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Primary Survey: November 2016.

22 Oct, 16 | by scarley


Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.


Rick Body


How Junior Doctors Think: A Guide for Reflective Practice

19 Oct, 16 | by rlloyd


In the UK, junior doctors will rotate through emergency medicine in their second year post-graduation (Foundation Year 2). They’re granted autonomy to make independent decisions and ‘own’ patients for the first time.

Elsewhere in the hospital, a junior’s role is largely secretarial, and generally within the confines of ‘normal working hours’. In the ED, the hours are brutal, the pace is relentless, and the sudden spike in responsibility ED is daunting. The learning curve is steep, but rewarding.

‘My first shift in the ED was the first time I felt like a real doctor.’

Perhaps the most unique element is the density of decision-making. Each shift serves up a broad menu of undifferentiated patients ‘fresh’ from the community, often requiring multiple investigations/interventions. When you consider the wider landscape of an ageing population, over-burdened health service, and the much maligned 4-hour target, it’s an undeniably tough job for rookies; a pressure-cooker workplace that’s fertile ground for misdiagnosis and clinical error.

Therefore, in the interests of patient safety (and junior doctors overall wellbeing) it’s important to understand the mechanisms by which junior doctors collect/process information, and make decisions. Otherwise known as ‘clinical reasoning’.

Published in the EMJ in June 2016, Adams et al have qualitatively investigated clinical reasoning in junior doctors rotating through the ED for the first time. Thirty-seven doctors were interviewed and took part in focus groups. Questions and discussion were based around retrospective recall of two cases (one straightforward and one difficult case).

The authors used ‘dual cognition theory’ (DCT) as a framework. DCT describes two distinctive cognitive approaches to decision-making: ‘Type 1’ thinking (T1) is automatic and intuitive; ‘Type 2’ (T2) is deliberate and analytical.

This system was, of course, pioneered by Daniel Kahnemen in his book ‘Thinking Fast and Slow’ (essential reading). Below is a video which provides a useful visual explanation.

Key findings from the paper:

  1. There are 3 phases of clinical reasoning in junior doctors – each is briefly explained below, but for more complete explanations please read the original paper.
  2. During all 3 phases, both thinking pathways (T1 and T2) were working in parallel.

*Please note: indented sentences in italics are my own interpretation of the research, not actual quotes from the data.

Phase 1: Case Framing

Initially, a decision needs to made whether to go into clerking mode (i.e. systematic enquiry) or ‘resuscitation’ mode (call for help, ABC approach etc).

The information processed to make this decision are clues from the patient demographics, triage note and ‘end-of-the-bed-o-gram’.

Phase 2: Evolving Reasoning

The next phase involves establishing a diagnosis. This happened in two ways:

1) Diagnosis instantly recognised (T1 predominant)

Usually from a single cue in the assessment.

‘This patient has right iliac fossa pain. It’s probably acute appendicitis.’

These reflex diagnoses are then interrogated for error via:

  • Screening for ‘red flag’ features
  • Diagnostic timeout’ to organise thoughts
    • Reflection whilst writing patient notes
    • Informal discussion/presentation to a colleague
  • Begin another task, allow opportunity for spontaneous thought (passive diagnostic timeout)

2) Diagnosis not recognised, further analysis commences (T2 predominant)

With no immediate diagnosis reached, ‘hypothetico-deductive reasoning’ is employed. This is where multiple possible hypotheses are generated, and then the history, physical examination, and investigations are used to test these hypotheses, with a view to eliminating them one-by-one.

The ‘SOCRATES’ mnemonic is a useful tool for challenging hypotheses in chest pain patients.

‘Site? Onset? Character? Radiation? Associated symptoms? Timing? Exacerbating/relieving factors? Severity?’

Ongoing observation is also employed to test diagnostic hypotheses, and to screen for an evolving clinical scenario.

‘The inflammatory markers are higher than I thought they’d be. This patient is likely to be septic. Let’s start IV antibiotics and refer to the medics.’

