As a paediatrician I have learnt that auscultation often adds little
to my assessment of children with possible pneumonia. If the patient
(adult or child) has other clinical features of pneumonia e.g hypoxia,
pleuritic pain, tachypnoea, then a chest radiograph will probably be
requested anyway.
Interestingly the British Thoracic Society guidelines on Community
Aquired Pneumonia in Adult...
As a paediatrician I have learnt that auscultation often adds little
to my assessment of children with possible pneumonia. If the patient
(adult or child) has other clinical features of pneumonia e.g hypoxia,
pleuritic pain, tachypnoea, then a chest radiograph will probably be
requested anyway.
Interestingly the British Thoracic Society guidelines on Community
Aquired Pneumonia in Adults (Thorax 2001;56 (suppl IV)) state that a chest
radiograph is not indicated for the majority of patients diagnosed with
pneumonia in the community but also state that "diagnosing pneumonia
clinically without a chest radiograph is inaccurate".
So do you perform a chest radiograph or do you give antibiotics -
whether they have crepitations or not?
In introducing Goodacre et al's paper on low risk chest pain
patients, the Primary Survey of the December 2009 issue prompts emergency
physicians to reflect on "why [they] take histories at all in this patient
group".(1,2) This is, in our opinion, an inappropriate reaction to the
results of the study. The patients under investigation were those with a
potential diagnosis of a cardiac cause of chest pain, and according t...
In introducing Goodacre et al's paper on low risk chest pain
patients, the Primary Survey of the December 2009 issue prompts emergency
physicians to reflect on "why [they] take histories at all in this patient
group".(1,2) This is, in our opinion, an inappropriate reaction to the
results of the study. The patients under investigation were those with a
potential diagnosis of a cardiac cause of chest pain, and according to the
exclusion criteria were only enrolled if the history and examination in
the emergency department had ruled out other serious treatable causes of
chest pain such as pulmonary embolism or aortic dissection. As discussed
at the end of the paper, it is likely that many patients who had been
diagnosed as having a benign non-cardiac cause of chest pain were not
included in the study. Additionally, the majority of patients with typical
presentations of other conditions such as pneumonia, pericarditis,
pneumothorax, cholecystitis, pancreatitis or chest trauma were presumably
not included even if chest pain was a major component of the presenting
complaint. Therefore the study cohort comprised only those patients with
chest pain whose clinical assessment had failed to suggest an obvious
alternative diagnosis. Such assessment necessarily involves taking a
careful history(3). Of the entire set of patients presenting with chest
pain, the study group represents the subset that retains some diagnostic
uncertainty despite a careful history.
To ask why we take a history at all in a group of patients that have
already been defined by their history is begging the question. Suggesting
to your readers that they may wish to reflect on whether they should take
a history at all in this group not only overlooks this point, but invites
them to miss other obvious and important treatable illnesses in the rush
to "exclude MI". It must be remembered that there are many more
diagnostic categories than "acute coronary syndrome" and "non-specific
chest pain".
Only a minority of acute coronary syndromes present with a non-
diagnostic ECG(4). What Goodacre's study illustrates is that if we take a
group of patients with acute chest pain in whom the underlying diagnosis
is not clear, a small proportion will be due to unusual presentations of
acute coronary syndromes, and that this subset is not identifiable in
advance by their symptoms alone. This is useful because it highlights
that if an alternative diagnosis is not obvious then there is scope for
doubt and that caution is advisable. It is not an argument for abandoning
a careful history, which remains in everyday practice our most useful
clinical assessment tool.
References
1. Clinical diagnosis of acute coronary syndrome in patients with
chest pain and a normal or non-diagnostic electrocardiogram
Emerg Med J 2009 26: 866-870
S Goodacre, P Pett, J Arnold, et al.
2. Primary Survey
Emerg Med J 2009;26:843
Kevin Mackway-Jones
3. Evaluating the Patient with Chest Pain: The Value of Comprehensive
History.
Journal of Cardiovascular Nursing. July/August 2005; 20(4): 226-231
Reigle J
4. Prognostic Value of a Normal or Nonspecific Initial
Electrocardiogram in Acute Myocardial Infarction
JAMA. 2001;286:1977-1984
Robert D. Welch, MD; Robert J. Zalenski, MD; Paul D. Frederick, MPH, MBA;
Judith A. Malmgren, PhD; Scott Compton, PhD; Mary Grzybowski, PhD, MPH;
Sophia Thomas, MD; Terry Kowalenko, MD; Nathan R. Every, MD, MPH; for the
National Registry of Myocardial Infarction 2 and 3 Investigators
We congratulate Mueller et al. investigating the usefulness of serum
protein S-100B to save
cranial CT resources in the management of patients with minor head injury
[1]. Although we
definitely support their conclusions about the usefulness of protein S-
100B, two major
concerns regarding the methodology of their study ought to be considered:
Firstly, despite the well-described diagnostic time frame of S-100B...
