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