Phase 3: Ongoing Uncertainty

This was predictably common in an inexperienced cohort of doctors, and dealt with via:

  • Delaying discharge and continuing to observe
  • Simplifying the overall decision: ‘is this patient too unwell to go home?’
  • Sharing responsibility
    • With seniors
    • With peers via informal discussion
    • With patients via safety netting

Three points I’ve taken from the paper…

1) Inexperience can lead to ‘misframing’

T1 judgement was the dominant thinking pathway during ‘case framing’, particularly when it came to first impressions – a ‘gut-feeling’ assessment of acuity.

A lack of experience might prevent juniors from picking up on subtleties (e.g. sweating, mild agitation), or get falsely reassured by certain details (e.g. normal vital signs) that a senior doctor would not, and ‘misframe’ the patient’s level of acuity. Clearly, this has the potential to be detrimental to patient outcomes.

For this reason, focused reflection on this crucial phase of the assessment via case-based discussion with a senior colleague is critical. It will encourage juniors to gain some insight into how their own intuitive thoughts play a prominent role, and perhaps encourage them to interrogate those thoughts for biases.

‘Did you make any assumptions about this patient before seeing them?’

‘Were there any clues or triggers when you first saw them that changed how you felt about the case?’

‘Can you think of any other clues that might subtly point to the patient being more unwell than the triage note suggests?’

2) Diagnostic time-outs should be encouraged

It was established that junior doctors would utilise diagnostic time-outs whilst writing notes or via informally presenting to peers. This is an important part of the clinical reasoning process, particularly in complex patients. It can safeguard against premature ‘closure’ of a case (i.e. jumping to conclusions, and then sticking with them incorrectly) .

Again, this part of the process needs to be reflected on, so that it’s utility is appreciated.

‘It was when I was writing the notes about the 68 year-old male that I thought had renal colic, that the possibility of ruptured AAA came into my head. It’s a useful moment to think about the case.’

Diagnostic timeouts should be encouraged by higher ups, despite being potentially time-consuming, and particularly if the shop floor is manned heavily by junior doctors (a not-uncommon scenario). Despite the overburdened and target-driven climate of UK  emergency medicine, departments must avoid falling into the trap of pushing their staff to work faster. Patients are safer when junior doctors are given the chance to slow down and think.

3) Juniors should be given protected time for case follow-up

The transient nature of our patient encounters in the ED can lead to an ‘out of site, out of mind’ culture, where we fail to follow-up uncertain or particularly interesting cases. Again, this is re-enforced by the pressure to work quickly. This represents a glaring missed opportunity for learning, and the lack of diagnostic feedback potentially leads to the propagation of flawed clinical reasoning, particularly in inexperienced doctors.

Perhaps juniors should be given protected time to follow-up on cases they’ve seen (read discharge summaries/visit ward/call patient at home if discharged). They could then log this process, and formally reflect on notable cases with a supervisor.

This paper has highlighted that junior doctors have a tendency to make judgements on single cues, as opposed to pattern recognition, and can draw premature conclusions from insufficient clinical information. There is no doubt that regular feedback on real cases will serve as a powerful tool to improve clinical reasoning. It will gradually nudge them towards the realm of expertise.

Much like the encouragement of diagnostic timeouts, the key is likely to be departmental culture change. This will require brave consultants and senior nurses.

Final Thoughts

This paper should serve as a guide for junior doctors (and their supervisors) for more focused, effective reflective practice.

It’s not just about reflecting on the pathology encountered and decisions made, it’s also about the clinical reasoning process that led to those decisions. The journey is just as important as the destination. Junior doctors should be reflecting on how they think.

Additionally, departments should strive to create a healthy environment for regular reflective practice, and not to prioritise targets over the development of junior doctors clinical reasoning skills.