We congratulate Mueller et al. investigating the usefulness of serum
protein S-100B to save
cranial CT resources in the management of patients with minor head injury
[1]. Although we
definitely support their conclusions about the usefulness of protein S-
100B, two major
concerns regarding the methodology of their study ought to be considered:
Firstly, despite the well-described diagnostic time frame of S-100B as a
screening tool in
minor head injury [2, 3, 4], the authors interpreted the results of two
patients false negative.
However blood sampling of both patients was 11.5 and 48 hours subsequent
to the incident
far beyond recommended time frame to rule out traumatic brain injury,
which was also
mentioned by the authors themself in their discussion section. Therefore
we completely
agree with the authors' recommendation to ensure blood sampling for S-100
B as a screening tool within a maximum of 3 hours following the incident.
If S-100B cannot be measured within 3 hours, it should not be considered
to exclude traumatic brain injury [3].
Secondly, the authors found one patient with a skull fracture not been
detected by serum S-100B. The patient was therefore interpreted as false
negative as well. However protein S- 100B is a brain-specific serum
protein to detect traumatic brain injury not skull fractures.
Compared to missed or delayed diagnosis of traumatic brain injury,
isolated asymptomatic skull fractures do not progress and rarely endanger
patients' health.
Acknowledging these circumstances, the sensitivity and the negative
predictive value of serum-S100B would be 100%. Therefore the authors'
conclusions may mislead clinicians considering the implementation of S-
100B to manage patients with minor head injury in the
emergency department. Clinicians intending serum protein S-100B as a
screening tool for decision making in adult mild traumatic brain injury in
the acute setting should be familiar with its capabilities and
limitations. If those are considered, S-100B is able to reduce the number
of cranial CT by 30% [4].
Yours sincerely,
M. Zock, Chirurgische Klinik und Poliklinik, Campus Innenstadt,
Klinikum der Universitaet
Muenchen, Germany
Dr. B.A. Leidel, MD, Interdisziplinaere Rettungsstelle und
Notfallaufnahme, Campus Benjamin
Franklin, Charite - Universitaetsmedizin Berlin, Germany
References:
1. Mueller B, Evangelopoulos DS, Bias K et al. (2010) Can S-100B
serum protein help to save cranial CT resources in a peripheral trauma
centre? A study and consensus paper. Emerg Med J.
DOI:10.1136/emj.2010.095372
2. Townend W, Dibble C, Abid K et al. (2006). Rapid elimination of
protein S-100B from serum after minor head trauma. J Neurotrauma. 23(2):
149-155
3. Jagoda AS, Bazarian JJ, Bruns JJ et al. from the American College
of Emergency Physicians and Centers for Disease Control and Prevention
(2008). Clinical Policy: Neuroimaging and decision making in adult mild
traumatic brain injury in the acute setting. Ann Emerg Med. 52: 714-748
4. Biberthaler P, Linsenmeier U, Pfeifer KJ et al. (2006). Serum S-
100B concentration provides additional information for the indication of
computed tomography in patients after minor head injury: a prospective
multicenter study. Shock. 25(5): 446-453
Even though the electrocardiogram(ECG) may be entirely non-
diagnostic, and entirely innocent of any ST segment deviation in as many
as 38% of patients with myocardial infarction attributable to left
circumflex artery occlusion(1), clinical features that simply help to
confirm the diagnosis of acute coronary syndrome(ACS(2))will have greater
practical value, in this context, than in patients who have diagnostic
ECG. The...
Even though the electrocardiogram(ECG) may be entirely non-
diagnostic, and entirely innocent of any ST segment deviation in as many
as 38% of patients with myocardial infarction attributable to left
circumflex artery occlusion(1), clinical features that simply help to
confirm the diagnosis of acute coronary syndrome(ACS(2))will have greater
practical value, in this context, than in patients who have diagnostic
ECG. The reason is that, failure to recognise the entity of non-diagnostic
ECG attributable to circumflex artery occlusion represents a massive
missed ooportniny, in the short term, for potentially life saving
treatment in those patients who present with typical symptoms well within
the optimal reperfusion time window(3). In one study, even in the long
term, patients with circumflex artery occlusion(38% of whom had no ST
segement deviation on admission)had similar probability of recurrent
cardiac events as patients with right coronary artery occlusion and
counterparts with left anterior descending artery occlusion(1).
