I am an avid reader of your Best Evidence Topic reports (BETS)
section. In your November issue I was particularly interested to read the
BET by Andrew Munroe on skull fractures and intracranial injury –
particularly as I had recently presented a BET on the same subject in
October.
There were several striking differences between my BET and the one
published in November. In particular I fin...
I am an avid reader of your Best Evidence Topic reports (BETS)
section. In your November issue I was particularly interested to read the
BET by Andrew Munroe on skull fractures and intracranial injury –
particularly as I had recently presented a BET on the same subject in
October.
There were several striking differences between my BET and the one
published in November. In particular I find the inclusion of the studies
by Wang et al and Dietrich et al surprising for the following reasons: In
the Wang study plain radiographs were not used (a fact acknowledged in
Munroe’s BET). This study therefore has little relevance to the original
scenario in which the child has no fracture seen on plain films. In the
Dietrich study the incidence of intracranial injury with (or without)
skull fracture visible on plain x-ray (as opposed to being visible on CT
scan) was not given (again acknowledged in Munroe’s BET). Without these
figures it is difficult to see the relevance of the paper on the original
question/scenario.
I also found it surprising that studies by Teasdale et al [1], Masters
et al [2] (both prospective); Mandera et al [3] and Gruskin et al [4] (both
retrospective) were not included in the final analysis. Whilst I recognise
that prospective studies represent a more reliable study design I do not
feel that retrospective studies should have automatically be excluded from
analysis as appears to have happened with this BET.
The differences between Munroe’s BET and my BET call into sharp focus
the issue of what constitutes a paper which is “irrelevant or of
insufficient quality to include”. I do not wish to denigrate what appears
to have been a genuine effort to answer a exceedingly complicated clinical
question and I am in complete agreement with the author’s conclusions. It
is also of note that Munroe’s BET included a relevant paper which I had
missed in my literature search. I fully acknowledge that my own BET could
well have similar criticisms levelled at its search strategy and paper
selection. I do, however wish to point out that in using similar methods
(although a different search strategy) to answer the same clinical
question I selected several different papers. I, therefore, believe that
my experience illustrates that there is a subjective element to BETS that
I was previously unaware of. It is important that readers are aware that
there is a potential for this to bias the conclusions reached. I do,
therefore, caution readers against the automatic acceptance of the
conclusions (or clinical bottom line) of the published BETS – particularly
in complicated questions with many papers revealed by the search strategy.
My experience has shown that authors investigating the same question could
select different papers as being relevant to the “best evidence” – which
might lead to different conclusions.
Yours Sincerely,
David Geggie
References
(1) Teasdale G, Murray G, Anderson E et al. Risks of acute intracranial haematoma in children and adults: implications for managing head injuries. BMJ. 1990; 300: 363-367
(2) Masters SJ, McClean PM, Arcares JS et al. Skull X-Ray Examinations after head trauma. Recommendations by a multidisciplinary panel and validation study. N Eng J Med 1987;316:84-91
(3) Mandera M, Wencel T, Bazowski P, Krauze J. How should we manage children after mild head injury. Childs Nervous System.16(3):156-60,2000 Mar
(4) Gruskin KD, Schutzman SA. Head trauma in children younger than 2 years: are there predictors for complications? Arch of pediatrics and Adolescent Medicine. 153(1):15-20 1999 Jan
I was interested to read the published article
concerning the use of IV magnesium in refractory VF
[1]. However I am puzzled about the possible inclusion
of episodes of torsades de point in the VF study
group. The differentiation of torsades from VF in an
ambulance must be extremely difficult and the text
does not elucidate on the accuracy of monitor reading.
Neither is mention made of any verification system for...
I was interested to read the published article
concerning the use of IV magnesium in refractory VF
[1]. However I am puzzled about the possible inclusion
of episodes of torsades de point in the VF study
group. The differentiation of torsades from VF in an
ambulance must be extremely difficult and the text
does not elucidate on the accuracy of monitor reading.
Neither is mention made of any verification system for
the monitor diagnosis of VF. Given that magnesium is
an established treatment, although without definitive
level 1 evidence [2], for torsades is this study not
in danger of becoming an underpowered study evaluating
the effectiveness of magnesium in torsades de pointes.
