You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Exit Block Kills: College of Emergency Medicine launches new campaign

9 Sep, 14 | by scarley

Launched at the UK College of Emergency Medicine conference in Exeter today. Cliff Mann launched the latest campaign following from the CEM 10.

The bottom line is that crowded emergency departments harm patients.

Watch the video to learn more.


This month’s primary survey from EMJ

8 Sep, 14 | by scarley

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?

3 Sep, 14 | by rradecki

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

31 Aug, 14 | by scarley

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.



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

8 Aug, 14 | by scarley

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:

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.

Why do we call it ‘Teaching’?

4 Aug, 14 | by scarley

A Reflection on Teaching and Learning Culture in UK Emergency Medicine


One of the things that most amuses my school teacher friends is my insistence on referring to postgraduate educational opportunities as ‘teaching sessions’, e.g. ’I’ve got regional teaching this afternoon’. I’m not alone here in referring to ‘teaching’ – it’s common amongst doctors and medical students alike.

And an all too commonly heard moan for doctors, (I’ve done it myself, many times), is that they aren’t getting enough ‘teaching.’ At the recent College of Emergency Medicine and British Medical Association joint seminar held as part of the Emergency Medicine Trainees Association 2014 conference a recurring theme was a perceived need for more shop-floor teaching.

This is all anecdotal of course, but there is very little evidence out there regarding trainees views on this topic. The GMC National Training Survey[i] is a good place to start, but when you look at the actual questions and how the scores are calculated, it becomes clear that a score of 70-ish for local teaching (which it has been steadily since 2012) means very little, being calculated as it is from a combination of questions like ‘How many hours a week do you receive local specialty specific training?’ (What does this mean? Shop floor supervision? Small group seminars?), and ‘Who carries out local specialty specific training?’ (Senior doctors scores highly here but is that a true marker of quality? Does being a Consultant automatically make you an excellent teacher?) We are also asked to rate the quality of our teaching sessions, but against what standard? In summary, this survey is not an especially valid way of evaluating the quality of a teaching programme.

What do we actually mean when we say ‘teaching’? As postgraduate learners, we have a wealth of opportunities available to us, from organised lecture programmes and seminars, to shop-floor supervision to simulation courses.

Calling these varied learning opportunities ‘teaching’ turns them into passive activities and implies the spoon feeding of facts and transfer of knowledge direct from our teachers to our brains. It absolves us of our responsibility as learners to make the most of them.

The complaint of ‘not enough teaching’ is generally used to refer to shop floor learning, where a trainee is directly supervised doing something by a senior, (for example leading a team or performing a procedure), hence the regular comparisons with the one-to-one training that junior anaesthetists receive. That juniors in emergency medicine have senior supervision available for absolutely every single patient that they see seems to pass us by. That senior anaesthetic trainees practice independently for much of the time without constant one-to-one supervision also seems to escape us.

In actual fact, we do receive a significant amount of this kind of teaching. In the departments I have worked in, there has been consultant presence on the shop-floor for the vast majority of time in-hours. My current department has consultants on the floor for 16 hours a day. Supervision is therefore available to me for the vast majority of my working hours. Are we counting those ‘Can I just ask you about?’ and ‘What do you think of this?’ as being ‘teaching’?

As well as this, the College of Emergency Medicine has an exhaustive list of workplace based assessments that we are all required to complete. They are near universally despised, yet they represent direct hands on supervision opportunities, or to put it another way; ‘teaching’. Why then do we hate these assessments? Rather than seeing them as irritating tick box forms, can we reframe them as empowering us to request direct training and feedback on our performance?

And what exactly do we want ‘teaching’ on/about? If you’re a surgeon, then understandably you want to spend lots of time performing surgery, learning the craft of each procedure. If you’re a gastroenterologist, then the hours spent as a general medical registrar probably seem less relevant to your career compared to the endoscopy lists and clinics. This just doesn’t apply in emergency medicine. As an EM doctor, every single patient that we see on every single shift is a potential learning opportunity. We cannot just see the critically ill – our speciality is far broader than this. We need to be happy with the bread and butter of our specialty, not just the jam. Head injuries, elderly patients with falls, acute confusion, intoxicated patients both drugs and alcohol, febrile children, vague chest pain, dizziness, non-specific abdominal pain, deliberate self-harm, red eyes…It’s all on our curriculum and forms the vast majority of our workload[ii],[iii].

As senior emergency medicine doctors, we do not need to be directly supervised seeing these patients, but we should not dismiss them as non-learning or pure service provision events. There is no substitute for seeing large volumes of real patients and building up a bank of experience. Experience is what tells you that the ‘drunk’ patient with confusion has a subdural haematoma, or that the ‘back pain’ is an abdominal aortic aneurysm beginning to rupture (but experience is not everything – see below!) And sending a patient home reassured, happy and without what they thought came for (scan, antibiotics, xray) is as much an art as running a really slick arrest call.