Accordingly, the prognostic concerns voiced by the authors(2) have
relevance, not only for the long term(2) but also for the short term in
those patients who have non-diagnostic ECG attributable to left circumflex
artery occlusion. References
(1) Huey BL., Beller GA., Kaiser DL., Gibson RS
A comprehensive analysis of myocardial infarction due to left circumflex
artery occlusion; comparison with infarction due to right coronary artery
and left anterior descending artery occlusion
J Am Coll Cardiol 1988;12:1156-66
(2)Goodacre S., Pett P., Arnold J et al
Clinical diagnosis of acute coronary syndrome in patients with chest pain
and a normal or non-diagnostic electrocardiogram
Emrg Med J 2009;26:866-70
(3)Krishnaswamy A., Lincoff M., Menon V
Magnitude and consequences of missing the acute infarct-related circumflex
artery
Am Heart J 2009;158:706-12
We would like to thank van Veen et al. for their evaluation of the
Manchester Triage System (MTS) in children. This study was based on
simulated case scenario to investigate the repeatability of triage, with a
total compliance of nurses with the MTS. We would like to highlight that
in real life experience, strict adherence of nurses to triage protocol is
rare.
Wacher et al. (evaluating the implementation of a set of stan...
We would like to thank van Veen et al. for their evaluation of the
Manchester Triage System (MTS) in children. This study was based on
simulated case scenario to investigate the repeatability of triage, with a
total compliance of nurses with the MTS. We would like to highlight that
in real life experience, strict adherence of nurses to triage protocol is
rare.
Wacher et al. (evaluating the implementation of a set of standardized
pediatric telephone triage protocols) have found that 58% of nurses felt
confined to the protocols, and 42% admitted intentional deviation from
them, when they believed that optimal patient care mandated that they do
so .1 Correlation among dispositions determined by triage providers was
poor, despite instructions to follow protocols as closely as possible.
Although it is a basic assumption that protocols operate by
standardization, these results indicate that nurses did not reliably
choose the same protocol in a given case and did not reach the same triage
endpoint even when they followed the same protocol. As suggested by Poole
et al., nurses may decide under some circumstances to follow their
intuition rather than the recommendations. 2 Piccotti et al. evaluated the
percentage of consistency with the triage process drawn up at the level of
pediatric emergency department (ED), and concluded that they were a need
for further efforts to improve compliance with the protocol and pursue a
higher degree of uniformity in evaluation by triage personnel. 3 The
triage in ED relies on two key factors: accurate triage tools for
identifying major cases, and compliance of medical staff with the triage
protocols. The MTS must be studied rigorously in daily practice before it
can be safely disseminated for general use, as far as many bias linked
with poor adherence can make it less seducing in practice.
1. Wacher DA, Brillman JC, Lewis J, Sapien RE. Pediatric Telephone
triage protocols: standardized decisionmaking or false sense of security?
Ann Emerg Med 1999; 33: 388- 94.
2. Poole SR, Schmitt BD, Carruth T et al: After-hours telephone coverage:
The application of an area-wide telephone triage and advice system for
pediatric practices. Pediatrics 1993; 92: 670-79.
3. Picotti E, Magnani M, Tubino B et al. Assessment of the triage system
in a pediatric emergency department. A pilot study of critical codes. J
Prev Med Hyg 2008; 49: 120-23.
I was not sure if the September supplement was
plagarised from something written 100 years ago or if
it was for real. If this is truly the attitude of
senior ED staff in the UK then I suggest trainees
emigrate. Australasia has female medical staff, sick
leave, police with better things to do than pamper
medical egos, and eminent specialists who do not
equate true leadership with being called "Doctor"; all
th...
I was not sure if the September supplement was
plagarised from something written 100 years ago or if
it was for real. If this is truly the attitude of
senior ED staff in the UK then I suggest trainees
emigrate. Australasia has female medical staff, sick
leave, police with better things to do than pamper
medical egos, and eminent specialists who do not
equate true leadership with being called "Doctor"; all
things which appear to be lacking in the UK if this
article is to be believed. I hope the supplement does
not reflect the attitudes of the British Association
for Accident and Emergency Medicine.
I read with interest the Commentary by Roland and Coats with regard
to early warning scores(1). The evidence base for the use of track and
trigger systems (TTS)in the Emergency Department is not particularly
strong and I agree that using a system that is designed for hospital
inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring
sy...
