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Diagnosing Small Bowel Obstruction in the ED: A Role for Ultrasound?

23 May, 16 | by rlloyd

real
Diagnosing small bowel obstruction (SBO) is bread-and-butter work for the emergency physician. It accounts for 2% of patients presenting to the ED with abdominal pain, and 20% of all surgical admissions[1]. In the developing world the majority of SBO patients have had previous intra-abdominal surgeries causing adhesions… But I won’t delve into aetiology, let’s talk diagnostics.

The May 2016 EMJ issue’s ‘Image Challenge’ is a classic case[2]. An adult male with significant surgical history (caecal adenocarcinoma with subsequent right hemicolectomy) presents to the ED complaining of abdominal pain and vomiting. His abdomen is distended and diffusely tender. Slam dunk.

How would I manage this patient in the ED? Having made them nil by mouth, started IV fluids, and given adequate analgesia, I’ll request the routine plain x-rays (abdominal and erect chest) that almost all of my acute abdomen patients get. A positive AXR for SBO (centrally distributed dilated loops with valvulae conniventes/air fluid levels) will prompt me to insert a nasogastric tube, and call the surgeons with a view to CT/a trip to theatre. I imagine that’s fairly common practice up and down the UK.

The image provided for the discussed case is an ultrasound image showing dilated, fluid-filled loops of bowel – suggestive of SBO. It turns out AXR is pretty useless at detecting SBO, particularly when you consider how much we rely on it traditionally, with a sensitivity of 50-60%[3]. Ultrasound is a quick, cheap, radiation-free option available to us in the ED. And guess what? It’s more reliable than AXR for detecting SBO. Some evidence was published in the EMJ back in 2013 – let’s take a look. 

Jang et al prospectively enrolled 76 adults in the ED who were suspected to have SBO, and going for a CT[4]. All patients had an ultrasound exam performed by an EM resident, along with an AXR interpreted by a radiologist. The reference standard for SBO diagnosis was the CT result.

Each EM resident already had a basic understanding and experience of point-of-care scanning, having all undergone a prior introductory course. They were given only a 10 minute (!!) practical tutorial in SBO ultrasonography, and then 5 practice scans prior to being let loose on the study patients. A 10 minute tutorial is fairly minimal prep I think most would agree.

A positive ultrasound was defined as either:

  1. Dilated loops (>2.5cm) of fluid-filled dilated bowel proximal to normal/collapsed bowel
  2. Reduced peristalsis – back-and-forth movement of spot echoes inside fluid-filled bowel

Participants were taught to scan in the paracolic gutters bilaterally, epigastric and suprapubic regions. This is the standard approach to SBO ultrasound – see this video for a great tutorial on how to perform the scan. Interestingly, in this study the phased array probe was used instead of the curvilinear – the usual option for transabdominal scanning.

Ultrasonography comfortably outperformed plain radiography in detecting SBO. A sensitivity of 93.9% and specificity of 81.4% left AXR trailing behind with a sensitivity of 46% and specificity of 67%. Dilated loops on ultrasound proved to be far more sensitive than reduced peristalsis – probably because reduced peristalsis is generally considered to be a late finding in SBO, often seen with strangulation[5].

Of course there are limitations with this small study. There was a disproportionately high prevalence of SBO in the study population (33 out of 76 patients – 43%), bringing into question its external validity. The doctors performing the US exams volunteered themselves, indicating they were enthusiasts – potentially introducing what the authors describe as ‘ultrasound-interest’ bias. And of course, the participants knew they were being compared to a standard, bringing the Hawthorne Effect into play. Nonetheless, pretty convincing stuff.

And there’s more. Here is some further reading:

Unluer, E.E., et al., Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med, 2010. 17(5): p. 260-4.

Schmutz, G.R., et al., Small bowel obstruction: role and contribution of sonography. Eur Radiol, 1997. 7(7): p. 1054-8.

Something else to consider, is that additional information can be picked up when performing a bedside scan on a patient in whom there is a concern for SBO – free fluid between bowel loops, no peristalsis, or >3mm bowel wall thickening suggests bowel wall ischaemia[6]. Gallstones in the presence of dilated loops? Think gallstone ileus. A lurking AAA might even be picked up.

