Accident and emergency medicine--still a useful 'apprenticeship'?

The objective of this study was to compare the expressed confidence of senior house officers (SHOs) at performing practical medical procedures before and after working in an accident and emergency (A&E) post. The extent of formal teaching of these skills and opportunity for independent performance of them was also assessed. A postal questionnaire was sent to all SHOs completing an A&E post in the Trent region of the United Kingdom. Doctors were asked to grade their subjective confidence at performing listed practical skills before and after working in A&E. Eighty-four replies from 120 questionnaires were received (70% response rate). There was a significant improvement in confidence ( <0.0001) for all the skills studied after working in A&E. The proportion of doctors who received instruction varied for each of the skills. The expressed confidence of SHOs in performing practical procedures improved dramatically after working in A&E. Although remaining a valuable 'apprenticeship' for junior doctors, structured training is inadequate in the accident and emergency SHO post.

Senior house officer withdrawals from hospital posts: a questionnaire survey.

OBJECTIVES: To assess the nature and number of unexpected withdrawal by senior house officers (SHOs) after acceptance of a hospital post at interview, and to investigate the reasons and possible solutions. DESIGN: Postal questionnaire based study. SUBJECTS: Medical staffing departments, accident and emergency (A&E) consultants, and withdrawing SHOs in England. MAIN OUTCOME MEASURES: Unexpected withdrawals by hospital specialty, three year trend in A&E departments, notice and reasons given, and action taken. RESULTS: 39% of medical staffing departments reported unexpected withdrawals in a broad spectrum of specialties for February 1998. In the specialty of A&E medicine this occurred in 34% of departments. Overall 72% of A&E departments had experienced this problem over a three year period, and the trend is increasing. The majority of A&E consultants (70%) took no action, and there was a lack of consensus among all respondents on the appropriate course of action to prevent this escalating problem. CONCLUSIONS: Unexpected SHO withdrawal is a substantial issue in hospital medicine and has been increasing in A&E medicine. Measures to prevent this national problem are urgently needed.

Fatal flecainide intoxication.

Flecainide acetate is a potent class 1C antiarrhythmic agent used mainly for the treatment of supraventricular arrhythmias. Acute overdose of this drug is rare but frequently fatal. The clinical course of a patient that ingested a large quantity of flecainide as a suicide attempt is described and current therapeutic strategies discussed.

CS gas exposure in a crowded night club: the consequences for an accident and emergency department.

A case is reported of deliberate release of CS gas (O-chlorobenzylidene malononitrile) in an enclosed space and the consequences for an accident and emergency department.

How do individuals with diabetes use the accident and emergency department?

OBJECTIVE: To determine whether the frequency and pattern of use of the accident and emergency (A&E) department by individuals with diabetes is different from that of the general population. METHODS: A historical cohort of 696 individuals with diabetes from six randomly selected general practices and a non-diabetic comparison cohort matched on age, sex, and general practice were identified. The use of an urban A&E department by the two cohorts was compared for number of visits between 1984 and 1996 for injuries, diabetes related and non-diabetes related illness, proportion referred by a general practitioner, proportion arriving by ambulance, and proportion admitted. RESULTS: More visits were made by the diabetic cohort (1002 v 706, P = 0.0001); 121 visits were directly related to diabetes, including 52 for hypoglycaemia. The diabetic cohort also had more visits for medical illness unrelated to diabetes (357 v 231, P = 0.0001). The number of visits for injuries was similar (524 v 475, P = 0.3). Individuals with diabetes who attended A&E were not significantly more likely to be referred by a general practitioner (14% v 16%) or admitted (20% v 17%). CONCLUSIONS: Individuals with diabetes made more frequent visits than the general population to the A&E department. Since there was no excess of visits for injuries and the proportion requiring admission was similar, the hypothesis that they have a different threshold for attending is not supported.

Prehospital cardiac arrest in Leicestershire: targeting areas for improvement.