Russell Boyd
References
(1)Hassan TB, Jagger C, Barnett DB. A randomised trial
to investigate the efficacy of magnesium sulphate for
refractory ventricular fibrillation Emerg Med J
2002;19:57-62
(2)Guidelines 2000 for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care. Circulation 2000;
102(8) supplement : p112-128
In their best evidence report, Yuen et al conclude that the Ottawa
Ankle Rules will become applicable to pre-school children [1]. From the
studies mentioned it is indeed likely that they will become a useful
addition to the clinician’s diagnostic armamentarium for ankle injury in
this age group.
It is of note however, that despite positive Ottawa Ankle Rules,
subsequent ankle radiographs...
In their best evidence report, Yuen et al conclude that the Ottawa
Ankle Rules will become applicable to pre-school children [1]. From the
studies mentioned it is indeed likely that they will become a useful
addition to the clinician’s diagnostic armamentarium for ankle injury in
this age group.
It is of note however, that despite positive Ottawa Ankle Rules,
subsequent ankle radiographs may frequently appear normal in young
children [2]. An actual bony injury may be present in a proportion of such
cases, and only be discernable after careful scrutiny, or after more
detailed imaging. In Stuart’s study of a cohort of children with
radiograph-negative inversion ankle injuries, 50% were found to have
direct evidence of growth plate injury on subsequent magnetic resonance
imaging [3].
Positive Ottawa Ankle Rules with apparently normal ankle radiographs
in the young patient can pose a management dilemma for junior Accident and
Emergency staff. In these cases, the clinician should still retain a high
index of suspicion for the presence of a growth plate injury, and seek
more experienced advice.
References (1) Yuen M, Saunders F. The Ottawa ankle rules in children. Emergency
Medicine Journal: Best evidence topic reports. 2001: 18: 466-467.
(2) Singh-Ranger G, Marathias A. Comparison of current local practice
and the Ottawa Ankle Rules to determine the need for radiography in acute
ankle injury. Accident and Emergency Nursing 1999: 7: 201-206.
(3) Stuart J, Boyd R, Derbyshire S, Wilson B, Phillips B. Magnetic
resonance assessment of inversion ankle injuries in children. Injury 1998:
29 (1): 29-30
I performed a similar literature search two years ago and came to the
same conclusion that in the semi-elective setting (rather than time
critical emergencies) the use of local anaesthetic with an appropriately
small needle should make the procedure less painful and no more difficult
– particularly relevant in COPD and asthma when patients may be subjected
to multiple punctures during an admission. I fo...
I performed a similar literature search two years ago and came to the
same conclusion that in the semi-elective setting (rather than time
critical emergencies) the use of local anaesthetic with an appropriately
small needle should make the procedure less painful and no more difficult
– particularly relevant in COPD and asthma when patients may be subjected
to multiple punctures during an admission. I followed this up with a
pigeon-hole survey of the practice of the junior doctors in my hospital at
the time. The results were as follows:
12 responded
9 never used local
3 did sometimes
nobody used it ‘most of the time’ or ‘always’
Of those who did two based its use on their personal experience of
benefit and one on the recommendation of another doctor. None had looked
at the (limited) evidence.
Of those who did not use it one claimed it didn’t work in their
experience, five felt the need for two punctures made it more painful,
eleven said it took too long to use local and 3 said they had never
considered it (because of time and needing two punctures). One claimed it
made the procedure harder.
I think this is a good example of a procedure that would benefit
greatly from the use of needle-less injection technology, juniors could
carry their own “pen” of local for use at all cannulations or ABG
sampling. This would require validating in the first instance and would
not be cheap but may make a significant impact on the patients’ perception
of their hospital visit.
I was interested to read the article on the effect of
separate streaming for minor injuries by Cooke et al as
we have recently introduced a similar system with
similar results. In our department all ambulatory
attendees are seen on arrival by a doctor and a nurse
or a nurse and a nurse practitioner together. Patients
who need simple advise or treatment are seen, treated
and discharged from two room...
I was interested to read the article on the effect of
separate streaming for minor injuries by Cooke et al as
we have recently introduced a similar system with
similar results. In our department all ambulatory
attendees are seen on arrival by a doctor and a nurse
or a nurse and a nurse practitioner together. Patients
who need simple advise or treatment are seen, treated
and discharged from two rooms off the waiting area.
Patients in need of more complex or lengthy treatment
are triaged in the normal manner and taken to a cubicle
in the main area of the department or asked to wait in
the waiting area.