I’m not suggesting that plain radiography no longer has a role in the suspected SBO patient. Surely though, adding bedside ultrasound to our list of investigative options is an opportunity to improve patient care. A negative scan would provide added reassurance when ruling the diagnosis out in less concerning patients; and we can expedite initial/definitive management in the high-risk patients who have an equivocal AXR.

Ultrasound will always be operator-dependent, but Jang et al have demonstrated that scanning for SBO is a relatively easy skill to acquire. Encouraging stuff.

What is your approach? Does ultrasound have a role in these patients? We would love to hear your thoughts in the comments.

Robert Lloyd

Some more online resources

A video with some more discussion on the Jang paper – the Ultrasound Podcast

Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool

Ultrasound for Small Bowel Obstruction – emDocs blog

References

  1. Delabrousse, E., et al., CT of small bowel obstruction in adults. Abdom Imaging, 2003. 28(2): p. 257-66.
  2. John Eicken, S.E.F., Image challenge: Adult male with abdominal pain and vomiting. Emerg Med J 2016;33:5 337 doi:10.1136/emermed-2015-205181.
  3. Dr Henry Knipe, D.J.J., Small Bowel Obstruction, in Radiopaedia.org.
  4. Jang, T.B., D. Schindler, and A.H. Kaji, Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J, 2011. 28(8): p. 676-8.
  5. Guttman, J., et al., Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department. CJEM, 2015. 17(2): p. 206-9.
  6. Alice Chao, M.a.L.G., MD, FACEP, Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool? Emergency Ultrasound Section Newsletter – October 2014.

New RCEM Guidelines – Acute Behavioural Disturbance

19 May, 16 | by cgray

RCEM ABD

The Royal College of Emergency Medicine in the UK has today published new guidelines (PDF) on the management of acute behavioural disturbance (ABD) in the emergency department. This follows a year after NICE guidance was released on the management of violence and aggression, but focuses specifically on ABD. The guidelines have been published in conjunction with the Faculty of Forensic and Legal Medicine.

ABD is a medical emergency, comprising acute delirium in conjunction with autonomic dysfunction. Sudden death occurs in around 10% of presentations. It can be challenging clinically as there is no definitive diagnostic investigation, and symptoms can overlap with multiple severe and life-threatening presentations such as serotonin syndrome and heat stroke.

The main recommendations in the guidelines are:

  • Restraint measures should commence with verbal calming and de-escalation techniques. Physical restraint should be kept to a minimum and used as a last resort option to facilitate chemical sedation.
  • Sedation should ideally be administered intravenously, however this comes with safety considerations and clinicians should keep these in mind. Dynamic risk assessment may prompt intramuscular (IM) sedation followed by cannulation.
  • Intramuscular lorazepam is recommended for first line use by NICE, however benzodiazepines have a variable response between patients and may require active titration. Onset time is also slow and can be unpredictable when given IM. Ketamine has a more consistent profile and has the benefits of airway reflex and respiratory drive preservation, though could theoretically worsen any cardiac instability. Clinicians should use sedatives that they are familiar with, full patient monitoring should be used, and early anaesthetic input should be sought.
  • Patients should be closely monitored for development of hyperkalaemia, rhabdomyolysis and disseminated intravascular coagulation (DIC), both clinically and by utilising appropriate blood tests.
  • Active cooling should be undertaken early and aggressively to treat hyperthermia.
  • Intravenous fluids should be used early to treat hypovolaemia and correct metabolic acidosis.
  • Patients are likely to require ongoing management in a critical care environment. This should be decided on an individual basis.

This is a summary of the guidance. The full document can be read here together with references and a table of dose, onset and duration for commonly used sedatives and tranquillisers.

UK emergency department performance: Failure or Success.

14 May, 16 | by scarley

GEY

Recent figures suggest that UK emergency systems are failing to meet the 4-hour standard (aka the 4 hour target). At first glance this is true the data shows that 88.7% of patients are seen and discharged/admitted within 4 hours as compared to the target (I’m going to stick with target) of 95%.

This has been described as ‘worst ever month’ and if we look at simple percentages that’s true.

Sadly, comments such as failure and worst are demoralising for the teams who are working really hard to deliver emergency care in an overworked and stressed system. The key here is in the percentages, they underestimate the number of patients actually seen in a system that is seeing more patients every year.

It is perhaps worthy to note that in the last quarter figures there were 5,867,323 attendances at UK emergency departments. Of these 711,201 waited more than 4 hours.

