I find it concerning that, as shown by this study, a number of
Consultants believe they are above the law with respect to traffic
offences. I would have liked to think that consultants utilising Green
Beacons would recognise the limitations of their use; both legally and
practically. I would also like to hope that they recognise the danger in
which any 'emergency' driving places members of the pu...
I find it concerning that, as shown by this study, a number of
Consultants believe they are above the law with respect to traffic
offences. I would have liked to think that consultants utilising Green
Beacons would recognise the limitations of their use; both legally and
practically. I would also like to hope that they recognise the danger in
which any 'emergency' driving places members of the public and the driver
in question.
Perhaps many of these Doctors are confusing the use of Green Beacons
with BASICS Doctors who utilise Blue and Green Beacons when responding to
assist the Ambulance Service.
I read with great interest this article. I believe IMA did not add
any benefit over myoglobin in terms of early ruling-out Acute Myocardial
Infarction, as the negative predictive value of myoglobin is about 99% in
the first 1-3 hours. Moreover, both of them are not specific for Acute MI.
Troponins are sensitive in 6-12 hours post symptoms, specific for the
heart, especially cardiac troponin I, but both...
I read with great interest this article. I believe IMA did not add
any benefit over myoglobin in terms of early ruling-out Acute Myocardial
Infarction, as the negative predictive value of myoglobin is about 99% in
the first 1-3 hours. Moreover, both of them are not specific for Acute MI.
Troponins are sensitive in 6-12 hours post symptoms, specific for the
heart, especially cardiac troponin I, but both, troponin I and T, are not
specific for Acute MI.
I believe what we really are in need of is a biomarker that is both
sensitive and specific for Acute MI. Until that time, thorough history
including risk stratification, meticulous physical examination, EKG and
TIMI score for Unstable Angina/Non-ST-Elevation MI, are the pearls we have
to diagnose ACS.
The very fact that the author has written this article at all
demonstrates to me a profound lack of understanding on his part of the
complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of
accidents is not a requirement to provide expert or definitive care - it
is simply a moral duty to provide what help one can given ones own skill
set and available resources. As the...
The very fact that the author has written this article at all
demonstrates to me a profound lack of understanding on his part of the
complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of
accidents is not a requirement to provide expert or definitive care - it
is simply a moral duty to provide what help one can given ones own skill
set and available resources. As the author rightly points out, opening an
airway or stabilising a cervical spine may indeed be life-saving.
Furthermore, the inability to provide expert or definitive
interventions does not reflect inadequacies on the part of medical school
curricula, but more the reality that, without equipment (which no-one
caries with them except BASICS doctors), the best any practitioner (or
student) can offer at the road side is basic life support/ first aid - and
this is already taught in medical schools.
Most importantly of all, there already exists a body of prehospital
care experts who spend on average of three years training to provide
assistance to accident victims - they are called paramedics, and trust me,
they do not appreciate over-enthusiastic medical students/ junior doctors
'helping' them on scene - whether or not their medical school has provided
them with prehospital care training.
Prehospital care is highly specialised, and those that practice
within the speciality have extensive experience within the critical care
domains and (assuming they have the right equipment available) can
sometimes offer the trauma victim an extra survival advantage. Everyone
else should stand well back and let the paramedics do what they do better
than anyone else.
Conflict of Interest:
I am a registrar in retrievals medicine, involving primary and secondary retrievals.
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
Table 1 states decreased ipsilateral expansion found in tension
pneumothorax. This is incorrect. A HYPER-expanded (and hypo-mobile)
ipsilateral hemi-thorax is almost pathognomonic of this condition.
As commercial air travel is moving toward an internet driven consumer
booking system[1] opportunities exist to remind travellers who may require medications to bring them in their carry on luggage and not to pack them.
The first opportunity to do this occurs in the booking process where a
flash
screen reminding potential travellers that they should carry their
medication
could be programmed. If ai...
As commercial air travel is moving toward an internet driven consumer
booking system[1] opportunities exist to remind travellers who may require medications to bring them in their carry on luggage and not to pack them.
The first opportunity to do this occurs in the booking process where a
flash
screen reminding potential travellers that they should carry their
medication
could be programmed. If airlines were sufficently worried about this they
could also include a tick box on the booking screen asking individuals
whether they require medication. This could then be printed on their
eTicket
to remind them to carry the medication. Finally at the ticketless check
ins,
which are becoming more common, the individual traveller could again be
reminded to carry their medications and not to place them in the luggage
when they log in. Not all emergencies can be prevented but at least an IT
solution does exist to prevent those emergencies which arise as a result
of
missing medications.
