physicians. Clinician inexperience has been identified as being associated with a higher number of complications.[2]
Mansfield did not find that ultrasound usage in his study group,
patients
requiring chemotherapy, was beneficial. Miller[3] howev...
Atkinson et al.[1] in their paper highlighted how catheterisation of
central
venous system for vascular access is an essential skill for emergency
physicians. Clinician inexperience has been identified as being associated with a higher number of complications.[2]
Mansfield did not find that ultrasound usage in his study group,
patients
requiring chemotherapy, was beneficial. Miller[3] however showed that
ultrasound usage resulted in a shorter time from skin puncture to blood
flash, a significant reduction in the number of attempts required to
secure
access and reduction in time to line placement. All laudable goals in an
emergency department environment where time is a precious commodity.
Miller achieved these results with a short intense 1 hour training
session for
both residents and faculty. As the number of such procedures performed by
an individual emergency physician in the UK or Ireland are likely to be
low
skill maintenance has rightly been higlighted as being important. Atkinson
suggests that teaching the technique to other staff may help in this
regard.
Rosenberg[4] identified that ‘video game aptitude appears to predict the level of laparoscopic skill in the novice surgeon’. Hand eye coordination or
visual-spatial skills are also required for the technique of ultrasound guided
vascular
access. Could it be possible that there is some benefit to being a member
of
the ‘playstation generation’ with respect to development of visual-spatial skills compelementary to medical practice?
One other method of skill retention could be to utilise ultrasound for difficult peripheral access intermittently to maintain familiarity with kit, machine
and
the visual spatial skills required. Abboud[5] suggests that the general
application of ultrasound guidance for venous access in the ED has reached a
critical mass and the recent focus on patient safety and clinical outcomes
has
lead to increased attention being given to use of ultrasound in the
emergency
department. Even at a cost of £15,000 per ED and the requirements for
ongoing training and certification it would appear as if the time of
ultrasound
has come for the emergency physician
References
1. Atkinson P, Boyle A, Robinson S, Campbell-Hewson G. Should
ultrasound
guidance be used for central venous catheterisation in the emergency
department? Emerg Med J 2005;22(3):158-64.
2. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM.
Complications
and failures of subclavian-vein catheterization. N Engl J Med
1994;331(26):
1735-8.
3. Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B.
Ultrasound
guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002;9(8):800-5.
4. Rosenberg BH, Landsittel D, Averch TD. Can video games be used to
predict or improve laparoscopic skills? J Endourol 2005;19(3):372-6.
5. Abboud PA, Kendall JL. Ultrasound guidance for vascular access.
Emerg
Med Clin North Am 2004;22(3):749-73.
McGregor et al. (1) posed the question “What is the
difference…between monkshood and wolfsbane?”, but looked to a work of
fiction for the answer, rather than a botanical text. Monkshood is a
common name for Aconitum napellus, which is native to the UK, and has blue
-mauve flowers. Wolfsbane, or wolf’s bane, refers to A. lycoctonum, a
yellow-flowered species from continental Europe through to Western Asia.
T...
McGregor et al. (1) posed the question “What is the
difference…between monkshood and wolfsbane?”, but looked to a work of
fiction for the answer, rather than a botanical text. Monkshood is a
common name for Aconitum napellus, which is native to the UK, and has blue
-mauve flowers. Wolfsbane, or wolf’s bane, refers to A. lycoctonum, a
yellow-flowered species from continental Europe through to Western Asia.
The images in the article were taken from TOXBASE, which has permission to
use this copyright material. They originally came from the CD-ROM
identification system produced jointly by Royal Botanic Gardens Kew and
Guy’s Poisons Unit(2). If the CD-ROM itself had been consulted the
confusion over the common names would have been avoided. Also note that
although the left image is of A. napellus, the right is of A. carmichaelii
‘Kelmscott’. TOXBASE includes information for all species of Aconitum
under the name of a single species, A. napellus, without any
differentiation.
In Chinese medicine the potential toxicity of species such as
Aconitum carmichaelii and A. kusnezoffi is well understood so the roots
are processed to hydrolyse and detoxify the aconitine alkaloids before
oral therapeutic use. We have also found that cases of poisoning tend to
result from incorrect preparation or use of the root(3). In contrast to
Hong Kong, in the UK, medicinal use of Aconitum species is restricted by
Statutory Instrument 2130(1977) so incidents of poisoning are rare. In the
15 years that we have been investigating and monitoring adverse effects
from herbal medicine, we are aware of 3 cases of possible Aconitum
poisoning in the UK. Health professionals who are concerned about Chinese
herbs and require advice on use or safety can contact us for specialist
information, by email chimas@gstt.nhs.uk or phone 0207 771 5157.
(1) McGregor AC, MacMillian MH, Ferguson J. Potter’s Potions Emerg
Med J 2008;25:217-218
(2) Dauncey E (ed.) Poisonous Plants and Fungi in Britain and Ireland.
Interactive identification systems on CD-ROM. Royal Botanic Gardens, Kew
and Medical Toxicology Unit, Guy’s & St Thomas’ Hospital Trust, 2000.