In other words we managed 5.15 Million patients within the 4 hour target.

Well done all. This is not a failure, it’s an incredible achievement considering the current staffing, political and financial climate. Times are tough, the target may not be met, but let’s keep some perspective.

This is a huge achievement.

vb

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Further reading

BBC on worst ever results for UK Emergency care

RCEM response to figures

King’s fund response to latest statistics.

NHS emergency care statistics

Highlights from the May 2016 issue.

11 May, 16 | by scarley

Simon Carley, Social Media Editor

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I’m rather hoping that in the Northern Hemisphere at least, our May edition will feel as though summer has arrived with perhaps slightly more time for personal and organisational development. Winter was tough here in the UK, so let’s hope the better weather brings a bit of relief. Even now crowding looms large in our collective memory with an interesting paper and accompanying editorial focusing on its effect on our emergency departments (EDs).

The complexities of measuring crowding in the ED

Adrian Boyle and colleagues examined two scoring systems, NEDOCS and sICMED together with staff perceptions to look at ways of measuring crowding in the ED. Clearly crowding is a multifactorial perception including aspects such as patient load, flow and severity. They collected real time data using these measures demonstrating that some of this data can be collected in real time but that they cannot reflect hour by hour variation. Further work is needed to give us a score that could be used to track and compare ED crowding and it’s inherent dangers to patients and staff.

Parents, paediatrics and perceptions

As a consultant who works in a paediatric ED I can understand why Astha Singal and colleagues decided to examine avoidable paediatric ED visits. Although this study is from the US, with alternative funding and insurance mechanisms the implication here about increasing numbers of primary care visits to the ED for children will be familiar to many of us, regardless of where we work. They found that the families socio-economic position, notably food security, was a strong predictor of attendance. Many parents agreed that alternative health providers could have cared for their children, but difficulties in accessing alternative services led to children being brought to the ED. This is another useful study demonstrating that public health and economic factors have significant impact on our workload and patient mix.

Paediatric early warning score scores and predictions

More paediatrics from the UK this month with an analysis of the ability of paediatric early warning score (PEWS) to predict admission and significant illness. PEWS has certainly been popular in recent years, with several papers published in the EMJ on the subject, but the score was designed to be used in the in patient setting, In this single centre study PEWS performance was assessed in the ED population. Interestingly they found a high specificity, but low specificity which is typically the opposite of what we require of an ED screening tool. The reported sensitivity, as low as 30%, means that it’s ability to screen for significant illness or admission is too low. Perhaps we need something better derived from the ED population.

Tanzanian Gestalt for anaemia

In this study clinicians were challenged to predict the outcomes of a blood count using clinical judgment (described as Gestalt in this paper). In this clinical setting anaemia is common and an important diagnostic finding. Clinically the physicians did well as measured by concordance, but that is to be expected. However, their ability to pick up severe anaemia only had a sensitivity of 64%, and for moderate anaemia only 56%. This may be on the low side for clinical practice and thus laboratory testing will still be needed. The specificity for moderate and severe anaemia was better and may be high enough to guide resuscitation whilst waiting for the lab results.

Tailored training improves CPR performance

Govender and colleagues examined the impact of a tailored teaching programme to teach CPR to paramedics. The addition of tailored pre and post interventions improved performance. The bottom line is that if you teach people more often and with a range of materials they learn more and can do better.

Transcutaneous carbon dioxide

We frequently measure CO2 levels in the ED, with the use of arterial blood gases acting as the gold standard. However, these can be difficult to obtain, painful for the patient and are not without potential complications. A non-invasive method would surely be better and such devices do exist. This month Nicolas Peschanski and colleagues compare transcutaneous readings with arterial samples amongst patients with respiratory problems in the ED (the group we would be interested). Sadly only about a third of readings were within 5 mm Hg between the non invasive method and the blood gas. Clearly we can’t abandon the blood gas yet.

Prehospital referrals for falls

Elderly fallers are a high risk population for all in emergency medicine and in prehospital care. A simple fall may be a harbinger of significant pathology that may be eminently treatable. In this systematic review by Zozula et al the evidence for prehospital teams assessing and referring patients for referral to falls services shows that the evidence base is pretty weak. In this incredibly important area we clearly need better work linked to patient outcomes before we can assess the impact of prehospital referral.