The Paper

Clinical reasoning of junior doctors in emergency medicine: a grounded theory study
E Adams, C GoyderC HeneghanL BrandR Ajjawi
Emerg Med J emermed-2015-205650
Published Online First: 23 June 2016 doi:10.1136/emermed-2015-205650

Many thanks to Dr. Emily Adams, the primary author, for her assistance in the creation of this blog post.

Robert Lloyd

Become an EMJ reviewer

18 Oct, 16 | by scarley


The EMJ, like most journals relies on peer review to help the editorial team make decisions on submitted papers.You can have a look at the list of people who have reviewed for us here, and we are always looking for more.

Now peer review has had some tough times of late. Ex editors of major journals have described it as ‘A flawed process at the heart of journals’ and it is true that it is not a perfect process. However, it has also been argued, also by Richard Smith that it there is no obvious alternative and that is respected by the scientific community.

Personally I am a sceptic when it comes to peer review and am increasingly an advocate of a blend of pre and post publication review. I particularly like the idea of post publication review facilitated through social media and of course we encourage letters and comments through any of our social media outlets on papers published in the EMJ.

However, for now, peer review is here to stay prior to publication and that means we need the brightest and best people to help us make decisions for the EMJ. So, if you are good at critical appraisal, if you have expertise in an area of EM practice and/or research design and if you want to help the EMJ publish the best papers then get in touch.

Contact us here and send us your details. Help us make the world a better place.



Peer review: a flawed process at the heart of science and journals Richard SmithJ R Soc Med. 2006 Apr; 99(4): 178–182. doi:  10.1258/jrsm.99.4.178 PMCID: PMC1420798

BMJ Blogs on peer review

Dr Fikru Maru

12 Oct, 16 | by scarley


I was recently at the European Society of Emergency Medicine meeting in Vienna where I met up with a great friend and colleague from Sweden. Katrin Hruska is an inspirational Swedish emergency physician who is leading the establishment of EM in her country as President of the Swedish Society of Emergency Medicine. When I meet people like Katrin I am reminded that there is an esprit de corps amongst emergency physicians around the world. I was therefore deeply moved by a story that she is sharing about a fellow physician caught in very difficult situation in Ethiopia. I invited Katrin to tell the story from her perspective. Please read and get in contact with Katrin if you can help.


Dr Fikru Maru

There is a joke in Ethiopia about how there are three kinds of Ethiopians: The ones who are in jail, the ones who have been in jail and the ones who are waiting to go to jail. I don’t think Dr Fikru Maru ever expected to be thrown in jail, but on the other hand he is no longer an Ethiopian citizen, but a Swedish one, having spent the last forty years of his life in Sweden.

It was in Sweden Fikru went to medical school and where he built a career as an interventional cardiologist. And it was with the support from Swedish investors and colleagues that he founded the Addis Cardiac Hospital ten years ago, with the hope of providing care that simply wasn’t available anywhere in Ethiopia. Dr Fikru implanted pacemakers and performed PCIs for patients who would otherwise have had to go abroad for treatment. The nurses and doctors at his hospital got training in Sweden and Swedish doctors would travel to Addis regularly to treat patients and help build local competence.

Swedish hospitals donated supplies and equipment that Fikru would bring one his trips to Addis. On one trip in 2010, when declaring the goods to customs, there was a disagreement on the value of the goods and Fikru found the custom fees asked for too high, so he decided to leave the bags at the airport. On his way home he paid the stipulated 5% tax on the goods he was taking back to Sweden. (Apologies for the lack of logic, but logic has very little to do with the fate of Dr Fikru.) But unfortunately he didn’t have enough cash to pay the fees for excess luggage and credit cards weren’t accepted. Running out of time to catch his flight, Fikru asked the airport staff to take the bags back to customs and bordered the plane. Before takeoff he was arrested by the police, accused of attempting to smuggle medical supplies into Ethiopia.

