This month’s primary survey from EMJ

EMJ_100x100Highlights from this month’s issue

  1. Steve Goodacre , Deputy Editor
  2. Ellen J Weber,  Editor in Chief

 

Restart a Heart

What do you have planned for October 16? Perhaps it’s a shift, or a few meetings, or a day of walking? All important, but perhaps you can spare a few minutes that day to encourage someone you know to take a CPR class? Or you can call the school your children go to and ask when they are going to start teaching CPR (and volunteer to help!). October 16 is European Restart a Heart Day, and in anticipation, we’ve included four articles in this issue—commentary and research—from international authors highlighting failures and opportunities to improve on bystander involvement in emergencies. Professor Tzi Bun Ng discusses the tragedy of a middle-aged woman who collapsed in a busy Chinese subway station but neither bystanders nor station employees came to her aid. The study by Vaillancourt, and. a systematic review by Zhimin He et al provide data on teaching first aid and resuscitation to the oldest and youngest among us. Andrew Lockey provides a commentary making a very good case for teaching CPR in schools.

Predicting ambulance journey times

Reconfiguration of emergency services is a topic that regularly attracts a lot of attention in EMJ. The potential benefit to patients from centralising specialist care needs to be balanced against the potential harm caused by increasing ambulance journey times. This means that before services are reorganised we need to estimate the impact of reorganisation upon ambulance journey times. An obvious way of doing this is to use commercially available Geographic Information Systems (GIS) software to estimate journey times, but do these estimates provide an accurate reflection of emergency ambulance journey times? McMeekin and colleagues compared GIS predictions to recorded times for 10 156 emergency ambulance journeys and found that the mean prediction discrepancy between actual and predicted journey times was an under prediction of 1.6 min. This difference is unlikely to be clinically significant and suggests it is reasonable to estimate journey times for service planning using generic GIS software. However, if you are thinking of using GIS software to predict the journey time of a specific patient to your hospital, then it might be worth bearing in mind that an average may not reflect substantial variation in the individual data.

Laryngeal mask airway or endotracheal intubation?

Endotracheal intubation may be seen as the gold standard for securing and protecting the airway but high failure rates and the risk of complications have led to concerns about use in the pre-hospital setting. As a consequence the laryngeal mask airway has been suggested as an alternative. Bosch and colleagues evaluated the use of a laryngeal mask airway in 50 patients in the Dutch ambulance service and report a 100% success rate with 98% success at the first attempt. This suggests potential for the laryngeal mask airway to provide better airway control than endotracheal intubation but randomised data are clearly required to determine comparative effectiveness. The scene is set for a trial of pre-hospital airway management—is anyone bold enough to take on the challenge?

Point of care testing—is it worth the cost?

Point of care devices can provide quicker availability of results and shorten emergency department length of stay but usually incur increased costs compared to laboratory testing. It is tempting to assume that a point of care test that provides results an hour earlier than the laboratory will reduce length of stay by an equivalent amount. However, randomised comparison is required to test this assumption. Asha and colleagues randomised 811 patients to receive either point of care or laboratory testing and found that point of care testing was associated with mean reductions of 26 minutes in time to disposition decision and 20 minutes in emergency department length of stay. Mean pathology costs were $12 higher in the point of care group, so $113 was being paid per hour saved in time to disposition. This adds up to a lot of dollars but also a lot of potential time saved across an emergency department population. Careful consideration is required to decide whether such expenditure is worthwhile.

Diuretic administration in acutely decompensated heart failure

Intravenous diuretics are often used in acute heart failure. The intense urine output achieved after administration is often viewed with satisfaction by the clinician, if not the patient. Llorens et al aimed to determine the effect of different administration strategies upon diuresis and a number of secondary outcomes in a randomised controlled trial of 109 patients with acutely decompensated heart failure. They found that continuous infusion produced a greater 24 hour diuresis than bolus administration but was more likely to result in hypokalaemia. There were no significant differences in improvements in clinical symptoms or signs between the three groups. This raises the question of whether there is any causal association between producing a substantial diuresis and improving relevant outcomes in acutely decompensated heart failure.

Lumbar puncture for suspected subarachnoid haemorrhage

This is another topic that engenders strong debate, often between those with contrasting perspectives of the problem. Emergency physicians see a large unselected group of patients often indiscriminately investigated with CT and doubt whether all those with negative CT really need lumbar puncture. Neurologists and neurosurgeons see the highly selected group with positive tests, including those with negative CT but positive lumbar puncture, and conclude that failure to perform lumbar puncture is unthinkable. Stewart and colleagues add some more data to inform the debate. In a cohort of 244 patients investigated for suspected subarachnoid haemorrhage they found that the sensitivity of CT for subarachnoid haemorrhage was 93.8%, rising to 95% if limited to scan performed within 12 hours of ictus. This suggests that CT alone is inadequate to rule out subarachnoid haemorrhage when it is suspected. The question remains though—when should we suspect subarachnoid haemorrhage? The prevalence of subarachnoid haemorrhage in the study cohort was 29%. If clinicians were able to select such a high prevalence cohort for investigation the debate about lumbar puncture would become largely irrelevant.