Stress tests after Troponin

There has been a huge amount of work regarding the exclusion of myocardial damage using troponin testing in the ED. However, thee have been concerns that simply troponin testing will miss patients with significant coronary disease, but who have yet not manifest myocardial damage as shown by a troponin leak. In this study by Aldous and colleagues they looked at patients who were negative for troponin tests, but who then had a stress test. Interestingly they identified 34 patients from 709 who subsequently went on to revascularization. It’s tricky to know what this means for clinical practice, and of course we must remember that the new generation of high sensitivity troponins might yield a different result.

Acute Kidney Injury in the ED

Finally, we have a review article from Patrick Nee and colleagues on the recognition of Acute Kidney Injury in the ED. This is a common problem in the ED and one where emergency physicians should have some expertise in. It’s also quite a common question in exams, so there is something for everyone on this important topic.

Highlights from the April 2016 issue.

11 Apr, 16 | by scarley

Ellen J Weber, Editor in Chief

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CLICK HERE FOR THE APRIL TABLE OF CONTENTS

The articles in this issue are about error. Error was rarely discussed “out loud” in the medical journals until the Institute of Medicine (IOM) in the US published its 1999 report “To err is human” documenting the many lives that were lost as a result of errors in the delivery of health care.1 Even today, physicians find it hard to talk about their errors, not simply because of the fear of a lawsuit, but out of embarrassment and their sense of personal failure. In the years since the IOM report, we’ve seen much more in the news, the peer-reviewed literature and from the leadership of our institutions about avoiding errors, much of it couched under kinder terms, such as safety and quality. To avoid laying blame (which might hinder disclosure of errors), the focus has shifted to how systems of care contribute to a patient sustaining harm. Anyone who has attended a patient safety lecture has been entertained by Reason’s diagram of all the holes in the swiss cheese lining up.2

But to face facts, physicians do make errors. And while it is important to engineer the delivery system so that the errors can be caught (and sometimes prevented), we also need to understand how our own thinking processes lead us to make errors in the first place. For this reason, our issue on error begins with an insightful commentary by Pat Croskerry, an emergency physician and psychologist who is an internationally recognised expert on patient safety and diagnostic errors. Cognitive bias, he explains, is lurking behind every patient interaction to potentially trip us up. Finding ways to recognise—and mitigate—that cognitive bias is essential to improving our ability to make good diagnostic decisions.

We then present two ‘studies in scarlet,’ so to speak: investigations of the types of diagnostic errors physicians make. Okafor and colleagues analysed 509 incidents voluntarily reported by physicians and found that 209 were related to diagnostic errors. They classified the errors as cognitive, system related or unremediable; while system factors were found in 34% of cases, cognitive errors were more frequent, occurring in 41% of cases. Medford-Davis and colleagues reviewed the charts of 100 adult ED patients presenting with abdominal pain who were discharged, or who returned within the next 10 days and were hospitalised. 35 of the patients had diagnostic errors, with about ½ of these considered to have the potential for serious harm. Most of the errors could be classified as due to failure to obtain an appropriate history or physical, not ordering appropriate tests, and failure to follow up on the tests.

In a third report by Broder and colleagues, you will undoubtedly identify with the young emergency physician who finds himself in the middle of a procedure with an unfamiliar piece of equipment, and continues the procedure, with a resulting complication. The paper dissects many contributors to error: perceived time constraints, lack of experience, lack of control over the environment (such as equipment choices) over-confidence, and non-intuitively designed and marked devices. This paper, which might rightly be titled “anatomy of an error” also demonstrates what measures can be taken to prevent this from happening again.

Looking at our errors is one way to avoid them in the future. Additionally, we need, as Dr Croskerry writes, to devise strategies to mitigate our cognitive bias. One of these is to improve the accuracy and details of our history and physical examination, as greater understanding of the problem can prompt a wider differential. I would argue this is particularly important for our younger physicians, who have not encountered the breadth of disease or its many manifestations, and who may be too quick to jump to an investigation to answer the question. Two papers in this issue address workplace strategies to avoid errors for cases that may be particularly challenging. Haworth et al created a proforma for the documentation of the exam in patients with facial injuries, resulting in much more detailed description of injuries. Marsh et al took advantage of the imprinting of childhood games by adapting “Rock, Paper Scissors” (in Brooklyn NY it was “rock, paper, scissors, match, actually) to “Rock, Paper, Scissor, OK”, creating an aide memoire for examining nerve function in children with upper extremity injuries.