We have carried out a pilot study for one month initially
using both senior medical staff and Senior House
Officers with no recordable detriment to the waiting
times of triage 1-3 category patients and no additional
staff. The percentage of patients treated within one hour
has risen from 55% to 72%. These figures include all
medical and surgical patients waiting in the department
who have been referred by their general practitioners.
Unfortunately , we were not able to staff the project for
more than 10 hours per day and not all weekends.
However we have been so encouraged by our initial
results that we hope to provide a more comprehensive
service in the near future with the addition of a further
nurse practitioner and a staff grade doctor.
I read with interest Kerr et al’s highly informative article,
Tricyclic antidepressant overdose: a review.[1] However, I would like to
highlight an important point which the authors have not mentioned. In
cases of mixed overdose, of tricyclic antidepressants and benzodiazepines,
flumazenil (Anexate) is contraindicated. It has produced convulsions and
ventricular arrhythmias in the presence of tricyclics....
I read with interest Kerr et al’s highly informative article,
Tricyclic antidepressant overdose: a review.[1] However, I would like to
highlight an important point which the authors have not mentioned. In
cases of mixed overdose, of tricyclic antidepressants and benzodiazepines,
flumazenil (Anexate) is contraindicated. It has produced convulsions and
ventricular arrhythmias in the presence of tricyclics.[2] The mechanism
for this interaction is thought to be unmasking of tricyclic
antidepressant-induced seizures as a consequence of flumazenil
antagonising the anti-epileptic effect of concomitantly ingested
benzodiazepines.[3] This interaction has resulted in a number of
deaths.[2,3]
In patients presenting following overdose, it is not always easy to
obtain a clear and accurate history regarding what substances have been
ingested. The administration of flumazenil as a diagnostic aid in these
patients is potentially dangerous and should be avoided, particularly if
Tricyclic antidepressants have been taken.
References
(1) Kerr GW, McGuffie AC, Wilkie S. Tricyclic
antidepressant overdose: a review. Emerg Med J 2001;18:236-241.
(2) Burr W, Sandham P, Judd A. Death after Flumazenil. BMJ 1989;298:1713.
(3) Haverkos GP, DiSalvo RP, Imhoff TE. Fatal seizure after Flumazenil
administration in a patient with mixed overdose. Ann Pharmacother
1994;28:1347-9.
Kerr et al[1] point out in their review that despite the introduction
of newer antidepressant agents in recent years, a large number of
prescriptions for tricyclic antidepressants are still issued. Data from
our unit suggests that overdose with selective serotonin re-uptake
inhibitors (SSRIs) has now become more common than with tricyclic
antidepressants. Despite this, there were 4981 accesses to i...
Kerr et al[1] point out in their review that despite the introduction
of newer antidepressant agents in recent years, a large number of
prescriptions for tricyclic antidepressants are still issued. Data from
our unit suggests that overdose with selective serotonin re-uptake
inhibitors (SSRIs) has now become more common than with tricyclic
antidepressants. Despite this, there were 4981 accesses to information on
dothiepin or amitriptyline on TOXBASE last year, suggesting that tricyclic
poisoning remains a substantial problem. [2]
The authors also suggest that advice given from National Poisons
Information Service (NPIS) centres may differ. TOXBASE, the clinical
toxicology database of the UK NPIS, provides information on drug toxicity
and advice on clinical management after overdose. It is the recommended
first point of access to poisons information by all centres of the NPIS
and has been available on the internet since August 1999.[3] All new drug
entries, and revisions of existing entries, are circulated to the
directors of all the NPIS centres for comments before going live on the
system. In many cases there is a paucity of evidence on which to base
treatment and in these cases the advice given is based on consensus of the
NPIS centre directors. Evidence-based treatment is clearly referenced in
recent entries.
In complicated or difficult cases, advice beyond that given on
TOXBASE may be required and discussion with an NPIS centre is encouraged.
We hope the more widespread use of TOXBASE on the internet will
standardise the advice given. We also anticipate that the introduction of
a single telephone number for enquiries, 0870 6006266, which will route the
caller to the nearest NPIS centre will reduce any confusion, which in the
past has been caused by clinicians ringing different centres about the
same case. The inevitable differences in emphasis given by callers will
affect advice received. We continue to encourage calls about unusual or
complex cases, particularly multiple ingestions of potentially toxic
amounts. If there appears to be inconsistent advice from TOXBASE and an
NPIS centre, we encourage discussion with us (spib@luht.scot.nhs.uk) so
that the matter can be brought to the attention of the NPIS directors.