After being detained for eleven days, Fikru was released and travelled back to Sweden. He continued his work in Addis, but was naturally upset about the indictment hanging over him. After discussing the matter with the Minister of Health, the Director of Customs was contacted, who eventually talked to the prosecutor. The case was closed and the matter settled. At least that is what everyone thought.

Three years later, in the middle of the night, Fikru was pulled out of bed by police officers entering his house. He was arrested and spent four months sleeping on the floor together with other prisoners, awaiting a court hearing. His back is covered with scars from the bed bug bites he sustained there. He spent his time going through everything he had been doing in Ethiopia, trying to work out why he had been arrested. The charges came as a surprise. He was being accused of corruption. The prosecutor claimed that he had been using his connections and was aware of the fact that the Director of Customs was interfering with the judicial process when the smuggling case was closed three years earlier.

Another three and a half years later, Fikru is still detained in Ethiopia, waiting for his trial to finish. On 2 September he developed a spontaneous pneumothorax. His condition is deteriorating rapidly, since every attempt to remove the drainage has resulted in a relapse. Fikru needs thoracic surgery, that is not available in Ethiopia. To speed up his process, he has declined the right to defend himself and is willing to accept the verdict of the Ethiopian court. But there is no process to speed up, only a tormenting standstill. The last month has been filled with dates when a verdict would be given, but every time the judges have come up with a reason to postpone, a few days at a time. New obstacles are introduced randomly, one being that Fikru needs to be present in court for the verdict to be read, but on the day of the hearing the prison guards have not been given the order to take him there.

It is a desperate situation where a man is denied a life saving procedure, for incomprehensible reasons. The irony of a doctor’s desire to improve health care in a country in need, resulting in him risking to die from a simple pneumothorax is painful. The processes of the Ethiopian court are an insult to every health care provider who accepts the risk of working in a developing country. Fikru is losing and so are all the patients in need of better health care.


Katrin Hruska


Swedish Doctors for Human Rights.

Swedish Society for Emergency Medicine

Lessons from Camels. EMJ Blog.

8 Oct, 16 | by scarley

EMJ Blog

Life long learning and developing is vital for the good ED practitioner,  treatments change, pathologies change and even opinions change over months and years, and we on the front line must continually adapt and change with them.

To highlight the importance of this I would like to tell you a story. It is a story about a camel.

In 2006 palaeontologist Natalia Rybczynski was tramping through the artic wastes in the far North of Canada (as you do) as she came across some unusual grey rocks. Now personally I would have stubbed my toe on these rocks, cursed and wandered off in search of a hot chocolate, but being a shrewd and observant palaeontologist Natalia saw that these were fossils of a type she had not encountered before. She collected these, and returned over the next few years, managing to find around 30 fragments of what appeared to be a fossilised tibia(1).

Subsequent super clever collagen fingerprinting techniques revealed that these remains amazingly were from a hitherto undiscovered giant camel. Now this raised some interesting questions.  Camels are sublimely adapted to the hot and dry desserts, with their large spoon-like feet for walking on sand, and large fat filled hump meaning they can survive for longer without food. The function of having all your fat reserve in a single hump also means that you can do without the surrounding layer of adipose tissue, allowing these animals to dissipate heat easily in their hot climates.

So how could these hot weather specialists have survived in the arctic, where temperatures often plummet deep into the negative figures. (I promise I am getting to the medicine!)

To get the answer we need to re-examine what we think we know about camel’s adaptations, and take them out of the context we always find them in (the desert). For example, those wide flat feet could easily be adapted to snow, as well as sand, in fact it is likely they initial evolved to walk in soft snow and then subsequently were found to be of an advantage in the desert sands. That hump with the fat reserves would be vital when trying to survive in a place were for 6 months of the year there is darkness and nothing grows.

We have thought of camels as hot weather beasts for hundreds of years, and then all of a sudden someone finds a few lumps of rock in the arctic that causes us to completely reconsider what we think we know, and to have to think in new ways to explain things we thought we had sorted.