Airlines are already directing resources towards providing emergency
medical
kits, AEDs, monitors etc.[2,3] Some have access to ground based medical
consultations in flight. Prevention in the first instance through directed
reminders could reduce the need for inflight diversions and ensure a safer
environment for the increasing market of elderly travellers.
References
1. Horvath LL, Murray CK, DuPont HL. Travel health information at
commercial
travel websites. J Travel Med 2003;10(5):272-8.
2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP, 3rd. Inflight
medical
emergencies. Aviat Space Environ Med 2000;71(8):832-8.
3. Rayman RB, Zanick D, Korsgard T. Resources for inflight medical
care. Aviat
Space Environ Med 2004;75(3):278-80.
In Yeovil District Hospital (YDH), o2 alert cards are currently
issued by the respiratory nurse specialist. Patients are usually referred
by a doctor or the ward nurses for a respiratory nurse review to optimise
management of a respiratory disorder and arrange appropriate follow up in
the community. If a patient has a documented episode of type II
respiratory failure the respiratory nurse will issue an o2 alert card as...
In Yeovil District Hospital (YDH), o2 alert cards are currently
issued by the respiratory nurse specialist. Patients are usually referred
by a doctor or the ward nurses for a respiratory nurse review to optimise
management of a respiratory disorder and arrange appropriate follow up in
the community. If a patient has a documented episode of type II
respiratory failure the respiratory nurse will issue an o2 alert card as
recommended by BTS.
A retrospective audit was carried in Yeovil District Hospital in 2013 to
determine if oxygen alert cards are achieving their intended purpose. This
included assessing whether alert cards were issued correctly to at-risk
patients and to review the compliance of oxygen administration in both
ambulances and hospital with BTS guidance. 79 patients were issued o2
alert cards over the 12 month period; 63 notes were available and audited.
The results showed that all patients audited had a documented ABG
confirming an episode of hypercapnoea; the majority of which had a
diagnosis of COPD. Of those 63 patients audited, 19 patients were
readmitted with a total of 38 admissions. Therefore the average number of
re-admissions per patient was 2 (range: 1-5)
During 33 of these episodes the patient was brought to hospital via
ambulance. There were only 2 ( reports of alert cards being shown and
appropriate venturi masks being issued to the ambulance staff. Furthermore
on 76% of episodes, o2 administered in the ambulance was not appropriate
and oxygen saturations exceeded the targeted 88-92%.
On arrival to hospital there were no recordings of any alert cards being
shown to staff and issued with the appropriate venturi mask. On first
saturation measurement whilst in hospital only 29% were within the target
range and in over 50% these were not acted on appropriately.
During the admissions, there were 8 incidents where an ABG was not
preformed. However, in the remaining 30 admission episodes in which an ABG
was preformed, appropriate action and oxygen titration was carried out in
90% of the episodes.
It is clear from this audit that currently, in Yeovil District Hospital,
the o2 alert cards issued to patients are not being used. The audit has
also demonstrated that oxygen administration in both ambulatory services
and hospital setting are not following the current recommendations set by
BTS in regards to the administration of oxygen to patients at risk of
hypercapnoea. Patients are continuing to be inappropriately administered
oxygen and are being put at high risk of the potentially dangerous side-
effects of high-flow oxygen. It appears from the study that in the
majority of patients it is only after an ABG that oxygen administration
levels are appropriately titrated. However, worryingly not all patients
have an ABG on admission.
There are probably a number of reasons why the o2 alert cards are not
currently working. The alert cards are a relatively new scheme in Yeovil
District Hospital and therefore education will play a crucial role for
improving the use of o2 alert cards. Patient and carers will be targeted
as the main source of education and it is hoped that providing them with
BTS leaflets on oxygen administration will increase understanding.
Obviously education of health professionals will also be important to
raise awareness of the scheme and guidelines.
Communication between primary and secondary services is another area that
could possibly develop; one idea is that the home address and ideal oxygen
dose or target saturation ranges of at-risk patients could then be flagged
in the ambulance control systems and communicated to ambulance crews when
required.
A further idea is that the name of the o2 alert cards could be changed to
something which implies a more serious danger hopefully this would
encourage the use by patients similar to the reporting of drug allergies.
I read with interest Moharari et al study and their conclusion that
intra-articular lidocaine produces the same pain relief as intravenous
meperidine and
diazepam and that is a suitable alternative to sedation-analgesia for
closed reduction of anterior shoulder dislocation.
The authors achieved a very high rate of successful reduction with
the traction counter-traction technique by two specifically trained
ope...
