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Preview: Emergency Medicine Journal current issue

Emergency Medicine Journal current issue



Emergency Medicine Journal RSS feed -- current issue



 



Highlights from the issue

2018-02-20T06:19:05-08:00

Happy 50th birthday, UK Emergency Medicine

As we saw out 2017 we also celebrated the 50th anniversary of Emergency Medicine (EM) in the United Kingdom. This special commemorative issue of the journal celebrates the momentous occasion with a number of pieces to reflect on the history of the specialty and to look forward to its future. In another 50 years, emergency physicians will undoubtedly look back at this issue of the journal as a key reference to the state of EM in 2018. It is without doubt, therefore, a must read for all emergency physicians.

How did we get here?

The issue includes some fascinating reports on the history of UK EM. As we begin to see a glimmer of light appearing towards the end of what has been the bleakest of winters for our specialty, we think back to a time when the challenges, though still...




Looking back and forward: emergency medicine in its 50th year

2018-02-20T06:19:05-08:00

The farther backward you can look, the farther forward you are likely to see – Winston Churchill.

On this 50th anniversary of our specialty in the UK, we should rightly remember and pay thanks to the giants and also unsung heroes of our specialty. With tenacity and political skill, they took our EDs from a ‘Cinderella like’ dark corner of the hospital to the very highest profile central hub for delivering emergency care 24 hours a day. It is a powerful journey indeed and one to be justly proud of.

Beginning from the Casualty Surgeons Association to the British Association for Emergency Medicine, those in the forefront took our specialty through the Faculty of Accident and Emergency Medicine, then the College of Emergency Medicine and now the Royal College of Emergency Medicine (RCEM).1–3 Subspecialisation has occurred in paediatric emergency medicine, prehospital care and...




Brief history of the specialty of emergency medicine

2018-02-20T06:19:05-08:00

This is a brief overview of the development of the specialty of Emergency Medicine from small beginnings fifty years ago. It describes how the specialty evolved simultaneously in the UK and the USA and later in Australasia and Europe.




Being a pioneer in emergency medicine

2018-02-20T06:19:05-08:00

I qualified in London in 1968. Being the first doctor in my family, I had little idea of medical career structure. My first post was as House Surgeon in a small hospital in North London. We worked a one in two rota. Two medical staff lived in each night, a House Surgeon and a House Physician. There were Senior House Officers (SHOs) who could go home at night and Registrars whose work was mainly in larger units nearby.

During my first night on duty, being called to attend Casualty was a bit of a surprise. I can remember one airway problem which I was expected to handle by myself, luckily with the help of nursing colleagues. Fifty years on, I still remember the difficulty of clearing undigested food from the pharynx.

We dealt with limb fractures not requiring hospital admission, even displaced Colles’ fractures. I think one House Officer...




Emergency nursing: recognising and celebrating the contribution

2018-02-20T06:19:05-08:00

In 1911, a BMJ editorial expressed concern over what was viewed as "an increasing tendency for nursing associations to employ nurses who are not only allowed but apparently in many places encouraged to prescribe and administer drugs, to treat minor injuries and generally act as minor medical practitioners". In the view of the editor "in her proper place a nurse is invaluable both to the patient and to the doctor but that the training and qualifications of a nurse do not fit her and were never intended to fit her to discharge the functions of an independent practitioner".1 There are some who would still concur with this view, but just as no one conceived of a male nurse in 1911 (they are now 17% of the workforce), the evolution of emergency medicine, combined with social, political and economic forces in healthcare, have provided a fertile environment for...




Brief history of Pre-Hospital Emergency Medicine

2018-02-20T06:19:05-08:00

Introduction

Pre-Hospital Emergency Medicine (PHEM) often involves provision of critical care in a resource limited and physically challenging setting. Add to this the combination of medical emergency, time pressure and an unfamiliar ‘flash’ team and one wonders why any healthcare professional would seek to immerse themselves in this area of clinical practice. Yet over the last 50 years, a surprising number of doctors have chosen to do so—largely on a voluntary and altruistic basis. In 1994, one of those doctors, an emergency physician who subsequently became a national clinical director for emergency care, challenged those involved in pre-hospital care ‘to progress from a group of enthusiasts of varying qualifications and standards ...’.1 The challenge was accepted. PHEM has now been established as a GMC-approved subspecialty. As with emergency medicine (EM), a new generation of consultants are shaping the future.

Historical context

The development of...