The recent example from the field of medicine is the FEAST trial (2) We have believed for many years that fluids were the mainstay in the treatment of severe sepsis and septic shock, and then someone comes along with a brilliant study that casts doubt on this assumption and causes us to have to rethink what we thought we knew. The FEAST trial shows us that we do not understand pathophysiology of septic shock as well as we think we do. As good clinicians we should accept this and try to explain the apparent paradoxical findings. The authors to their credit, offer the explanation that fluid boluses may cause damage through reperfusion injury, effecting pulmonary compliance or myocardial function. The FISH (Fluid In SHock) trial is currently running in hospitals across the UK to follow-up FEAST and see if we should be changing our practice.

As clinicians we have a duty to continually question what we think we know, and to search for better and more efficient ways of treating our patients. The doctor who clings to dogma and does things a certain way, because they have always been done that way is doing his patients a disservice and indeed could be putting them in harms way.

We will never know everything, and what we believe we know now will change over the course of our careers and even our lives, so I would urge everyone to learn the lessons of the giant camels, and never stop questioning what we think we know, to enable us to always do the best possible for our patients.

Chris Arrowsmith

ST4 Emergency Medicine
Current Paediatric Intensive Care and Acute Retrieval Clinical Fellow, Bristol


1. Rybczynski N, et al. 2013. Mid-Pliocene warm-period depostis in the High Arctic yield insight into camel evolution. Nature Communications, 4:1550

2. Maitland K, et al and the FEAST Trial Group. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med. 2011 May 26.

Why Are Wee Waiting?!

30 Sep, 16 | by cgray

Why are wee waiting?

As anyone who has worked in an emergency department that caters for our younger patients knows, at any point during the day you can almost guarantee that there’s a parent somewhere, clasping a bowl to their child, waiting for them to wee.

The clock is ticking, the managers are on your back, and all the while you’re at the mercy of a tiny bladder.

Wouldn’t it be so much easier if there was some easy (and non-invasive!) way to just get that baby to pass urine quicker?

Published online at the EMJ last month, Jonathan Kaufman and team from the Children’s Hospital in Melbourne, Australia have designed and trialled a possible solution called the Quick-Wee method. This was developed through anecdotal reports of children voiding during perigenital cleaning, which the team hypothesised stimulates newborn cutaneous voiding reflexes. Their technique is to perform ten seconds of perigenital cleaning with sterile saline-soaked gauze, then rub saline-soaked gauze suprapubically in a circular motion for up to five minutes. It’s a technique that requires just a single member of staff, and one that they hope can decrease the time it takes to get a clean catch urine sample.

This was a single centre, feasibility study, and therefore all patients had the technique performed and there was no control group. Room temperature saline-soaked gauze was used in half the patients, with cold saline used for the remainder, as it was thought that temperature might have a role here too. The researchers looked at outcomes of voiding within five minutes, successful catch, and parent/clinician satisfaction on a five point Likert scale.

Previous studies have determined an average time to void of between 25 and 60 minutes, with only around 12% passing urine within five minutes. In this study, of 40 children aged between 1 and 24 months old, twelve children (30%) had successful voids in under five minutes, and all of those were under 12 months old. Cold gauze appeared more effective, but not significantly so, and all involved were reportedly satisfied with the technique.

This is a small study, but one that appears to show improvement compared with just waiting with a pot. It’s a technique that is technically easy, and could be performed by a parent or guardian rather than a healthcare professional. The protocol for their randomised controlled trial has already been published, and it will be great to see the results of this once the study is complete.

You can see Dr Kaufman present the team’s findings at the Australasian College of Emergency Medicine Annual Scientific Meeting 2015 here.



Help set UK EM research priorities

24 Sep, 16 | by scarley


Hopefully you already know about the James Lind Alliance 1–4. If not have a look at the St.Emlyn’s blogs and podcasts, but in brief the Royal College of Emergency Medicine is working with the JLA to set the most important research priorities in emergency medicine. The process has been running since the middle of last year and after a lot of work led by Professor Jason Smith and Richard Morley we are down to the last 60 questions.