I read with interest the Commentary by Roland and Coats with regard
to early warning scores(1). The evidence base for the use of track and
trigger systems (TTS)in the Emergency Department is not particularly
strong and I agree that using a system that is designed for hospital
inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring
system that was derived in a non-surgical ED in Sweden (2) and
subsequently validated in a study of almost 12,000 patients (3). Area
under ROC curve for in-hospital mortality was 0.852 (Standard Error of the
Mean 0.014). It has also been evaluated in a UK-based study by Goodacre et
al (4).
Clearly, TTS are here to stay and we need one which is appropriate to
our patient population and helps to identify critically ill patients when
they arrive in the ED. REMS was derived on ED patients, includes age as
part of its scoring (itself an independent predictor of mortality) and
studies involving it have much greater sample sizes than work on MEWS. It
has its limitations, in that it has only (so far) been used on medical
patients and it is a more complicated tool than MEWS. Also a recent survey
of UK EDs (conducted by the author) revealed that whilst MEWS is in
widespread use, REMS is not being used at all.
However, if we are looking for a TTS to use in ED, should we not
start with REMS, rather than modify a ward-based system?
A postal survey of 254 UK EDs was undertaken. Responses
were received from 145 departments giving a response rate
of 57%. 87% of respondents are currently using early
warning scores. Of those, 80% are using MEWS, 10% are
using the Patient at Risk Score (PARS) and none are using
REMS. 93% of respondents are in support of early warning
scores in the ED.
References:
1. Roland D, Coats TJ. An early warning? Universal risk scoring in
emergency medicine. Emerg Med J 2010;1.doi10.1136/emj.2010.106104
2. Olsson T, Lind L. Comparison of the Rapid Emergency Medicine Score
and APACHE II in nonsurgical emergency department patients. Acad Emerg Med
2003;10:1040-1048
3. Olsson T, Terent A, Lind L. Rapid emergency medicine score: a new
prognostic tool for in-hospital mortality in nonsurgical emergency
department patients. Journal of Internal Medicine 2004;255:579-587
4. Goodacre S, Turner J, Nicholl J. Prediction of mortality among
emergency medical admissions. Emerg Med J 2006;23:372-375
I was working at a A&E department in North West few years ago and had
similar questions as to why patients not taking any analgesia before
attending the department. I did a survey on this matter and this is the
result of the survey.
Objectives
To determine the percentage of patients attending the accident and
emergency department with pain but without taking any analgesia prior t...
I was working at a A&E department in North West few years ago and had
similar questions as to why patients not taking any analgesia before
attending the department. I did a survey on this matter and this is the
result of the survey.
Objectives
To determine the percentage of patients attending the accident and
emergency department with pain but without taking any analgesia prior to
attendance and to find out the reasons for not taking analgesia.
Methods
A questionnaire was filled by 122 patients attended the minor unit of
accident and emergency department.
Results
57% of patients had not taken any analgesia. Most of the patients
(61%) were less than 45 years old and 64% of them had not taken any
analgesia. Nearly 80% of patients presented with limb pain and 64% of them
had not taken any analgesia. Main reasons for not taking analgesia were
'have not thought about taking it' (51.4%), 'did not think need any'
(8.6%), 'did not have any' (7.2%) and 'did not like taking them' (5.7%).
Nearly 94% of patients who had not taken analgesia were eventually
discharged home with analgesia as the definite management. Out of 43% of
patients who had taken analgesia, paracetamol was the main choice.
Conclusion
There was high proportion of patients attending the accident and
emergency department without any analgesia. Most of these patients were
eventually discharged home with analgesia. Improvement in patients
awareness and education is recommended.
We read with interest the work by Mills and Crawford regarding timely
medicines reconciliation. We have seen similar results in the acute
medical department.
The presence of pharmacists, pharmacy technicians and a formalised
medicines reminder system for junior doctors in acute medicine also
significantly improves the rate of medicines reconciliation in the first
24 hours of an in-patient stay.
We read with interest the work by Mills and Crawford regarding timely
medicines reconciliation. We have seen similar results in the acute
medical department.
The presence of pharmacists, pharmacy technicians and a formalised
medicines reminder system for junior doctors in acute medicine also
significantly improves the rate of medicines reconciliation in the first
24 hours of an in-patient stay.
Some responses to the in tray problems at St Judes
(1) Dear Chief Executive,
Thank you for welcoming me to the trust. I look forward to working with
you in solving the many problems challenging the Emergency Dept (a term I refer to as Casualty). I'd be grateful if your PA can arrange our meeting urgently.
I'd like to know from you where the ED and its service fit in with the
strategic direction of the Tr...