OBJECTIVE: To identify the impact of advanced life support skills on outcome for prehospital cardiac arrest in a defined population and to assess the value of certain physiological variables in predicting the outcome in those successfully resuscitated in the accident and emergency (A&E) department; to identify areas for improvement in the outcome of such patients. DESIGN: Prospective 12 month study. SETTING: Leicestershire, United Kingdom. MAIN OUTCOME MEASURE: Survival to hospital discharge and status at 6 months. RESULTS: 266 patients were identified as having suffered a prehospital cardiac arrest; of these, 86 had their resuscitation attempt terminated in the community by a general practitioner and 180 were transferred to the A&E department of the Leicester Royal Infirmary. Of the latter, 159 were felt to be of cardiac aetiology, and 19 were eventually discharged from hospital. All survivors had experienced a witnessed cardiac arrest, ventricular fibrillation (VF) being identified as the initial rhythm. After adjusting for age and sex using logistic regression, the Glasgow coma score (GCS) was found to be associated with subsequent mortality (chi 2 = 18.22 on 2 df, P < 0.0001). Compared to a baseline GCS of 9-15, the relative odds of death for a GCS of 3 were 25.3 (95% confidence interval 4.3 to 149-9), while a GCS of 4-8 gave a relative odds of death of 12-18 (95% CI 1.8 to 80.2). No significant association was found between postarrest arterial pH and mortality. CONCLUSIONS: The immediate GCS on admission is a predictor of outcome and it is important to monitor its trend in the first 24 h. Multidisciplinary audit and joint guidelines with other specialties are important in optimising the care of these patients.

The effect of legislation on injuries sustained by rear seat car passengers.

A study of 206 injured rear seat passengers was undertaken over two 4-month periods before and after the introduction of legislation enforcing use of rear seat-belts on 1 July 1991. The proportion of both adults and children using rear seat-belts increased after the law. Those wearing belts were less likely to suffer serious injury. The majority of passengers comply with the law but many rear seat passengers remain unrestrained because cars are not fitted with belts.

The importance of lower limb injuries in car crashes when cost and disability are considered.

The United Kingdom Cooperative Crash Injury Study (CCIS) database has been used to produce a sample of restrained, front-seat car occupants who survived a frontal impact. The lower limb was found to be the most frequently injured body region in car crashes of all impact types and the second most injured region in frontal impacts. 67% of all lower limb fractures in this sample were found to occur below the knee. 31% of these fractures occurred at the ankle. A review of literature reveals that injury of the lower limb above the knee produces worse disabilities and longer recovery times than injury to below the knee. The costs incurred as a result of above knee injuries are estimated as being greater than those below the knee. A review of European type approval legislation reveals that car design is not regulated sufficiently to prevent lower limb injury. Further work is suggested using the CCIS database in order to get a better understanding of the mechanisms involved with a view to suggesting areas where changes could be made to improve this situation.

Unscheduled return visits by patients to the accident and emergency department.

To determine why patients reattend an A&E department we surveyed 235 patients who returned unscheduled in a one-month period. Sixty-two per cent returned because of persistent symptoms. Sixty-three per cent presented within a week of their initial visit. Only 32% had attempted to see their GP. Thirty-five per cent of all patients claimed that A&E staff had advised them to return if they had problems. Half of the patients did not require treatment and 61% were discharged home. Twenty-one patients had pathology that had been missed on their first visit. Better patient education may minimize misuse of the service allowing better care for those who need it.

Assessment of a triage label system during a major incident exercise.

The Metag triage label system was assessed during a major incident exercise at an international airport. The exercise simulated a crash of a plane carrying 40 passengers within the airport boundaries. A secondary incident also was staged involving an explosion resulting in a fire with three victims injured. The exercise involved the airport, fire, police, ambulance, and medical services of three counties--Leicestershire, Derbyshire, and Nottinghamshire. Use of the labels enabled evaluation of the triage process, early medical intervention for victims, and completion of the cards.

Accident & Emergency Department's response to patients' inquiries by telephone.