I read with interest Moharari et al study and their conclusion that
intra-articular lidocaine produces the same pain relief as intravenous
meperidine and
diazepam and that is a suitable alternative to sedation-analgesia for
closed reduction of anterior shoulder dislocation.
The authors achieved a very high rate of successful reduction with
the traction counter-traction technique by two specifically trained
operators. There were no failures in the 48 patients who had their
dislocations reduced, 24 patients received 25 mg of meperidine and 5 mg of
diazepam and 24 patients received 20 ml of 1% lidocaine intra-articularly.
The administered doses of analgesic in the study seem lower and that
of sedative higher than those that most would normally use. The mean pain
scores before reduction in both groups were 57.9 in the intravenous
sedation-analgesia arm and 52.6 in the intra-articular lidocaine group,
which is suggestive of insufficient analgesia in both groups and over
sedation in the intravenous group, as 5 out of 24 patients had respiratory
depression requiring bag mask ventilation.
Many would use more than one technique and most would administer the
combination of a titrated dose of an intravenous opiate with a smaller
dose of a short acting benzodiazepine such as Midazolam. Propofol with
remifentanil 1 and etomidate alone 2 are recent additions to the multiple
drug combinations available.
There must be very few situations in clinical practice where intra-
articular lidocaine should be considered as first choice. Furthermore, the
majority of those reducing dislocated shoulders do not have sufficient
experience with its use, perhaps because it has failed to convince. Until
more date is made available, intravenous sedation-analgesia in safe and
effective doses should remain the first choice. Familiarity with a
combination of techniques is an important advantage for successful
reduction.
Emergency medicine physicians should become proficient with a number
of techniques and medications in order to quickly and safely reduce
shoulder dislocations.3
References
1. Dunn M, Mitchell R, Souza CD, et al. Evaluation of propofol and
remifentanil for intravenous sedation for reducing shoulder dislocations
in the emergency department. Emerg Med J., 2006; 23(1): 57-58
2. 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
3. Cunningham N J. Techniques for reduction of anteroinferior shoulder
dislocation. Emerg Med Aus., 2005; 17: 463-471
Thank you for your article which I found very interesting. I have
undertaken some work in this area with a colleague of mine from the, now,
South Western Ambulance Service NHS Trust, (Mr. David Halliwell). I was
also asked to advise the National Scaffolding and Access Confederation
(UK)(NASC) on the formulation of a "Rescue Plan" as required under the
Working at Height Regulations. Having researche...
Thank you for your article which I found very interesting. I have
undertaken some work in this area with a colleague of mine from the, now,
South Western Ambulance Service NHS Trust, (Mr. David Halliwell). I was
also asked to advise the National Scaffolding and Access Confederation
(UK)(NASC) on the formulation of a "Rescue Plan" as required under the
Working at Height Regulations. Having researched the HSE texts and advice
that you cite, and also after discussing the anatomy and physiology with
Professor Douglas Chamberlain, I came to a view that the sitting position
being advocated for all casualties was flawed and did not take sufficient
cognisance of the unconscious casualty. I therefore advocated that an
unconscious casualty should be initially managed, if required, in a "head
uppermost" inclined supine position. I further advised that "ABC" and
"BLS" protocols should underpin any training given to staff working in
these envirionments. This is now published as NASC Guideline SG19:06. I
have also urged the HSE to look at producing a laminated "Action Card" to
be used on all sites where such workers may be injured to inform pre-
hospital care providers so that, given the nature of pre-hospital care,
they can take this advice into account when actually on scene.
From a Mountain Rescue Team (MRT) perspective the newly published 2nd
Edition of the Casualty Care in Mountain Rescue manual (August 2006), uses
the term Suspension Induced Shock Syndrome. The manual has a section on
the management and treatment of such a casualty in the MRT envirionment.
They also quote an interesting reference from the Alpine Club of Canada
written by a Dr. Millar - (http://alpineclub-
edm.org/accidents/SuspensionInducedShockSyndrome.htm).
Like you I feel that there is a need for more research in this area.
I also feel that the term Suspension Trauma is a misnomer as actual trauma
may not be present. I prefer the terms Suspension Induced Shock Syndrome,
or Orthostatic Incompetence. I also feel that the design and correct
fitting of harnesses is a crucial factor in this scenario.
I would also add a note of caution for those involved in any form of
"Casualty Care" education / training etc... It is possible to induce these
effects in "willing volunteers" who are acting as patients when they have
been strapped immobile into various lifting & carrying devices, and
not necessarily for long periods of time.
Yours sincerely,
David Whitmore,
Senior Clinical Advisor to the Medical Director
I read, with considerable interest, your case history of a 21 year
old man who was stabbed in his buttock and went on to suffer a
hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting
transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes
of physiology to your Emergency Department his outcome wo...