What about pre-hospital care? Patterson and colleagues, who previously published a study in the EMJ about teammate familiarity in the ED, provide a study demonstrating workplace injuries are far more frequent (100 fold) for paramedics who worked one shift together compared with those who work 10 or more together in a two-year period. Murphy and colleagues describe the development of key performance indicators for prehospital care, going far beyond the traditional focus on response time. While conducted in Ireland, the results of this study have universal application. This month’s View from Here describes a stabbing case in which the victim received suboptimal care—and how they have used this event to make major improvements.

Finally, we present a provocative idea that may allow physicians to acknowledge uncertainty. In our first “Concepts” paper, Whyte and Vincent remind us of the concept of measurement uncertainty (MU) which gives a range of the possible values of the test, rather than single figure. The authors argue that by reporting MU clinicians would need to rely on their clinical impression (based on history and physical) to interpret the result, thereby restoring the power of clinical observation expounded by Sir William Osler.

Given all these articles on error and how we might prevent it, you might wonder how safe emergency medicine is. Ramlakhan and colleagues review the many potential hazards we face, and the data on how they impact patient safety. Surprisingly, they conclude that “when compared with other clinical areas or specialties, the ED is not particularly unsafe.” Perhaps its because, as this issue shows, we are willing to think about thinking, acknowledge our errors, and are continually working to mitigate against the threats we face, even if in the end, we are only human.

Highlights from the March 2016 issue.

11 Mar, 16 | by scarley

Richard Body, Associate Editor

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DOWNLOAD THE TABLE OF CONTENTS HERE

The burden of alcohol

Anyone who works in an Emergency Department (ED) will know how many attendances seem to be related to the use of alcohol. In this issue, the paper by Parkinson et al quantifies the problem, informing us about the proportion of cases that are attributable to alcohol and the most common reasons for alcohol-related attendance. They also estimate the substantial financial cost that this incurs. This fascinating study combined a retrospective chart review of attendances and a prospective evaluation in which breath alcohol concentration was measured in patients attending the ED. The authors found that the peak time for alcohol-related attendances was between 2am and 3am, during which period 59% of patients attending the ED had ingested alcohol. Looking only at attendances on Fridays and Saturdays between 2am and 3am, a staggering 71.9% of all attendances were alcohol-related. One in every six of these patients was admitted to an inpatient ward at a mean cost of £851 per patient, which makes for an expensive night out on the National Health Service. Building on and interpreting those findings, the President of the Royal College of Emergency Medicine asks what we can do to address this problem. In a fascinating commentary, Dr Cliff Mann discusses the potential role of everything from alcohol pricing to licensing hours.

Perimortem caesarean section

There is little doubt that one of the most stressful situations an emergency physician can ever face is to be responsible for treating a heavily pregnant woman in cardiac arrest. Emergency physicians will be fully aware of the need to rapidly proceed to emergent caesarean section, but (given that this is thankfully an extremely rare situation) how many of us are actually prepared to undertake that procedure? Richard Parry provides a comprehensive overview of this procedure including a very practical 25-step ‘how to’ guide that is likely to be an extremely valuable resource for emergency physicians. Dr Parry goes on to appraise the evidence for this procedure, highlighting the ‘4 minute rule’ to deliver the baby and how the evidence supports the time critical nature of peri-mortem caesarean section as a means of preventing neurological sequelae for the baby. Clearly, minutes matter.

Editor’s choice: Can ultrasound confirm central line placement?

Central venous catheter (CVC) placement is another intervention that is often time critical in the ED. Confirming accurate line position can be time consuming, however, when we rely on chest radiographs. This month the Editor’s choice is a prospective cohort study from North Carolina in the United States, which compares the use of ultrasound with chest radiography (the reference standard) for confirming CVC placement. Although the number of line misplacements was small (n=4), this study has described a promising technique (the saline flush echo test) that effectively had 75% sensitivity for detecting suboptimal CVC tip placement. Perhaps the greatest advantage of ultrasound over chest radiography was the time taken to test completion, which was a median of 23.8 minutes faster with ultrasound.