(3) Shaw D, Leon C, Kolev S et al. Traditional Remedies and Food
Supplements – a 5 year toxicological study. Drug Safety 1997;17(5):342-
356
Much has been written about the current difficulties of recruiting
and retaining doctors in key specialities: most recently psychiatry (1)
and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of
doctors choosing to enter speciality training immediately upon finishing
their FY2 year: in 2013 only 64% of FY2's chose to enter speciality
training (3). Instead, many FY2's opt...
Much has been written about the current difficulties of recruiting
and retaining doctors in key specialities: most recently psychiatry (1)
and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of
doctors choosing to enter speciality training immediately upon finishing
their FY2 year: in 2013 only 64% of FY2's chose to enter speciality
training (3). Instead, many FY2's opt to work abroad, or to take trust
grade positions.
Currently, going "off-program" allows junior doctors the flexibility
to develop their own skills and interests, in a way that rigidly
structured training programs don't. It gives them a chance to take
ownership of their own training, and to see their personal and
professional development as their own responsibility, rather than an
exercise in "hoop-jumping". They have a chance to work abroad, pursue
additional qualifications or research, and to choose where they live and
how many hours they work. They can choose to work in specialities that
they didn't get to experience during the foundation program.
As a "sessional" speciality which requires a broad portfolio of
skills, and doesn't require continuity of care, emergency medicine could
capitalise on juniors doctors' apparent desire to have greater flexibility
and freedom in their training: trainees could be offered "half-time"
contracts, which would leave them 6 months a year free to pursue other
interests, degrees, or specialities.
Similarly, a more permissive approach to offering sabbaticals, and a
greater variety of less-than-full-time-training rotas would offer FY2's
the best of both worlds: the flexibility associated with trust-grade work,
and the support and development opportunities afforded by training jobs.
Emergency departments would benefit from having committed doctors on full-
time contracts, who would be guaranteed to return the following year to
continue training.
Svirko et al identified that one of the key factors repelling
trainees from emergency medicine is the perceived lack of a "work-life-
balance" (2): emergency departments can improve this by offering a wider
variety of training contracts, to suit the different lifestyles and
interests of the diverse group of doctors who are drawn to the emergency
department.
(1) Mukherjee, Psychiatric Bulletin (2013) 37: 210-214
(2) Svirko, Lambert et al Emerg. Med. J. 2014 31:556-561
(3) Foundation Programme Annual Report
http://www.foundationprogramme.nhs.uk/pages/home/keydocs
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed.
To our surprise, the authors state, it is not proven tha...
We appreciate Dr Plutarco E Chiquito for his interest and comments about our recently published study of Intra-articular lidocaine versus intravenous meperidine/diazepam in anterior shoulder dislocation [1]. This letter is in response to his comments; however, it should be noted that not many studies are performed in this field, many of them have similar methods and limitations, suggesting that further studies are needed....
Hunter and colleagues gives a good method to distinguish COPD and heart failure in a dyspnoeic patient. May i politely suggest an easier, clinical marker which can help in this distinction?
This is based on the observation that patient who has prominent, bulging veins has COPD as the predominant cause for the breathlessness compared to the patient with heart failure who has collapsed, thready veins. The therapy...
To the Editor!
We have read the original contribution by Sutcu Cicek et al. [1] with high interest regarding the effect of nail polish and henna on pulse oximetry readings. In their study, these authors report on the influence of both factors in 33 normoxic healthy females. Although the study is interesting, it has significant limitations, which must be addressed. To our surprise, the authors state, it is not pro...
We commend Dr. Baskerville for highlighted the important issue of ionising radiation dose in the trauma patient population. The detail of his commentary, however, could lead to a great deal of confusion. It seems that the decision to use milligray in this commentary has been one of expediency and not necessarily accuracy. Dr. Baskerville talks of the average radiation exposure of his trauma patients, but then quotes a uni...
Dear Editor
I read this work with interest ..indeed CT examination can determine contrast material leakage to the lesser sac and different peritoneal spaces ,but ultrasonography with proper oral contrast can do the same . gstrosonography is indicated for several reasons . gastric masses, gastric polyps, reduced gastric capacity , wall thickening ,gastroesophegeal reflux ,gastrodudenal reflux and gastric perfor...
Dear Editor,
Atkinson et al.[1] in their paper highlighted how catheterisation of central venous system for vascular access is an essential skill for emergency physicians. Clinician inexperience has been identified as being associated with a higher number of complications.[2]
Mansfield did not find that ultrasound usage in his study group, patients requiring chemotherapy, was beneficial. Miller[3] howev...
McGregor et al. (1) posed the question “What is the difference…between monkshood and wolfsbane?”, but looked to a work of fiction for the answer, rather than a botanical text. Monkshood is a common name for Aconitum napellus, which is native to the UK, and has blue -mauve flowers. Wolfsbane, or wolf’s bane, refers to A. lycoctonum, a yellow-flowered species from continental Europe through to Western Asia. T...
Much has been written about the current difficulties of recruiting and retaining doctors in key specialities: most recently psychiatry (1) and emergency medicine (2).
Concurrently there has been a year-on-year decline in the number of doctors choosing to enter speciality training immediately upon finishing their FY2 year: in 2013 only 64% of FY2's chose to enter speciality training (3). Instead, many FY2's opt...
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