Also on our curriculum are a whole range of managerial and leadership skills. Whether we like it or not, managing patient flow, supervising juniors and maintaining an overview of the department will form part of our job as ED Consultants. While we might prefer to be in resus seeing that interesting trauma, learning how to run the floor is essential, and can only be learned through practice. Maybe it’s not such a bad thing to be asked to run the show while the boss is in resus doing the fun stuff sometimes? It all depends on whether you see doing that as a key part of your role and important for you to practice or not.

And practice is the key word here. ‘Practicing’ medicine is what we are licensed to do. We cannot learn our craft solely through our computer screens, high fidelity simulators or textbooks. It is widely believed that to become expert in something, approximately 10 years of practice is required[iv]. Yet many people play sports or musical instruments for years without achieving mastery. Experience alone is not enough:

‘You have not had thirty years’ experience, Mrs Grindle-Jones,’ he says witheringly. ‘You have had one year’s experience 30 times.’[v]

Deliberate practice is required in order to become expert[vi]. Deliberate practice means thinking about what we are doing with each and every patient. It’s about seeking out feedback, following up cases, reading around. About thinking ‘Next time, I’ll do that a bit differently’. The responsibility for this lies with us. Our teachers are there to assist us in this process, not to do it for us.

I believe it is time for us to take control of our own learning. Complaining that we’re not getting enough ‘teaching’ isn’t good enough. We are surrounded by learning opportunities and it is up to us to make the most of them. What do you think?



Sarah Payne




[i] GMC National Training Survey, General Medical Council; 2014 (accessed 30/7/14)

[ii] The Older Person in the Accident and Emergency Department, British Geriatrics Society; 2008

[iii] Health and Social Care Information Centre, Focus on Accident and Emergency, UK Government Statistical Service; 2013

[iv] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996:10

[v] Carr, JL. The Harpole Report, Quince Tree Press ; 1972: 128

[vi] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996: 21, 33

The Science Behind Telling “Sick” From “Not Sick”

31 Jul, 14 | by rradecki

Jeff Kline contributed a very interesting article to the Emergency Medicine Journal last week – offering up a bit of a potential science behind the “gestalt” in medicine. We’ve seen multiple examples where clinician gestalt performance is very similar to carefully-derived, evidence-based, risk-stratification criteria. Specifically, the diagnoses of “acute coronary syndrome” and “pulmonary embolism” have been evaluated in the past – and only the newest attribute-matching tools have offered any promise regarding improving upon simple clinician judgement.

This newest study from Kline, et al, evaluated 50 patients in the Emergency Department and their facial reactions to visual cues. It turned out, the 18 patients from this cohort ultimately diagnosed with significant cardiovascular syndromes displayed significantly decreased expressive variability when prompted with multiple stimuli. The reasonable conclusion, therefore, is patients with serious diagnoses may exhibit measurable, reproducible behavior changes. A small study, to be sure, but hence the idea – there is something encoded in our emotional intelligence helping us evaluate “sick” from “not sick” in the Emergency Department.

Supposing this observation holds up to further scrutiny, the results do not surprise me at all. Part of clinical training in Emergency Medicine involves simple voluminous exposure to as many patients as feasible. The behaviors of each different patient, their clinical features, and their outcomes become encoded in this entity, the clinician “gestalt”. And, what this study reflects is something we all recognize – a patient is not simply a collection of risk factors, or a Revised Geneva Score – the physicality associated with how a patient exists in the examination room provides additional information. The intuition of the experienced clinician, then, may be based as much in reading patients’ faces as it is synthesizing clinical knowledge.

This has interesting implications for other developments in medicine, as well. The time pressures in Emergency Medicine, or in other outpatient settings, that simply cut down on time spent with each patient, may detract from the quality of the evaluation. Telemedicine, another technological advance aimed at diluting and expanding coverage, may suffer as a result of diminished communication of these critical nonverbal cues.

Regardless, this study is quite unique in the spectrum of Emergency Medicine research, and hopefully inspires a follow-up generation of research.  Or, alternatively, what would you say forms the basis of our “gestalt”?

Link: “Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting






Ryan Radecki

Highlights from the July EMJ.

8 Jul, 14 | by scarley

Screen Shot 2013-10-22 at 08.04.20Simon Carley, Web editor

Ah, you’re back again then…

If you work in the emergency services you will be aware of frequent users. These are an interesting and diverse group of patients who can account for significant impacts on clinical services. EMJ has published a number of papers on the management of such patients and there is increasingly evidence that we can manage them better, but what are they really like? What’s the evidence for the attendance reasons behind this often maligned group who we see (by definition) frequently? Vinton et al have looked at US databases to characterize and compare infrequent, frequent and super-frequent users (a new term to me), and have found them to be a disadvantaged and vulnerable population with significant disease. This is a reminder to me that our EDs are a safety net for a vulnerable population and that there is much potential to improve the care for these patients through targeted care and management.