Some responses to the in tray problems at St Judes
(1) Dear Chief Executive,
Thank you for welcoming me to the trust. I look forward to working with
you in solving the many problems challenging the Emergency Dept (a term I refer to as Casualty). I'd be grateful if your PA can arrange our meeting urgently.
I'd like to know from you where the ED and its service fit in with the
strategic direction of the Trust and what resources you will be providing
me with.
These matters were only discussed loosely at my interview.
Best wishes
(2) Dear Mrs Penny,
I will look into this sad and tragic event as soon as possible. As you may
know I am newly appointed and am just finding my feet.
In the meantime I will write to the family and apologise for the events
surrounding the death. In due course I will be happy to meet them.
Best wishes
(3) Dear Personnel,
Before I complete this job description can you please forward me a copy of
the St Judes template for such posts. It is wise to have a consistent
approach to such things.
Best wishes
(4) Xray requests
I would ask to see the notes of some of the cases - the 1st to 8th, and 9th
cases. I would add to my action list to review the xray report system - not a
priority.
(5) The SpR letter.
I would file for now and wait for the outcome of my meeting with the CEO and
further chats with regional colleagues - middle priority.
(6) The computer - I would ask my business manager to sort it out as a top
priority.
Dear Editor,
As a paediatrician I have learnt that auscultation often adds little to my assessment of children with possible pneumonia. If the patient (adult or child) has other clinical features of pneumonia e.g hypoxia, pleuritic pain, tachypnoea, then a chest radiograph will probably be requested anyway.
Interestingly the British Thoracic Society guidelines on Community Aquired Pneumonia in Adult...
In introducing Goodacre et al's paper on low risk chest pain patients, the Primary Survey of the December 2009 issue prompts emergency physicians to reflect on "why [they] take histories at all in this patient group".(1,2) This is, in our opinion, an inappropriate reaction to the results of the study. The patients under investigation were those with a potential diagnosis of a cardiac cause of chest pain, and according t...
Sir,
We congratulate Mueller et al. investigating the usefulness of serum protein S-100B to save cranial CT resources in the management of patients with minor head injury [1]. Although we definitely support their conclusions about the usefulness of protein S- 100B, two major concerns regarding the methodology of their study ought to be considered: Firstly, despite the well-described diagnostic time frame of S-100B...
Even though the electrocardiogram(ECG) may be entirely non- diagnostic, and entirely innocent of any ST segment deviation in as many as 38% of patients with myocardial infarction attributable to left circumflex artery occlusion(1), clinical features that simply help to confirm the diagnosis of acute coronary syndrome(ACS(2))will have greater practical value, in this context, than in patients who have diagnostic ECG. The...
We would like to thank van Veen et al. for their evaluation of the Manchester Triage System (MTS) in children. This study was based on simulated case scenario to investigate the repeatability of triage, with a total compliance of nurses with the MTS. We would like to highlight that in real life experience, strict adherence of nurses to triage protocol is rare. Wacher et al. (evaluating the implementation of a set of stan...
Dear Editor
I was not sure if the September supplement was plagarised from something written 100 years ago or if it was for real. If this is truly the attitude of senior ED staff in the UK then I suggest trainees emigrate. Australasia has female medical staff, sick leave, police with better things to do than pamper medical egos, and eminent specialists who do not equate true leadership with being called "Doctor"; all th...
I read with interest the Commentary by Roland and Coats with regard to early warning scores(1). The evidence base for the use of track and trigger systems (TTS)in the Emergency Department is not particularly strong and I agree that using a system that is designed for hospital inpatients will not be appropriate for our specific patient group.
The rapid emergency medicine score(REMS) is a physiological scoring sy...
Dear sir
I was working at a A&E department in North West few years ago and had similar questions as to why patients not taking any analgesia before attending the department. I did a survey on this matter and this is the result of the survey.
Objectives
To determine the percentage of patients attending the accident and emergency department with pain but without taking any analgesia prior t...
We read with interest the work by Mills and Crawford regarding timely medicines reconciliation. We have seen similar results in the acute medical department.
The presence of pharmacists, pharmacy technicians and a formalised medicines reminder system for junior doctors in acute medicine also significantly improves the rate of medicines reconciliation in the first 24 hours of an in-patient stay.
Dr Tom...
Some responses to the in tray problems at St Judes
(1) Dear Chief Executive,
Thank you for welcoming me to the trust. I look forward to working with you in solving the many problems challenging the Emergency Dept (a term I refer to as Casualty). I'd be grateful if your PA can arrange our meeting urgently. I'd like to know from you where the ED and its service fit in with the strategic direction of the Tr...
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