We need your help in prioritising the final questions.

We need professionals and the public to follow this link to a survey that will finalise a list of questions that will then go through to a final round in January where the top 10 research priorities will be set.JLA flyer for download

We need everyone to help complete the survey, both patients and professionals.


Download this flyer and share in your department. Show it to friends, family, patients, professionals and get everyone involved.

Past processes have shown that if the JLA recommends a research priority then it significantly increases the likelihood of getting the projects funded. In other words this really matters and could shape UK EM research for the next decade.

So please. Have a look and complete the survey today.




On behalf of the JLA steering group.

James Lind Alliance and RCEM needs you. Published October 2015. Accessed September 24, 2016.
James Lind Alliance: Emergency Medicine. Published 2015. Accessed September 24, 2016.
Smith JE, Morley R. The emergency medicine research priority setting partnership. Emergency Medicine Journal. 2015;32(11):830-830. doi: 10.1136/emermed-2015-205353 [Source]
James Lind Alliance Update. Published December 2015. Accessed September 24, 2016.

Extending primary care reduces attendance – or does it?

13 Sep, 16 | by scarley

do-more-gp-appointments-lead-to-fewer-ed-visits_The debates around 7-day services, job contracts, scope of practice and emergency medicine overcrowding can sometimes feel like a maelstrom of fact, figures, spin and deceit. Even those of us working in emergency medicine find it difficult to determine the quality of what we hear through news channels and so it’s always good to read some science about really important issues that affect us.

A recent study in PLOS ONE has looked at the impact of extending primary care (GP) hours in Manchester, which also happens to be my home town. Over a one year period NHS Greater Manchester spent £3.1 Million pounds enabling groups of GPs to extend their services in the hope that they would reduce pressure on ED services.


This paper has already attracted interest and will no doubt be used by politicians and politicos to further their agendas. We on the other hand will be left to pick up the pieces.

They determined this by comparing attendance rates between GPs with the additional funding vs those without, and at first glance it looks like a success. The claimed rate of a 26.4% reduction in emergency department visits is a very tempting headline, but I was in Manchester in 2014 and I can assure you that we did not see fewer patients. The result is of course a relative risk and these are well known for being difficult to interpret and susceptible to making results appear more dramatic than they really are.

Let’s delve a little deeper from an emergency physician’s perspective.

  1. This is a really complex analysis and it’s tricky to find the raw data.
  2. They estimate that they had to provide 33,159 appointments to achieve 10,933 fewer ED attendances. So you have to offer 3 GP appointments to prevent a single ED visit.
  3. These were for minor problems (so it would not affect the more severe end of the ED)
  4. The analysis is complex as they are trying to compare reported attendance against trends but the suggestion of a 26.4% relative reduction is offset in my mind by the reported ED attendance rates per 1000 patients. In the control group it was 32.3 vs 29.4. Although statistically significant on their analysis I’m not convinced that we would notice.
  5. I am really struggling to understand how they came to the conclusion that there was a 3.1% reduction in ED attendances. It is stated in the paper but I just can’t see the baseline data to explain this (maybe it’s just me). They do state that it was a not a statistically significant finding.
  6. They do admit that a formal cost analysis was not done but do claim that costs have reduced in the EDs by £767,976 over the study period. I think this must refer to the ED costs WITHOUT taking into account the £3.1 Million spent. If I was reporting this I think I would subtract one from the other and call it roughly a £2.3 Million pound loss.
  7. No health outcomes were assessed and there was an assumption that admitted patients were ‘appropriate’ and not included in the analysis. I don’t like differentiating patients into appropriate and inappropriate on the basis of whether they were admitted. Anyone working in an ED knows that admission is not a good determinant of this.
  8. I would really like to see the data on ED attendances during the study period. Did this intervention really have any impact on what the local EDs saw in terms of patients numbers?