Is the Opioid Epidemic Just an American Problem?

Many problems among developed countries are unique to the United States. Gun violence is at levels comparable to locations of civil unrest around the world, and we are proud of our world leadership in obesity. Our dysfunctional healthcare incentives and payment system, despite many examples of innovative excellence, shows starkly different health status based on socioeconomic standing.

Opioid abuse and overdose is a rapidly increasing issue in the United States.  Even more damning is the obvious: all the opioids in circulation are at some point prescribed by physicians.  There are no fingers to be pointed except at ourselves.   Opioid abuse has given rise to increased heroin use and sporadic clusters of deaths, as unfortunate addicts find their typical supplies laced with fentanyl or acetyl-fentanyl, each far more potent concoctions.  Naloxone auto-injectors have recently gained notoriety – but, while these are life-saving in the appropriate circumstances, the devices cost several hundred dollars and address the symptoms of the epidemic, not the root causes.

The Academic Life in Emergency Medicine recently hosted an excellent Google Hangout discussing the challenges associated with opioid prescribing – balancing the alleviation of suffering with downstream diversion and other complications. Resident authors from the Harvard-Affiliated Emergency Medicine Residency were joined by clinical toxicologists from Toronto and Washington, D.C., to discuss appropriate analgesia in the Emergency Department. Surprisingly, many resident respondents felt this aspect of practice was highly neglected in their training.  The video discussion, the comments section, and the accompanying Twitter feed highlight questions and responses from all levels of training and expertise.

One of the other interesting question posed, however, was – how are prevalent are opioid prescribing and abuse issues outside the U.S.? Are you evaluated on patient satisfaction – and pressured to give opiates as a result? Are prescription databases widely available to screen patients at risk for abuse or diversion? How was your analgesic education handled?

Is the Opioid Epidemic Just an American Problem?

Many problems among developed countries are unique to the United States. Gun violence is at levels comparable to locations of civil unrest around the world, and we are proud of our world leadership in obesity. Our dysfunctional healthcare incentives and payment system, despite many examples of innovative excellence, shows starkly different health status based on socioeconomic standing.

Opioid abuse and overdose is a rapidly increasing issue in the United States.  Even more damning is the obvious: all the opioids in circulation are at some point prescribed by physicians.  There are no fingers to be pointed except at ourselves.   Opioid abuse has given rise to increased heroin use and sporadic clusters of deaths, as unfortunate addicts find their typical supplies laced with fentanyl or acetyl-fentanyl, each far more potent concoctions.  Naloxone auto-injectors have recently gained notoriety – but, while these are life-saving in the appropriate circumstances, the devices cost several hundred dollars and address the symptoms of the epidemic, not the root causes.

The Academic Life in Emergency Medicine recently hosted an excellent Google Hangout discussing the challenges associated with opioid prescribing – balancing the alleviation of suffering with downstream diversion and other complications. Resident authors from the Harvard-Affiliated Emergency Medicine Residency were joined by clinical toxicologists from Toronto and Washington, D.C., to discuss appropriate analgesia in the Emergency Department. Surprisingly, many resident respondents felt this aspect of practice was highly neglected in their training.  The video discussion, the comments section, and the accompanying Twitter feed highlight questions and responses from all levels of training and expertise.

One of the other interesting question posed, however, was – how are prevalent are opioid prescribing and abuse issues outside the U.S.? Are you evaluated on patient satisfaction – and pressured to give opiates as a result? Are prescription databases widely available to screen patients at risk for abuse or diversion? How was your analgesic education handled?

Developing EM in Brazil 2014

The following video tells us more about the fantastic project that is ‘Developing EM’. I found it on the excellent (and must visit site PHARM).

Bishan Rajapakse interviews Lee and Mark on what they hope to develop both in Brazil and in future conferences.

Please listen and consider attending in the future.

This year’s conference is in Salvador de Bahia from September 8-12th and although it might be a little late to get there this year please check out the website and consider making a late dash this year, or make time for 2015.

vb

Simon

PS – Bishan is famous for many things and is a real talent. Check out this clip to see what he gets up to in his free time….