An injured man with acute altered mental status

2018-02-20T06:19:05-08:00

Clinical introduction

A 58-year-old man sustained injuries due to accidental fall from a height of 5 m onto a solid floor while operating a crane. He was fully conscious without external evidence of head injury when presented to the ED. The patient had multiple fractures involving the fourth, fifth and seventh of the left ribs, left iliac wing and superior ramus of the pelvis, comminuted fracture of the left femur shaft, and an open fracture of the mandible. Two hours after ED presentation, the patient developed acute confusion and lethargy, which rapidly progressed to coma and respiratory distress, and was subsequently intubated with mechanical ventilation support. Emergent CT scan of the head is shown (figure 1).

Figure 1

CT scan of the head without contrast.

Question

What is the most likely diagnosis?

A. Cerebral haemorrhage

B. Brain metastasis

C. Cerebral fat embolism

D. Diffuse axonal injury




Emergency medicine research: how far have we come and where are we heading?

2018-02-20T06:19:05-08:00

Introduction

To misquote Isaac Newton, we all hope to see further by standing on the shoulders of giants. But which giants? In the early days of Emergency Medicine, we inherited the commonly accepted system of apprenticeships; practice was based not so much on what was known but on what our bosses thought they knew. Added to this the widely held but quite unfair view among other medical professionals that ‘casualty’ was for those who could not make the grade in a proper discipline and you had all the ingredients for an evidence-free specialty.

Our founding fathers were aware of this potential pitfall; they knew there were unknowns and even unknown unknowns in the path towards an evidence-based, scientific specialty—as we can read in the early papers of the Casualty Surgeons Association (CSA). The agenda for their meeting in Salford on 16 November 1973 contains wildly ambitious proposals: University Posts...




Emergency Medicine: great papers from the Summer of Love to 2017

2018-02-20T06:19:05-08:00

Introduction

Reviewing the landscape of Emergency Medicine (EM) publication and research over the past 50 years is an immensely rewarding exercise and emphasises with absolute clarity how far we have come as a specialty in such a relatively short time. The key words which apply to the review are prescient and resonant. The pioneering research undertaken in the earlier years of the specialty represents the very bedrock on which stands Emergency Medicine as we know it today. This paper will highlight some of the key publications during the 50 years of Emergency Medicine in the UK.

Great papers then and now

During the early years from 1967, issues regarding Emergency Medicine in the UK were published in the British Medical Journal  (BMJ) and Lancet, in the absence of any specific journal for the specialty then known as Accident and Emergency Medicine. In USA, the first edition...




How can emergency physicians harness the power of new technologies in clinical practice and education?

2018-02-20T06:19:05-08:00

As the Royal College of Emergency Medicine looks back on 50 years of progress towards the future it is clear that new and emerging technologies have the potential to substantially change the practice of emergency medicine. Education, diagnostics, therapeutics are all likely to change as algorithms, personalised medicine and insights into complexity become more readily available to the emergency clinician. This paper outlines areas of our practice that are already changing and speculates on how we might need to prepare our workforce for a technologically enhanced future.




How do we educate the next generation of emergency physicians: RCEM 50

2018-02-20T06:19:05-08:00

‘The great aim of education is not knowledge but action.’ H. Spencer

Introduction

The training needs of the next generation are based on the needs of the population they serve.1 These are the basis for curricula and each developed Emergency Medicine (EM) system has one. There is a move away from training based on time served or a list of EM presentations to be covered to one based on generic capabilities and defined activities that an EM clinician will have to do at work. This is happening in Australasian, Canadian and now UK EM education.

Generic competences for EM training has been described by FACEM in Australia in a curriculum framework.2 The Canadian Association of Emergency Physicians are changing their curriculum design as part of a national move to Competency-Based Medical Education (CBME).3 They have had a national generic framework of...




Characteristics and occurrence of type 2 myocardial infarction in emergency department patients: a prospective study

2018-02-20T06:19:05-08:00

Objective

To identify differences in prevalence, demographics, clinical features and outcomes for type 1 myocardial infarction (T1MI) and type 2 myocardial infarction (T2MI) in a cohort of patients presenting to the Emergency Department (ED) with chest pain.

Methods

This was a post hoc analysis of data collected from two prospective studies. Data were collected between November 2008 and February 2011 for the first study, and between February 2011 and March 2014 for the second. Participants were patients presenting to the ED with symptoms suggestive of acute coronary syndrome (ACS). The outcome was 30-day diagnosis; classified into T1MI, T2MI or non-MI. Descriptive statistics were used to compare the demographics, clinical history and presenting symptoms across diagnoses (T1MI, T2MI and non-MI). Cumulative mortality over 1 year was compared for T1MI and T2MI.