Reader’s choice: Frequent users of the ED

Perhaps at the other end of the spectrum for ‘excitement’ in Emergency Medicine, frequent attendees can account for a significant proportion of the ED workload. When patients attend the ED very regularly, it may be tempting to feel reassured and potentially (heaven forbid) even slightly cynical about the nature of their acute complaint. The systematic review by Moe et al examined prognosis in this group. Perhaps unsurprisingly for experienced emergency physicians, five out of six studies identified reported that frequent attendees have higher mortality than non-frequent attendees with a median odds ratio of 2.2. Frequent attendees were also more likely to be admitted to hospital and to use outpatient services following their ED attendance. The work highlights the need to take this important and vulnerable group of patients seriously and calls us on to undertake further research that may help to address their adverse prognosis.

Procedural sedation: Patient’s choice?

Procedural sedation is a core skill in Emergency Medicine in order to facilitate the undertaking of procedures that may otherwise be unbearably painful for patients. It is tempting to assume that our use of conscious sedation will leave patients blissfully unaware of the procedure afterwards. However, as Dr Gavin Lloyd and Dr Alasdair Gray discuss in a stimulating editorial, this may not be an accurate assumption to make. They discuss a recent report from the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain & Ireland, which recommends avoidance of falsely reassuring terminology when explaining procedural sedation to patients, and they call us on to seek feedback from patients after the procedure in order that we may know how satisfied they were and whether they did, in fact, have any painful recall.

Highlights from the February 2016 issue.

11 Feb, 16 | by scarley

Simon Carley, Social Media Editor

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DOWNLOAD THE TABLE OF CONTENTS HERE

Higher bed occupancy: Does it mean more deaths

In the UK we have heard a great deal about the ‘weekend effect’ the supposed increase immortality associated with weekend admissions. The size and reasons for that effect are hotly debated and in the emergency department we are used to seven day working, but what of the effect of crowding and bed occupancy? This month Boden et al show an association between bed occupancy and mortality. This is a paper you must read for yourself, as it’s quite likely to be spun by those with vested interests in this political hot potato.

Are junior ED placements stressful?

The working conditions of junior doctors in the UK are currently the focus of much political debate. Proposed changes to the national contract have spotlighted concerns about the working conditions and stressors on our junior colleagues. Mason et al studied the well being, confidence and self reported confidence of junior doctors (PGY2) working in UK emergency departments. ED placements are often quoted as being the most stressful and this study confirms this, albeit within the normal range for other health care workers. However, confidence and self-reported competence improves. The challenge for UK EDs is to diminish the stress without reducing the learning outcomes.

USS for renal stones

I’m a big fan of POCUS (point of care ultrasound), but also rather skeptical as enthusiasm does not equal science. This month we have an interesting paper looking at the surgical outcomes of 500 patients who were scanned within 24 hours of ED admission. Although not really POCUS (as these were radiologists scanning) the sensitivity for surgical intervention was high. What we don’t know is how an USS strategy might compare against the increasingly more prevalent CT strategies for the diagnosis and management of renal colic. For those working in areas where CT is unavailable this study may well help risk stratify patients.

Are guidelines good?

I frequently groan when the solution to every problem in the ED is another form, guideline or pathway, but perhaps my dismay at the formalization of medical care is unfounded. Perhaps guidelines really do improve care (I think they do really). Considering the ubiquity of guidelines it is perhaps surprising that they themselves have not been studied frequently. This month Ayobami et al evaluate the effect of introducing guidelines into a PED. Did it increase compliance? Yes. Did it affect the outcome of care? I’m not so sure as it did not alter return rates to the PED. We need more studies like this to assess the impact of process against clinical outcomes.

Whole body radiographs in acute medical emergencies

Whole body radiography has been around for some time and it’s something we looked at years ago before access to CT improved in the UK. Its still used in many areas of the world and a systematic review in this month’s journal looks at the evidence. Overall the review concludes that the system is equivalent to conventional radiography, but as we are using CT for many of these patients the generalizability needs careful consideration.

Can the VBG replace the ABG?

I’ve been lucky enough to hear Anne-Marie Kelly talk on the use of venous blood gases in critical care. She is a renowned world expert on the subject and this month she shares a review that has the potential to change clinical practice in many emergency departments. The ABG is not dead, but we may not need it quite as often as is traditionally taught.

Richer or poorer: who gets the CPR?