This paper has led to headlines suggesting that the funding really did cut ED visits such as this on the BMJ site, but I’m really not sure that it does.

What does this mean for us? It tells me that reducing ED attendance is complex and that simple measures such as extending opening hours do not always have the dramatic effect that politicians and some medical leaders predict.

It tells me that Emergency Departments provide really cost effective care, or does it. Rather it might just tell me that EDs are chronically underfunded and are providing care on the cheap.

I’ll leave it to you to decide, read the paper and get back to us.

Good luck with understanding the stats section.




BMJ Blogs Extending primary care hours cuts emergency department visits.

Associations between extending access to primary care and emergency department visits.

ECG Marksmanship: Posterior Wellen’s Syndrome

9 Sep, 16 | by rlloyd


One of the most rewarding elements of emergency medicine is spotting a potentially catastrophic situation at an early stage, and proceeding to ‘nip it in the bud’ before things start getting hairy.

To coin a military analogy: a battalion might be perfectly capable of neutralising the enemy in close-quarters combat, but in an ideal world, a shrewdly placed sniper will take care of business ahead of time. No need for bayonets if you’ve got a man on the roof.

The emergency physician acts as the sniper when Wellen’s Syndrome is spotted on the 12-lead ECG. A pain-free, haemodynamically stable patient might be moments away from a ‘widow-maker’ infarct, but if the subtle precordial biphasic T-waves are picked up, the enemy lesion can be taken out from range via percutaneous coronary intervention (PCI), sparing the patient’s anterior myocardium. No drama.

What is Wellen’s Syndrome again?

It was first discovered in 1982 by Hein J. J. Wellen, and describes characteristic T-wave changes in the right precordial leads (V1-V3) that represent critical stenosis of the left anterior descending (LAD) artery.

Most cases (approximately 75%) of Wellen’s Syndrome have a ‘Type B’ pattern – deep and symmetrically inverted T-waves. This is an easy spot, and should ring alarm bells even at novice level.


Wellen’s Type B (Image from ‘Life in the Fast Lane’)

A minority of cases (approximately 25%) will have ‘Type A’ pattern – biphasic T-waves. These are often more subtle, and easily overlooked, particularly if the patient is clinically well.

Wellen's Type A (Image from 'Life in the Fast Lane')

Wellen’s Type A (Image from ‘Life in the Fast Lane’)

The physiological basis for Wellen’s is spontaneous reperfusion of a previously occluded artery. Often patients will present to the ED following a bout of severe chest pain which has resolved. Classically, the ambulance ECG will demonstrate an impressive STEMI, which has disappeared once the patient has arrived in resus, pain-free. Despite being symptomatically better, these patients will have an active thrombus and are high risk for re-occlusion and STEMI. They need aggressive medical management, with a view to urgent angiogram/PCI.

Wellen’s waves are not exclusive to the anterior leads. They have been shown to correlate with spontaneous reperfusion in the left circumflex (LCx) and right coronary artery (RCA) when ECG changes are seen in the inferior and lateral lead distribution.

Interesting recent EMJ article – Driver et al, August 2016

Until recently, the literature has not described the ECG appearance of posterior MI (PMI) reperfusion.

An article published online first in the EMJ last month takes on this very challenge. Tellingly, one of the authors is Stephen Smith, author of ‘Dr. Smith’s ECG blog’ – one of the most prominent ECG #FOAMed resources available.

The classical acute PMI ECG demonstrates new ST depression in the right precordial leads – a mirror image of ST elevation in the hypothetical posterior leads (V7-V9). The posterior myocardium is supplied by either the LCx or RCA, depending on the patient’s anatomy.

The authors of this paper hypothesised that spontaneous reperfusion of the offending artery in acute PMI patients would result in Wellen’s waves (deep T-wave inversion) in the posterior leads, which would correlate with an increase in positive T-wave amplitude in the right precordial leads – again, the mirror image concept.