Results

147 patients (6.3%; 95% CI 5.3% to 7.3%) were classified as T1MI and 52 (2.2%; 95% CI 1.7% to 2.9%) were classified as T2MI. T2MIs were more likely to be female (OR 4.71, 95% CI 2.28 to 9.76), have an abnormal but non-ischaemic ECG (OR 2.95, 95% CI 1.45 to 6.00), report prior hypertension (OR 2.83, 95% CI 1.35 to 6.12), have tachycardia (OR 9.26, 95% CI 3.08 to 30.77) and pain at rest (OR 3.04, 95% CI 1.28 to 8.02) compared with T1MI. One-year mortality was similar between T1MI and T2MI (9% and 14.6%, respectively, p=0.37).

Conclusions

T2MIs comprised one quarter of all MIs diagnosed in the ED. Among patients presenting to the ED with symptoms of ACS, symptoms do not allow clinicians to reliably differentiate patients with T1MI and T2MI. Prior hypertension, tachycardia and abnormal non-ischaemic ECGs are seen more often in T2MI compared with T1MI. One-year mortality was substantial in patients with T1MI and T2MI, but low power precludes conclusions about mortality differences between groups.




Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

2018-02-20T06:19:05-08:00

Background

Hypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of hypocalcaemia in military trauma patients receiving blood products en route to a deployed hospital facility and to determine if intravenous calcium, given during the prehospital phase, has an effect on admission calcium levels.

Methods

This was a retrospective review of patients transported by the UK Medical Emergency Response Team in Afghanistan between January 2010 and December 2014 who were treated with blood products in the prehospital setting. Total units of blood products administered, basic demographics, Injury Severity Score and trauma type were collected. Ionised serum calcium levels on admission to hospital were compared between those who received blood products without prehospital intravenous calcium supplemental therapy (non-treatment) and patients who were treated with 10 mL of intravenous calcium chloride (10%) concurrently with blood products (treatment).

Results

The study included 297 patients; 237 did not receive calcium and 60 did. The incidence of hypocalcaemia in the non-treatment group was 70.0% (n=166) compared with 28.3% (n=17) in the treatment group. Serum calcium levels were significantly different between the groups (1.03 mmol/L vs 1.25 mmol/L, difference 0.22 mmol/L, 95% CI 0.15 to 0.27). In the non-treatment group, 26.6% (n=63) had calcium levels within the normal range compared with 41.7% (n=25) in those who received calcium. There was a dose response of calcium level to blood products with a significant decrease in calcium levels as the volume of blood products increased.

Conclusion

Trauma patients who received blood products were at high risk of hypocalcaemia. Aggressive management of these patients with intravenous calcium during transfusion may be required.




Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial

2018-02-20T06:19:05-08:00

Objective

To determine if intravenous paracetamol was superior to oral paracetamol as an adjunct to opioids in the management of moderate to severe pain in the ED setting.

Methods

A prospective, randomised, double-blind, double-dummy, controlled trial was conducted at a single academic tertiary care ED. Adult patients with moderate to severe pain were randomly assigned to receive either the intravenous paracetamol or oral paracetamol. The primary outcome was Visual Analogue Scale (VAS) pain reduction at 30 min. A clinically significant change in pain was defined as 13 mm.

Results

87 participants were included in the final analysis, with a median age of 43.5 years and 59.8% were female. Overall mean baseline VAS pain score was 67.9 mm (±16.0). Both formulations achieved a clinically significant mean pain score reduction at 30 min, with no significant difference between the groups with 16.0 mm (SD 19.1 mm) in the intravenous group and 14.6 mm (SD 26.4) in the oral group; difference –1.4 mm (95% CI –11.6 to 8.8, P=0.79). Secondary outcomes, including postintervention intravenous opioid administration, patient satisfaction, side effects and length of stay, did not differ between groups.

Conclusions

Overall, there was a small but clinically significant decrease in pain in each group. No superiority was demonstrated in this trial with intravenous paracetamol compared with oral paracetamol in terms of efficacy of analgesia and no difference in length of stay, patient satisfaction, need for rescue analgesia or side effects.




The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED

2018-02-20T06:19:05-08:00

Background

Return ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human telephone input into digital data. Use of IVRS has been explored in many healthcare settings but to a limited extent in the ED. We determined the feasibility of using an IVRS to assess for adverse events after ED discharge.