‘I’ve come for an X-ray doc’

I’m sure you’ve heard this opening gambit from many patients in the minor injury queue. It’s common to hear patients admit that they come to the ED for a specific intervention or investigation that they feel is required. However, on many occasions as clinicians we may disagree. For example we might decline an X-ray for Ottawa negative ankle sprains. Does this apparent conflict of expectation lead to dissatisfaction? It’s a good question as there is an ever increasing focus and use of patient satisfaction scores to assess clinicians. Goodacre and colleagues have examined this interesting question and reassuringly it seems that there is little link between unmet expectation and satisfaction.

Knees or feet

One of the advantages of getting a little older and wiser is that I don’t do much CPR these days. I’m often team leading cardiac arrests so leave the physical stuff to the younger and fitter members of the team. We know that the quality of CPR diminishes rapidly with time but would it degrade less quickly if we knelt rather than stood next to the patient? I’ve often thought that it would, and that it would avoid the difficulties of different height rescuers coping with a trolley at the same height. Je Oh et al have examined CPR performance in the kneeling and sitting positions and found little difference when simulating resuscitation on mannequins.

Predicting cardiac arrest outcome

Kamatsu et al in Tokyo have looked at factors that might predict outcome following cardiac arrest amongst 227 patients who survived their initial cardiac arrest. Despite looking at a number of factors commonly believed to be associated with outcome it appears that time to intervention remains the most important factor in achieving good outcomes.

What’s the REAL gold standard of a triage score?

Triage scores are designed to sort (obviously) but into what? Typically triage scores are measured against distant outcomes such as death or ICU admission, but arguably they should be evaluated against more proximal outcomes such as the need for intervention. Twomey and Lee have furthered these concepts through the use of an innovative Delphi study using case vignettes to define clinical urgency. This original approach relating triage to acuity is innovative and may have applications in many other areas of emergency practice.

Antibiotics and abscesses

We have a little bit of dogmalysis this month on the use of antibiotics in abscess management. A systematic review by Singer et al casts doubt on the routine use of antibiotics following incision and drainage concluding that the evidence is limited for their use, though there are surprisingly few (589) patients across all trials.

Too tall for a tape?

In Hong Kong Giles Cattermole and colleagues have again found that there are significant difficulties in estimating the weight of children. In this study the Broselow tape was found to be too short for many older children, but that even when too tall they did not reflect adult weight estimates. Like many studies in this area it is clear that simple methods of weight estimation usually fail owing to the variation in height, weight and body habitus in the paediatric population.

Is EM a fixed career?

As someone who came to emergency medicine late following an early surgical career, the paper by Svirko et al strikes a chord. EM physicians frequently make their career choice late and show greater variation in career choice as they move through their early clinical years. Whilst other specialties show greater consistency in choice only 27% of EM physicians choosing EM at 5 years post graduation had selected it in year one. The implications for specialty recruitment are complex, where, who and how should we channel our efforts in recruitment?

Apps and AEDs

Finally, a rather clever way of tracking public health resources, for this study Chang et al used a mobile app called Gigwalk to identify the locations of AEDs in Philadelphia county. Participants had to find and evidence the location of the devices thereby confirming that they were ‘findable’. This novel approach has several potential benefits to routine checks by providers and I think we may see more of this in the future.

What’s your target BP for ruptured abdominal aortic aneurysm?

29 Jun, 14 | by scarley

Untitled design(5) copy 2


A couple of years ago I was very (very, very) peripherally involved in an RCT investigating the management of ruptured abdominal aortic aneurysm. The IMPROVE trial was well designed and reported it’s results in 2014. The abstract is shown below, and I must admit that to my surprise there did not appear to be a definable advantage to endovascular repair.

Anyway, this post is not about the trials results per se, rather we received a comment from Prof. Janet Powell on behalf of the trial investigators that may have relevance for those of us in emergency and critical care medicine. One of the great advantages of large trials is the ability to look through data to see whether other themes and associations become apparent and this is what the trial team have done. Such data analysis has risks, but it can be an excellent way of generating hypotheses for future research, and observational data can also help us stop and think about current practice.

I digress. Read the letter from Janet below and then share your thoughts. As an emergency physician this observation raises a myriad of questions about data, analysis, resuscitation targets, association vs causality etc. and whenever I start thinking I know I’m getting better. So please, read, think, learn and please debate. Janet asks how we can work together to resolve and explore these results and surely that’s an offer that the EM and surgical communities should grasp.