We know that bystander CPR is vital in the chain of survival from cardiac arrest. We also know that not enough people receive it even if people are present, but what factors might affect whether our patients receive bystander CPR. Moncur et al have looked at socio-economic status and show an association between high socio-economic status and CPR. The implications and solutions to this are unclear but may include targeted training to areas and populations with low CPR rates.

Does time affect shoulder enlocation success?

I’ve always prioritized shoulder enlocation in the ED, but largely on the grounds of analgesia and patient experience. This month Kanki et al give us another reason. In this retrospective review time delay also appears to make a difference with increasing failure with delay. It’s more evidence to prioritize and manage these patients quickly (and of course safely).

Sexual assault and the ED

A disturbing Canadian paper from Sempsel et al reminds of the frequency and characteristics of sexual assault at mass gatherings. Although the data is collected from a sexual assault centre we must remember that victims can present to the ED seeking our help and we must be prepared to support them. However, French data from Denis et al examines the experience of sexual assault victims. The expectations of victims were frequently not met, especially with regard to psychological care. This pair of papers needs careful reflection and a consideration of how we might support our patients better.

Can we spot cardiac patients at triage?

The early identification of patients with suspected acute coronary syndromes is obviously important and we rely on the triage process to do this. Carlton et al show that nurses and doctors are equally accurate with high levels of sensitivity for major adverse cardiac events at 30 day follow up.

Highlights from the January 2016 issue: Emergency Medicine Journal.

11 Jan, 16 | by scarley

Click here for full table of contents.

Screening older patients in the ED

Having screening tools that are accurate in terms of specificity and sensitivity is essential to improving care for this vulnerable group. This issue includes two papers from different parts of the world that will be of interest to ED clinicians’ intent on improving screening and outcomes for older patients attending their departments.

The ISAR tool: how useful is it?

The Identifying Seniors at Risk (ISAR) tool has mixed predictive ability. Suffoletto and colleagues in Pittsburg undertook a prospective study of 202 adults over the age of 65 presenting to the ED to evaluate the ability of the ISAR tool to differentiate between older patients having a poor outcome within 30 days of ED care and those that did not. They also sought to establish whether self-reported ISAR risk factors correlated with objective measures and whether objective measures altered predictive ability. Their findings suggest that the ISAR tool does not differentiate well between older adults with or without 30 day hospital revisit or death. Furthermore, they found that related objective risk factors did not improve the performance so, clearly, we need to develop more effective tools and in the meantime use ISAR judiciously and with caution.

Missing delirium

In Thailand, Sri-on and colleagues conducted a prospective cross sectional study to determine the prevalence of delirium in patients over the age of 65 in their urban tertiary care emergency department. A secondary objective of this study was to identify risk factors and short term outcomes in elderly patients with delirium. In their sample of 232 patients, 27 (12%) were delirious in the ED of which 16 (59%) were not recognized as being delirious by ED clinicians. Unsurprisingly, patients with delirium had a higher mortality rate than those without delirium (15% versus 2% P=0.004). These findings from a middle income country are consistent with research findings from high income countries where the detection of delirium by ED physicians is also low. Clearly raising the profile of delirium as a medical emergency as well as further training for clinicians in recognizing this reversible condition is urgently needed.

Editor’s choice

Traumatic brain injury (TBI) in young people is a common presentation to the ED and many of these children, approximately 50% undergo computed tomography (CT) even though the majority with a mild TBI GCS 13–15 have no intracranial injury. Concerns have been raised over the possible overuse of CTs because ionizing radiation can lead to malignancies, so it was interesting to read of a prospective cohort study in three paediatric emergency departments in Switzerland by Manzano and colleagues which sought to assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury. They found S100B has an excellent sensitivity but poor specificity. So, it may be an accurate tool to help rule out an intracranial injury but it cannot be used as a sole marker due to its specificity. Used with clinical decision rules, S100B may contribute to decrease the number of unnecessary CTs and this itself is worthy of further consideration.

Why is it so difficult to recruit patients to research studies in the ED?

It’s long been recognized that medical research studies frequently struggle to meet patient recruitment targets. Many of the barriers and impediments to recruiting patients will be familiar to those of us who have undertaken research in the ED. Johnson et al in the UK have attempted to explore this problem further using the large multicenter AHEAD study which recruited patients at 33 Type-1 emergency departments in England and Scotland. They found overall recruitment varied greatly between sites with an eightfold variation in recruitment rates. In addition to the usual problems already documented in the literature, detailed interviews with three research nurses from the study identified other barriers and facilitators to recruiting patients. Interestingly, key to the success of the AHEAD study was a protocol that minimized the involvement of clinicians who are invariably too busy to engage. Retrospective recruitment and anopt out consent strategy also helped. So if you are in the process of planning research do read this paper, it may well change your recruitment strategy and help you reach your target.