Highlights from the August EMJ

Ellen Weber

Ellen Weber

Ellen J Weber, Editor in Chief

From DRC to DAR

Last fall, I had the extraordinary opportunity to spend two months at Muhimibili Hospital in Dar Es Salaam, teaching in the first emergency medicine residency in Tanzania. During this time, I was reminded of what a privilege it is to be a physician, and how lucky I was to grow up in a country where the path to medical school was straightforward, my life relatively stable, and my work, although stressful and chaotic, secure. This month, the view from here features an interview with an inspiring young physician who has travelled a far more dangerous and circuitous path. Dr Mudenga Mutendi Muller describes his experiences in a hospital during the war in Goa, assuring safety for his family, then leaving his home country to begin EM training in Tanzania. More of our interview can be heard in our podcast at: https://soundcloud.com/bmjpodcasts/drc-to-darone-physicians-journey-to-emergencymedicine/s-5ck7t

An old medication raises new possibilities–and questions

Methoyxflurane, an inhaled anaesthetic agent used in the 1960′s and 1970′s, has analgesic properties at sub-anaesthetic doses and has been used for pain management in Australia in pre-hospital and emergency care for many years. However, there are few randomized trials and it is not licensed in the US or UK. This month, Coffey et al report the findings of a multicenter placebo-controlled trial of methoyxflurane for pain in ED’s in the UK. Readers may ask why a comparison to placebo was necessary and how the results should be interpreted when other active agents exist. In a related commentary, Simon Carley and Richard Body discuss the issues.

You are getting sleepy–aren’t you? (Editor’s choice)

Oral midazolam for sedation of young children needing laceration repairs is unreliable, and has led many of us to IV or IM ketamine. But what about combining oral midazolam and oral ketamine? A double blind randomized trial by Barkan et al found that children given both agents had deeper sedation, and required less IV sedation, than those administered midazolam alone, although VAS scores for the two groups, as assessed by the investigators and parents, were not different. Another arrow in the quiver for pediatric sedation? Perhaps, but be aware that the children receiving both ketamine and midazolam stayed nearly an hour longer in the ED.

That CT scan may not be what parents want after all…

Two young parents bring their only child into the ED after he fell off a chair and hit his head. They are worried. After examining the child, you consult your head injury guidelines and, using your best bedside manner, make a recommendation to the parents. Have you convinced them? It depends. Seriken et al found that among parents of young children with minor head injuries, those with more education were less reassured at the end of the visit, and mothers were less reassured than fathers. Interestingly, parents whose child had a CT were no more reassured than those that didn’t, while neurosurgical consultation had a positive impact. The study was conducted in Turkey, but its findings hit home with me.

Its not about catching babies

A review of 66 obstetric cases retrieved by physician-led helicopter teams in Sydney reveals some staggering data on the skills needed for these critical transports. Two thirds of cases involved haemorrhage, followed by eclampsia. Nearly all patients required mechanical ventilation; retrieval physicians intubated in 23 cases and established central lines in 30 patients. The authors conclude that “Exhaustive training in obstetric emergencies may not reflect the learning needs of physicians in services such as ours” and propose a training curriculum.

Is it time to put mannitol on the bottom shelf? (Reader’s choice)

Mannitol has been the go-to osmotic agent for lowering intracranial pressure (ICP) in head trauma for nearly a century, but its primacy is being challenged by hypertonic saline. In a meta-analysis confined only to randomized studies of these agents for traumatic brain injury, Rickard et al found no significant difference in ICP-lowering ability, although the trend favored hypertonic saline. So is it time to shelve the mannitol? Unfortunately, more study is needed.

How happy are patients with Emergency Care Practitioners?

Emergency Care Practitioners (ECP) are nurses and paramedics with advanced training who work in a variety of care settings in the UK. O’Keefe et al report on a postal questionnaire sent to patients seen by either an ECP or more typical provider in these settings, which found that more patients seeing ECP’s were highly satisfied than those who saw the usual type of care provider. Although the study is limited by a modest response rate (38%), its findings are consistent with several studies of nurse practitioners and physicians’ assistants in other countries.

A starting point for ruling out scaphoid fractures

You know the drill. A patient has fallen on an outstretched hand, they have snuff box tenderness—and a negative X-ray. Plan: immobilize and repeat X-ray in 10 days. Perhaps. In a prospective study of 154 patients with wrist injuries and negative films, Bergh et al found that they could combine 3 exam findings into a clinical scaphoid score that predicted all 13 scaphoid fractures found on MRI. Caution: The NPV of 96% is hopeful, but will vary with prevalence of fracture. And the rule still needs validation in another population of patients and physicians.