References
(1) Kerr GW, McGuffie AC, Wilkie S. Tricyclic antidepressant overdose: a
review. Emerg Med J 2001;18:236-241.
(2) National Poisons Information Service Edinburgh Centre Annual Report
2000.
(3) Good AM, Bateman DN. TOXBASE on the internet. J Accid Emerg Med
1999;16:399.
The excellent editorial written by Carl Gwinnut raises
important issues regarding airway care of critically ill patients at the
interface between anaesthetics and emergency care medicine.[1] The
conclusion of the editorial suggested airway management in an emergency
department is dependant on the available personnel and resources present,
and that a co-ordinated approach is beneficial. As General Prac...
The excellent editorial written by Carl Gwinnut raises
important issues regarding airway care of critically ill patients at the
interface between anaesthetics and emergency care medicine.[1] The
conclusion of the editorial suggested airway management in an emergency
department is dependant on the available personnel and resources present,
and that a co-ordinated approach is beneficial. As General Practitioners
in rural Scotland, we feel that this is a constructive and positive
approach, which could be developed further in order to benefit
practitioners who cover isolated populations.
General Practitioners are mainly responsible for the running of
community hospitals in Scotland. Over the past ten years in rural Argyll,
there has been an increase in the frequency of multiple trauma dealt with
in the community hospitals. This precipitated a dialogue with the staff at
the teaching hospital to which these critically ill patients were
subsequently transferred. The result was that over the past four years
regular anaesthetic attachments have been secured for three of the doctors
from the practice. A co-ordinated programme has been introduced with the
help of consultant staff in Accident and Emergency and the department of
Anaesthetics. This is a rolling multi-faceted programme, which involves
theatre sessions where practical skills can be reinforced, coupled with
scenario-based learning, with critical care issues also explored.
There are obvious implications for our practice in taking on such a
role. We work to strict guidelines and are involved in ongoing audit of
our work. There are obvious and justifiable concerns regarding non-
anesthetists becoming involved in airway management.[2] We all agree that
specialist input for definitive airway management is the ideal.
Unfortunately, given our geographical location and that of other community
hospitals, this is not always possible. A retrieval service for critically
ill patients is still evolving, and we hope that some of these issues will
be overcome by a rapid response. Safe and responsible practice is
paramount. Regular training, audit, discussion of all cases and close
liaison with specialists is vital for airway management skills to be safe
and effective.
Chris Downs
Mark Simpson
Adrian Ward
General Practitioners. Mid Argyll Hospital, Lochgilphead Argyll PA31 8LU
References (1) Gwinnut CL. The interface between anaesthesia and emergency
medicine. Emerg Med J 2001;18:325-329
(2) Nicol MF. You can't anaesthetize patients-you are not employed as an
anaethetist (letter). Emerg Med J 2001;18:414
I was encouraged by reading the excellent articles by Gwinnutt [1],
Nightingale [2] and Shelley [3] in the Critical Care edition of the EMJ.
Emergency Departments routinely receive critically ill/injured patients, a
proportion of which will ultimately require admission to an intensive care
unit. Effective interfacing between A&E departments and critical care
units is essential to achieve the optimal...
I was encouraged by reading the excellent articles by Gwinnutt [1],
Nightingale [2] and Shelley [3] in the Critical Care edition of the EMJ.
Emergency Departments routinely receive critically ill/injured patients, a
proportion of which will ultimately require admission to an intensive care
unit. Effective interfacing between A&E departments and critical care
units is essential to achieve the optimal outcome for these patients.
Previous reports from the USA have confirmed that these critically ill
patients can often spend a number of hours in the Emergency Department.
[4] During this time they are subjected to a substantial amount of
critical care input, undergoing a spectrum of procedures similar to that
performed on the Intensive Care Unit. [5,6] In a recent UK audit adult
admissions to two intensive care units of large teaching hospitals in the
North West were examined over a two-year period (August 1997 to August
1999). During this time 243 patients were admitted either directly from
the emergency department or indirectly from theatre via the Emergency
Department to the two Intensive Care Units studied. The majority of
admissions were related to airway/respiratory failure requiring intubation
and ventilation (49%). The vast majority of these patients were intubated
and ventilated in the Emergency Department prior to being transferred to
the Intensive Care Unit. Significant aspects of critical care practice
were delivered during the patients stay in the emergency department
including invasive monitoring, inotropic support and anaesthetic sedation.