Reader’s choice

Attending the ED: an automatic choice – open access paper

Patients attending the ED with non-urgent medical problems is a growing problem in many parts of the world and St Vincents and the Grenadines in the West Indies is no exception.In this issue, Keizer-Beache and Gueli describe a qualitative study they undertook to understand why Vincentian patients with non urgent medical problems seek care in the emergency department rather than primary care facilities. Many of the reasons cited by participants have previously been documented and will be familiar to ED clinicians everywhere, such as convenience, dissatisfaction with primary care facilities etc. Perhaps more interestingly in this study, participants revealed that attending ED is automatic, describing this as a locally shared custom. They also suggested that this habitual use of the ED is reinforced by health professionals who routinely refer non urgent cases to the ED. The authors suggest that further health services research should reconsider rational choice behavior models. Is there a salient message in this paper for us all? Are we as ED clinicians inadvertently encouraging attendances in our own departments? I‘ll leave you to read this paper and ponder this question yourself.

Mary Dawood

Associate Editor

Why do Emergency Medicine?

21 Dec, 15 | by scarley

Great work from colleagues in Edinburgh.

Why would you do EM? Learn more by visiting their website at http://www.edinburghemergencymedicine.com/ and join the #EDvolution.

vb

S

Mistakes Were Made

17 Dec, 15 | by rradecki

This past month a pair of articles were published online in the EMJ concerning diagnostic error in the Emergency Department. This pair of articles, with the fabulous Hardeep Singh as senior author on each, attempt to describe the underlying foundations of error.

These are particularly important in the context of the ongoing resource constraints facing medical care. A common strategy to reduce the potential for error, and, certainly, the “easy way out”, is simply to overtest. This strategy seems to be associated with a pattern of reduced medicolegal liability, although it is a bit of a stretch to apply this surrogate to diagnostic accuracy. However, besides the obvious up-front costs associated with overtesting, there is an under-appreciated incidence of false-positive results in the setting of low pretest probability.

The first of two articles, by Medford-Davis, focuses on the errors associated with abdominal pain presentations in the Emergency Department. These authors reviewed patients with an initial presentation of abdominal pain, who then subsequently returned to the same institution within 14 days and were admitted. These cases, totalling 100 in all, were retrospectively examined for potential diagnostic error.

Rather distressingly, a full one-third of the return visits may have resulted in part to some diagnostic error on the initial visit, although the reviewers were not in good agreement on the presence of error in all cases. A small number of adverse outcomes were related to non-remedial patient factors, such as poor compliance, poor follow-up, and other factors relating to the study occurring at a facility comprised of an inner-city, indigent, and undocumented immigrant population. The bulk of errors, however, are tucked into the patient encounter itself. The initial root of errors is in the initial evaluation – if elements of history or physical exam are inadequately described, there is a cascading effect of missed indicated testing. Then, a second roadblock seemed to occur on the processing of information resulting from initial orders. Many patients returning for subsequent admission had abnormal studies that were incompletely addressed at the initial visit.

The second article, by Okafor, analyzed the content of cases from an institutional error reporting system. Rather than focusing on the specific phase of care in which errors occurred, these authors focus on the primary domains of error. They found, unsurprisingly, the cognitive dimensions of errors are complex, and include issues such as faulty data gathering, premature closure, and misinterpretation of results. However, they importantly observe errors rarely occurred in isolation. Cognitive errors were frequently complicated by process or resource-related issues, as well as simple factors relating to patient complexity. In all, three-quarters of errors resulted from a combination of factors.

The basic takeaway here probably relates to some of the most difficult issues to address in the Emergency Department. Diagnostic accuracy will be maximized when properly resourced physicians have the time they need to evaluate their most complex patients. Resources, time, and complexity, however, are not frequently seen in their optimal concentrations in the ED – but it is important to recognize any quality improvement efforts would be remiss without accounting for these factors, and focusing solely on individual physician remediation.

Diagnostic errors related to acute abdominal pain in the emergency department

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

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