It was a retrospective observational analysis of 72 patients with LCx or RCA occlusions who underwent PCI – mimicking spontaneous reperfusion. Forty eight patients met criteria for PMI – ‘presence of right precordial ST depression, maximal in leads V2 and/or V3, not explained by QRS abnormalities’. Twenty four patients did not meet criteria – i.e. they had occluded their LCx/RCA, but the posterior myocardium was not infarcted.

Post reperfusion:

  • PMI patients had a greater increase in V2 and V3 T-wave amplitude when compared to non-PMI patients (p=0.0005 and 0.03 respectively).
  • PMI patients had greater maximal T-wave amplitude in lead V2 (p=0.04) when compared to non-PMI patients.

The authors believe they have described an ECG finding for PMI reperfusion that is ‘analogous’ to typical Wellen’s waves. ‘Posterior Wellen’s Syndrome’ is born.

Of course there are the inherent limitations of a single-centre study with a small patient population, but nonetheless the paper is compelling reading. It’ll make you a more accomplished ECG marksman, taking better aim from the roof of your department.

For me, the take-home point is to always carefully consider treating and admitting a patient with resolved ischaemic-sounding chest pain and unusually big right precordial T-waves (however subtle) – particularly if they have risk factors for coronary artery disease. At the very least previous ECGs should be hunted down and interrogated.

As always, would love to hear others thoughts on the paper.


The Paper

Driver BE, Shroff GR, Smith S. Posterior reperfusion T-waves: Wellens’ syndrome of the posterior wall. Emerg Med J. 2016 Jul 29.

Additional resources used

Dispatching stress in the EOC #IAM999

5 Sep, 16 | by cgray

ou're never making just one decision_(1)

In this month’s EMJ, Astrid Coxon and team have published a study looking at the experiences of staff working in local Emergency Operations Centres (EOCs). Broadly, staff who work there are in two groups. There are call takers who answer 999 calls from members of the public, process the information they receive, triage it, and pass it to the dispatch team, and in some cases stay on the phone line to talk to the caller or give emergency medical advice. The other group are the dispatchers. They take the information from the call takers, and liaise directly with the frontline crews to co-ordinate and prioritise the medical response to the huge volume of calls that come in every day.

The study looked at this second group, who are largely invisible to the public, and aimed to identify key stressors in the workplace, so that these could be managed and reduced where possible. They hope that this could have a positive impact on the well-being of the staff, reduce sickness absence, and decrease staff turnover. The main factors found involved resources and pay, interpersonal difficulties, and feeling overworked and undervalued – themes that I’m sure many in all areas of healthcare can relate to. You can read about some of the ways the participants in the study felt that stress could be reduced, as well as some of the authors’ suggestions, in the EMJ or on the website.

This article, as well as the recent #IAM999 campaign on Twitter and other forms of social media, reminds us how crucial it is to remember that before our patient turned up nicely packaged by the paramedics, and indeed before the paramedics even arrived on scene, there was someone on the other end of the phone, supporting and giving advice to a worried patient, concerned relatives, or a distressed bystander. They may have been listening to the last words someone would ever say, or helping a child try to resuscitate their mother or father.  There are so many people who work behind the scenes in pre-hospital and emergency medicine. Their support and work are a huge part of the process that has led to your patient arriving in the ED, but too often we forget that this bit actually exists. It’s reassuring that work has been done to try to assess stress in these people, and to look for ways they themselves, as well as the organisation they work for, can make changes to reduce this.

It can’t be an easy job, particularly when, like ED doctors and nurses, time is rarely taken to process what’s happened before moving onto the next poorly patient. However, it’s a rewarding job, and one that can make a huge difference to the lives of patients and their families.

As Sam, who participated in the study, said, “I can honestly say I go home at the end of every single day and I’ve made a difference to at least one person…”.

And for me at least, that’s what emergency medicine, from the first 999 call, to the patient leaving the department, is all about.




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