It is well established that time critical emergency department
resuscitation of critically ill patients can have significant effects on
outcome. River’s et al showed that directed resuscitative efforts in
Emergency Departments can improve projected mortality rates by up to 14%
using predictive scoring systems. [7] More recent work showed a reversal
in physiological derangement by providing critical care intervention in
the Emergency Department. The size of this effect almost equated to the
effects of the first 72 hours of subsequent ICU care for these patients.
[8]
The recent Department of Health document entitled ‘Comprehensive
Critical Care’, proposes a significant expansion in intensive care and
high dependency beds over the next few years. [10] ICUs will become larger
and outreach teams will support the appropriate management of sick
patients wherever they are in the hospital. With the planned expansion in
consultants with an interest in intensive care medicine, the goal is
improve critical care hospital wide; the concept of "the ICU without
walls".The implications for Intensive Care Medicine as a specialty are
huge and there will have to be an expansion in staffing at all levels.
Such a development would increase the requirement for appropriately
trained trainees and consultants to work in critical care areas. The
training programme in intensive care medicine (ICM) provides an
opportunity for trainees from all disciplines to have more formal training
in intensive. This will undoubtedly provide emergency physicians with an
opportunity to compliment their training by gaining crucial further
experience of working with critical care patients.
The defining characteristic of emergency medicine is the rapid
application of life-saving measures. Available evidence from the UK and
USA suggests that significant amounts of critical care are delivered to
patients within the emergency department. Nationally there are moves
towards A&E doctors increasingly taking on the role of providing these
interventions with support from ICU colleagues. In recognition of this,
the Faculty of Emergency Medicine have identified that in future, all
emergency physicians will need to acquire the necessary skills to manage
critically ill patients for the initial 30 minutes after admission. Clancy
recently suggested that critical care will become more central feature of
A&E doctors training with up to one year of their training dedicated
to critical care.[9] This training must be A&E focused. I agree with
the view expressed by Gwinnutt that ‘it is important not to try to turn
emergency physicians into anaesthetists, but instead equip them with the
skills they need for their own environment and the problems they face.’[1]
Accident & Emergency Medicine as a speciality has developed
substantially over the last decade.The specialty is currently presented
with an ideal opportunity to expand its experience and training in
critical care with a view to ultimately expanding its role in emergency
care within the hospital.
References: (1) Carl L Gwinnutt
The interface between anaesthesia and emergency medicine
Emerg Med J 2001 18: 325-326.
(2) Peter Nightingale
Improving the care of the seriously ill patient: the interface between the
accident and emergency department and critical care areas
Emerg Med J 2001 18: 326-327
(3) M P Shelly
A&E/ICU interface: training in intensive care medicine
Emerg Med J 2001 18: 330-332.
(4) Varon J, Fromm RE, Levine RL. Emergency department procedures
and length of stay for critically ill medical patients.
Ann Emerg Med 1994;23:546-9.
(5) Graff LG, Clark S, Radford MJ. Critical care by emergency
physicians in American and English hospitals.
Archives of Emergency Medicine 1993;10(3):145-54.
(6) Fromm RE, Gibbs LR, McCallum WG, Niziol C, Babcock JC, Gueler
AC, Levine RL. Critical Care in the emergency department: a time-based
study. Crit Care Med 1993;21(7):970-6.
(7) Rivers EP, Doyle D, Nguyen B, Dereczyk B, Hays G, et al
Physiologic assessment of the critically ill: An outcome evaluation of
Emergency department intervention.
Acad Emerg Med 1998;5(5):530.
(8) Ngyuen HB, Rivers EP, Havstad S, Knoblich B, Ressler JA, Muzzin AM,
Tomlanovich MC.
Critical care in the Emergency Department.
Acad Emerg Med 2000;7(12):1354-61.
(9) Clancy M. Emergency Airway Management.
A&E Letter. The Royal Society of Medicine, January 2001.
(10) Department of Health. Comprehensive Critical Care: A review of
adult critical care services. Department of Health, London, May 2000.
I read with interest the paper on repeated use of the emergency
department by some patients. Like the authors I carried out a qualitative
study looking at use of the emergency department, focusing however on the
use made by homeless families for minor illnesses within the UK. To
explore the reasons underlying the reason to attend, I interviewed 10
families living in temporary accommodation (mainly...