I read, with considerable interest, your case history of a 21 year
old man who was stabbed in his buttock and went on to suffer a
hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting
transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes
of physiology to your Emergency Department his outcome would have been
worthy of a case report. However, it appears that he presented with no
more than cryptogenic shock (Hb 7.1) at worst (though there is no mention
of a FAST and IVC assessment being carried out) and one might argue that
prompt and aggressive damage control resuscitation with urgent surgery
would have avoided a cardiac arrest, rhabdomyolysis, ionotropic support,
hospital acquired pneumonia and a prolonged ITU stay.
Quite why the patient was moved to the emergency unit ward is not
clear but you do document that after two hours whilst still awaiting
transfusion he arrested and promptly went on to receive a hypothermia
inducing 4 litres of gelofusin to compound his already dysfunctional
clotting mechanism.
His age and physiological reserve saved his life - this phenomenon is
nothing new.
I am stunned that in these days of centralisation of trauma services
post the damning NCEPOD and NAO reports1 2 as well as the emphasis being
placed placed on trauma care nationally, cases such as these still occur
in our Emergency Departments. More concerning is that 'our' journal sees
fit to publish such horrors that would constitute a SUI in many
establishments.
The case highlights that the human body does have the ability to
survive critical physiological insult - it does not mean we should allow
our patients to reach these limits if there is no requirement to do so.
Major HJ Pynn RAMC
ST5 Emergency Medicine
1 Trauma. Who Cares? National Confidential Enquiry into Patient
Outcome and Death 2007.
2 Major Trauma Care in England. National Audit Office. Feb 2010.
Dear Editor,
I find it concerning that, as shown by this study, a number of Consultants believe they are above the law with respect to traffic offences. I would have liked to think that consultants utilising Green Beacons would recognise the limitations of their use; both legally and practically. I would also like to hope that they recognise the danger in which any 'emergency' driving places members of the pu...
Dear Editor,
I read with great interest this article. I believe IMA did not add any benefit over myoglobin in terms of early ruling-out Acute Myocardial Infarction, as the negative predictive value of myoglobin is about 99% in the first 1-3 hours. Moreover, both of them are not specific for Acute MI. Troponins are sensitive in 6-12 hours post symptoms, specific for the heart, especially cardiac troponin I, but both...
The very fact that the author has written this article at all demonstrates to me a profound lack of understanding on his part of the complexities of prehospital care.
Firstly, the obligation mentioned by the GMC to help victims of accidents is not a requirement to provide expert or definitive care - it is simply a moral duty to provide what help one can given ones own skill set and available resources. As the...
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,
Table 1 states decreased ipsilateral expansion found in tension pneumothorax. This is incorrect. A HYPER-expanded (and hypo-mobile) ipsilateral hemi-thorax is almost pathognomonic of this condition.
Dear Editor,
As commercial air travel is moving toward an internet driven consumer booking system[1] opportunities exist to remind travellers who may require medications to bring them in their carry on luggage and not to pack them. The first opportunity to do this occurs in the booking process where a flash screen reminding potential travellers that they should carry their medication could be programmed. If ai...
In Yeovil District Hospital (YDH), o2 alert cards are currently issued by the respiratory nurse specialist. Patients are usually referred by a doctor or the ward nurses for a respiratory nurse review to optimise management of a respiratory disorder and arrange appropriate follow up in the community. If a patient has a documented episode of type II respiratory failure the respiratory nurse will issue an o2 alert card as...
I read with interest Moharari et al study and their conclusion that intra-articular lidocaine produces the same pain relief as intravenous meperidine and diazepam and that is a suitable alternative to sedation-analgesia for closed reduction of anterior shoulder dislocation.
The authors achieved a very high rate of successful reduction with the traction counter-traction technique by two specifically trained ope...
Dear Editor,
Thank you for your article which I found very interesting. I have undertaken some work in this area with a colleague of mine from the, now, South Western Ambulance Service NHS Trust, (Mr. David Halliwell). I was also asked to advise the National Scaffolding and Access Confederation (UK)(NASC) on the formulation of a "Rescue Plan" as required under the Working at Height Regulations. Having researche...
Dear Sirs
I read, with considerable interest, your case history of a 21 year old man who was stabbed in his buttock and went on to suffer a hypovolaemic cardiac arrest whilst on the emergency unit ward awaiting transfusion and exploration of the wound under general anaesthesia.
A pH of 6.61 is undeniably low and had he presented at such extremes of physiology to your Emergency Department his outcome wo...
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