Methods

This before and after study assessed detection of adverse events among consecutive high-acuity patients discharged from a tertiary care ED pre-IVRS and post-IVRS over two 2-week periods. The IVRS asked if the patient was having a health problem and if they wanted to speak to a nurse. Patients responding yes received a telephone interview. We searched health records for deaths, admissions to hospital and return ED visits. Three trained emergency physicians independently determined adverse event occurrence. We analysed the data using descriptive statistics.

Results

Of 968 patients studied, patients’ age, sex, acuity and presenting complaint were comparable pre-IVRS and post-IVRS. Postimplementation, 393 (81.7%) of 481 patients had successful IVRS contact. Of these, 89 (22.6%) wanted to speak to a nurse. A total of 37 adverse events were detected over the two periods: 10 patients with 10 (6.5%) adverse events pre-IVRS and 16 patients with 27 (16.9%) adverse events post-IVRS. In the postimplementation period, the adverse events of seven patients were detected by the IVRS and five patients spontaneously requested assistance navigating post-ED care.

Conclusions

This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.




A diagnostic red herring

2018-02-20T06:19:05-08:00

Clinical introduction

A 29-year-old keen parachutist presented to the emergency services in Cyprus complaining of sudden-onset facial flushing, dizziness and a widespread rash. The episode began on a hot day, 1 hour after she had eaten a breakfast of tinned tuna, and while she was ascending in an aircraft to parachute from 10 000 ft. She completed her jump uneventfully. She had no significant medical history (figure 1).

Figure 1

Patient’s legs on presentation; this rash was generalised.

Question

Based on the history and rash, which ONE of the following is the most likely diagnosis?

  • Fish allergy

  • Heat-related eruption

  • Scombrotoxin poisoning

  • Stress-induced urticaria




  • What do emergency physicians in charge do? A qualitative observational study

    2018-02-20T06:19:05-08:00

    Introduction

    The emergency physician in charge role has developed in many large EDs to assist with patient flow. We aimed to describe and classify the problem-solving actions that this role requires.

    Methods

    We interviewed senior emergency physicians and performed iterative, qualitative observations, using continuous reflective inquiry, in a single centre. We reviewed and classified these approaches by consensus.

    Results

    Nine different problem-solving approaches were identified. These are deflecting, front loading, placing, plucking, flooding, targeting, chasing, guiding and juggling. These are useful for training and developing our understanding of how to manage an ED.

    Conclusions

    Emergency physicians in charge have a number of problem-solving approaches that can be readily defined. We have described and categorised these. These results are potentially useful for developing decision support software.




    Using an alumni survey to target improvements in an emergency medicine training programme

    2018-02-20T06:19:05-08:00

    Introduction

    The Accreditation Council for Graduate Medical Education (ACGME) is the governing body responsible for accrediting graduate medical training programme in the USA. The Emergency Medicine Milestones (EM-Milestones) were developed by the ACGME and American Board of Emergency Medicine as a guide and monitoring tool for the knowledge, skills, abilities and experiences to be acquired during training. Alumni surveys have been reported as a valuable resource for training programme to identify areas for improvement; however, there are few studies regarding programme improvement in emergency medicine. We aimed to use the EM-Milestones, adapted as an alumni self-assessment survey, to identify areas for training programme improvement.

    Methods

    This study was conducted at an urban, academic affiliated, community hospital in New York city with an emergency medicine training programme consisting of 30 residents over 3 years. Alumni of our emergency medicine training programme were sent an EM-Milestones-based self-assessment survey. Participants evaluated their ability in each EM-Milestones subcompetency on a Likert scale. Data were analysed using descriptive statistics.

    Results

    Response rate was 74% (69/93). Alumni reported achieving the target performance in 5/6 general competencies, with Systems-Based Practice falling below the target performance. The survey further identified 6/23 subcompetencies (Pharmacotherapy, Ultrasound, Wound Management, Patient Safety, Systems-Based Management and Technology) falling below the target performance level.

    Discussion

    Alumni self-evaluation of competence using the EM-Milestones provides valuable information concerning confidence to practice independently; these data, coupled with regular milestone evaluation of existing trainees, can identify problem areas and provide a blueprint for targeted programme improvement.