I read with interest the paper on repeated use of the emergency
department by some patients. Like the authors I carried out a qualitative
study looking at use of the emergency department, focusing however on the
use made by homeless families for minor illnesses within the UK. To
explore the reasons underlying the reason to attend, I interviewed 10
families living in temporary accommodation (mainly refugee families from
several countries).
While my findings were similar to this study, I found that
homelessness adds another dimension. Management of minor illness within
bed and breakfast accommodation appears to be beyond parents' percieved
locus of control; their anxiety is heightened and any sense of normality is
redefined. In addition primary socialisation to services within other
countries, poor security within temporary accommodation and social
isolation may contribute to the decision to attend the emergencey
department.
Homelessness places additional stress on young families and reduces their
ability to cope with minor illness, leading to the use of the emergency
department. It is important that greater recognition of these stress factors
(psychological, social and environmental) is made so that appropriate
services, be it in the emergencey department, or primary care can be
provided.
Dear Editor,
I am an avid reader of your Best Evidence Topic reports (BETS) section. In your November issue I was particularly interested to read the BET by Andrew Munroe on skull fractures and intracranial injury – particularly as I had recently presented a BET on the same subject in October.
There were several striking differences between my BET and the one published in November. In particular I fin...
I was interested to read the published article concerning the use of IV magnesium in refractory VF [1]. However I am puzzled about the possible inclusion of episodes of torsades de point in the VF study group. The differentiation of torsades from VF in an ambulance must be extremely difficult and the text does not elucidate on the accuracy of monitor reading. Neither is mention made of any verification system for...
Dear Editor,
In their best evidence report, Yuen et al conclude that the Ottawa Ankle Rules will become applicable to pre-school children [1]. From the studies mentioned it is indeed likely that they will become a useful addition to the clinician’s diagnostic armamentarium for ankle injury in this age group.
It is of note however, that despite positive Ottawa Ankle Rules, subsequent ankle radiographs...
Dear Editor
I performed a similar literature search two years ago and came to the same conclusion that in the semi-elective setting (rather than time critical emergencies) the use of local anaesthetic with an appropriately small needle should make the procedure less painful and no more difficult – particularly relevant in COPD and asthma when patients may be subjected to multiple punctures during an admission. I fo...
Dear Editor
I was interested to read the article on the effect of separate streaming for minor injuries by Cooke et al as we have recently introduced a similar system with similar results. In our department all ambulatory attendees are seen on arrival by a doctor and a nurse or a nurse and a nurse practitioner together. Patients who need simple advise or treatment are seen, treated and discharged from two room...
Dear Editor
I read with interest Kerr et al’s highly informative article, Tricyclic antidepressant overdose: a review.[1] However, I would like to highlight an important point which the authors have not mentioned. In cases of mixed overdose, of tricyclic antidepressants and benzodiazepines, flumazenil (Anexate) is contraindicated. It has produced convulsions and ventricular arrhythmias in the presence of tricyclics....
Dear Editor,
Kerr et al[1] point out in their review that despite the introduction of newer antidepressant agents in recent years, a large number of prescriptions for tricyclic antidepressants are still issued. Data from our unit suggests that overdose with selective serotonin re-uptake inhibitors (SSRIs) has now become more common than with tricyclic antidepressants. Despite this, there were 4981 accesses to i...
Dear Editor
The excellent editorial written by Carl Gwinnut raises important issues regarding airway care of critically ill patients at the interface between anaesthetics and emergency care medicine.[1] The conclusion of the editorial suggested airway management in an emergency department is dependant on the available personnel and resources present, and that a co-ordinated approach is beneficial. As General Prac...
Dear Editor,
I was encouraged by reading the excellent articles by Gwinnutt [1], Nightingale [2] and Shelley [3] in the Critical Care edition of the EMJ. Emergency Departments routinely receive critically ill/injured patients, a proportion of which will ultimately require admission to an intensive care unit. Effective interfacing between A&E departments and critical care units is essential to achieve the optimal...
Dear Editor
I read with interest the paper on repeated use of the emergency department by some patients. Like the authors I carried out a qualitative study looking at use of the emergency department, focusing however on the use made by homeless families for minor illnesses within the UK. To explore the reasons underlying the reason to attend, I interviewed 10 families living in temporary accommodation (mainly...
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