Blood pressure targets for the elderly with bleeding and vascular emergencies

The IMPROVE trial is the largest randomised trial of a strategy of endovascular repair versus open repair for ruptured abdominal aortic aneurysm, with over 600 patients [1]. Nearly all these patients started their care pathway in the emergency department and detailed evaluation of this large cohort of patients has raised some discussion points relevant for those in emergency care.

When we started this trial, we recommended that patients were managed with fluid restriction and hypotensive haemostasis, with systolic blood pressure targets of 70-80 mm Hg, to prevent further bleeding and optimise outcomes. These recommendations were based on emergency care guidelines for patients with abdominal trauma and the opinions of some leading vascular surgeons [2,3]. Hindsight is a wonderful thing. The patients we enrolled had an average age of 76.7 years: were these blood pressure targets far too low for this age group who were likely to have other cardiovascular disease and high cardiovascular resistance?

Cohort analysis has shown that there was a linear relationship between lowest systolic blood pressure and mortality (Table 1) and suggests that in these patients a blood pressure target of 100 mm Hg might save more lives. Lowest systolic blood pressure was directly related to outcome in a linear fashion, with each 10 mm Hg increase translating into a 13% relative improvement in the odds of survival to 30-days [4]. 30-day mortality rates of <30% were only achieved in those in whom the lowest blood pressure was 100 mm Hg or more.

Screenshot 2014-06-29 07.25.24

Management of other aortic conditions, particularly aortic dissection, may similarly be disadvantaged by unrealistic blood pressure targets. For aortic dissection the rapid blood pressure lowering to <100mm Hg, which is recommended [5], comes mainly from evidence in turkeys.

How can we work together to get the evidence for appropriate blood pressure targets for the elderly population with bleeding and other vascular emergencies? The current observational evidence is not sufficient and the question needs to be addressed in one or more randomised trials.

Janet Powell for the IMPROVE trial investigators


1 Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial IMPROVE trial investigators BMJ 2014;348:f6771
2 Joint Royal colleges Ambulance Liaison Committee. Ambulance Service Clinical Practice Guidelines; 2006.‎ [accessed 1 September 2013].
3 Mayer D, Pfammatter T, Rancic Z, Hechelhammer L, Wilhelm M, Veith FJ et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249: 510–515
4 Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. IMPROVE trial investigators Br J Surg 2014
5 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Accessed March, 2014 at


So you have your invitation. Get in touch with the IMPROVE team to discuss, share and explore this observation.





Predatory Journals – Enemies or Inspiration?

21 Jun, 14 | by rradecki

Science – unlike deranged, furious cursing – is not best cloistered behind closed doors, in the dark, with no audience. Dissemination of medical evidence is critical to refinement of practice and the generation of future research hypotheses. Yet, most evidence resides behind electronic publisher paywalls, accessible only for a fee, or to those with specific institutional access.

Those of us in academics take such access for granted – yet, the other 7 billion on Earth, many of whom toil in conditions with a lower standard of living, have a much higher barrier to entry. Many journals offer free access to visitors from certain countries, a generous, but incomplete, solution to the free flow of information. A growing alternative, however, to traditional publishing are “Open Access” journals. Such electronically published journals are free to access for all, and in lieu of the typical advertising + reprint business model used to support editorial and typesetting functions, the authors pay fees to support the costs of publication.

Some of these, such as PLOS ONE, have grown to become the largest journals in the world – publishing 31,000 articles in 2013 alone. At USD$1,350 per publication, the revenue associated with such a model is substantial. And therein lay the critical issue – the promise of such riches has attracted the usual unsavory crowd.

Now, we have the phenomenon of the “Predatory Publisher”, a faux journal whose primary function is profit. These publications, masquerading as legitimate science, have grown from 18 in 2011 to at least 477 in 2014. Most academics are likely familiar with the near-daily spam e-mails soliciting article submission, editorial positions, or conference speaking roles. In many cases, the journals are indistinguishable from reliable publishers, and well-meaning authors, hoping simply to increase the audience for an article, are sucked in.

Despite the shoddy or non-existent peer-review – in which nonsense articles by such renowned authors as Ocorrafoo Cobange pass through with nary a critical eye – these articles are entering the scientific ecosystem in ever-increasing numbers. One of the largest for-profit open-access publishers, MedKnow, from Mumbai, India, claimed over 2 million article downloads each month. In an academic professional reality where publication means promotion, and open-access publishing means unfettered distribution – it is no wonder such journals are thriving.

This phenomenon, of course, massively dilutes the scientific literature with a locust swarm of substandard evidence. Traditional journals, with strong reputations and robust Impact Factors, are holding strong for now. But, at the fringes – if funds are available, why would one risk rejection in a more rigorous, but low-impact journal, where the study would lay hidden behind a paywall?

While these journals are certainly the enemy of reliable evidence, and transitively, the public good, they represent an interesting lesson – and possible inspiration – for how traditional academic publishing might evolve.

Latest from Emergency Medicine Journal

Latest from EMJ