    Understanding cardiac troponin part 2: early rule out of acute coronary syndrome

    2018-02-20T06:19:05-08:00

    Chest pain of suspected cardiac origin is a very common emergency department presentation. Over the past decade, there has been an exponential growth in strategies that promote blood sampling at earlier and earlier time points after presentation to facilitate the rule out of acute coronary syndrome.

    In part 2 of this series, we examine key concepts from the recent literature with the aim of improving clinicians’ understanding of the rule-out strategies available to them and provide a structured overview of strategies that facilitate discharge with blood testing over <3 hours.




    Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary

    2018-02-20T06:19:05-08:00

    Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews but rather contain the best (highest level) evidence that can be practically obtained by busy practising clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line that indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.

    The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently...




    Bet 1: A slower rate of initial N-acetylcysteine infusion in the treatment of acute paracetamol overdose to reduce adverse reactions

    2018-02-20T06:19:05-08:00

    Clinical scenario

    While on a clinical shift in the emergency department you attend to a 24-year-old female who has taken a clinically significant paracetamol overdose and requires N-acetylcysteine (NAC), you are wondering if a reduction in infusion rate of NAC will reduce adverse side effects such as vomiting and nausea?

    Three-part question

    In an adult who has taken an acute clinically significant paracetamol overdose requiring treatment, does reducing the rate of the initial dose of NAC reduce adverse effects?

    Search strategy

    Ovid MEDLINE 1946 to present.

    Embase 1974 to 10 January 2018.

    paracetamol.mp OR acetaminophen/.exp OR paracetamol sulpahte.mp OR paracetamol derivative.mp AND Drug Overdose.exp OR Overdose.mp OR Poisoning.mp.exp OR ‘Chemical and drug induced Liver Injury’.exp OR paracetamol overdose.mp OR suicide, attempted.exp, OR self harm.mp or Suicide.exp AND acetlyceysteine.exp.mp OR NAC.mp OR antidote.mp OR antidotes.exp OR n-acetylcysteine.mp

    Limits: English language and humans.

    Results

    This...




    Bet 2: Estimating CD4+ counts from the absolute lymphocyte count in the ED

    2018-02-20T06:19:05-08:00

    Clinical scenario

    A 37-year-old patient who has never been to your hospital presents for shortness of breath. He reports a history of HIV but is not currently on treatment and does not know his last CD4+ count. His oxygen saturation is 94% on room air, and lung sounds are distant. His CXR shows possible interstitial markings in the right middle lobe, his LDH is 240, absolute lymphocyte count (ALC) is 2200 and he has a normal A-a gradient. In addition to covering for community-acquired pneumonia, should TMP/SMX be started in the emergency department?

    Three-part question

    In patients with known HIV, can the ALC accurately identify those with a CD4+ of <200?

    Search strategy

    PubMed via MEDLINE was searched as follows: November 2017.

    CD4[All Fields] AND ‘absolute lymphocyte’[All Fields]; CD4[All Fields] AND ‘absolute lymphocyte’[All Fields]; ‘total lymphocyte count’[All Fields] AND (estimated[All Fields] AND CD4[All Fields])....




    Correction: Best evidence topic reports

    2018-02-20T06:19:05-08:00

    Body R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Emerg Med J 2017;34:852-857.

    The authorship of this article is as follows: ’Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary' was edited by Richard Body, while ’Sharing decisions for patients with suspected cardiac chest pain in the emergency department' was authored by Abigail Ward and Charles Reynard.

    Richard Body, Abigail Ward and Charles Reynard are affiliated with the Department of Emergency, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK, and the Manchester Academic Health Science Centre, University of Manchester, Manchester, UK




    Abstracts from international Emergency Medicine Journals

    2018-02-20T06:19:05-08:00

    Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.




    What we can learn from global emergency medicine

    2018-02-20T06:19:05-08:00

    Context

    When discussing efforts, experiences and ambitions related to global emergency medicine (EM), I am often met with a variety of responses from colleagues, ranging from genuine interest and curiosity, to tolerance or disdain, and occasionally supportive like-mindedness. Part of the challenge has been to grapple with the stigma that can be associated with healthcare workers that volunteer or work in developing settings (part-timers, travel junkies, commitment issues), and articulating the relevance of the value they bring back to their home institutions. While there has been a recognition of the skills brought back to the NHS by those working overseas as outlined in the 2007 Crisp report on global health partnerships, these messages remain difficult to filter in times of increasing burden and strain on our Emergency Departments (ED). However, it may be precisely for these reasons that a global outlook needs to be embraced as we develop solutions...