A prospective survey of all telephone calls for medical advice to the Accident & Emergency Department of Leicester Royal Infirmary was undertaken. The objectives of the study were to quantitate the frequency and circumstances related to these inquiries. Over the study period of 10 days, details of 154 telephone calls were recorded. The results demonstrated the perception of the general public, that the A & E department was the most logical place to contact. Only 30% (46) attempted to seek advice from their general practitioner prior to calling the department.

Blood alcohol concentration measurement using a salivary reagent stick: a reliable tool for emergency departments?

Measurements of blood alcohol concentration (BAC) were made on patients who presented to an accident and emergency department with acute alcohol intoxication. A correlation of r = 0.418 was noted to exist between BAC as measured by sampling saliva and blood. Blood alcohol concentrations as measured by salivary reagent strip (ALCO-SCREEN, Chem Elec.) were significantly lower (p less than 0.0001) than those determined by gas chromatography of serum. Although such reagent strips offer a rapid measurement of BAC, it is concluded that they are unreliable for the quantitative measurement of BAC in accident and emergency departments.

Protective effect of rear-seat restraints during car collisions.

The nature of injuries to 2684 car occupants involved in 1055 car accidents were analysed. Less than 1% front-seat occupants were children, compared with 25% of rear-seat passengers. Nearly all (97%) rear-seat passengers were unrestrained. Type of impact was generally similar for front-seat as for back-seat occupants, except for rollover impacts, which were commoner among rear-seat passengers. Injury severity distribution was similar for front-seat as for rear-seat occupants. Except for minor-to-moderate neck injuries, which were the result of deceleration, most injuries to rear-seat passengers were due to contact with the front seat, with glazing materials, or with other parts of the car. The use of car restraints by rear-seat passengers should reduce the incidence and severity of injuries.

Ultrasound assessment of the suspected scaphoid fracture.

A prospective study of 111 patients thought to have sustained a recent scaphoid fracture on clinical grounds but who were radiologically negative was undertaken over a period of 7 months. All such patients were subjected to ultrasound scanning within a week of their injury under double blind conditions. All patients were re-X-rayed 2-3 weeks after their injury. The authors' results suggest that ultrasonic diagnosis of the possibly fractured scaphoid is unreliable.

The suspected fracture of the scaphoid: a rational approach to diagnosis.

It has been the policy of the accident and emergency department in Leicester to treat all clinically suspected fractures of the carpal scaphoid in plaster for 2 weeks, even after negative radiology. A preliminary audit of policy revealed that 150 wrists had been immobilized in plaster during a 6-month period and yet only eight fractures of the scaphoid were identified in this group. In order to reduce the degree of 'overkill' a new policy was introduced for the management of the clinically suspected, radiologically negative fracture of the scaphoid and results were assessed prospectively. The new policy was based on resting all such injuries in broad arm slings until review by a more senior member of staff was possible, always within 1 week. Results indicate that it is easier to make a definitive soft tissue diagnosis a few days after such injuries and, therefore, the number of plasters applied dropped substantially. Not all fractures of the scaphoid were apparent on initial radiographs, but despite this it was possible to treat all such injuries appropriately on the strength of their clinical signs when reviewed. The new scheme of management is recommended for general use in accident and emergency departments on the strength of a prospective study of 111 patients with pain after injury, tenderness and swelling in the anatomical snuffbox.

Use of the resuscitation room for trauma.

This study was designed to assess the use of the resuscitation room for trauma cases, the information being used to identify particular problem areas and put forward possible solutions. One hundred and fifty consecutive resuscitation room trauma patients were studied prospectively, with details being obtained both at the time of admission and 48 h later. The results have highlighted the importance of all patients with major trauma being assessed and treated by senior medical staff. In addition, the presence of more than one doctor when managing any resuscitation room trauma patient was shown to be beneficial. Many cases were seen by SHO only, and there is a need for more senior medical staff to be informed of every trauma patient entering the resuscitation room. Recording of vital signs was found to be less than satisfactory and there is a necessity for a departmental policy on this.

Use of analgesia in severe pain in the accident and emergency department.

The adequate management of severe pain in accident and emergency departments depends on knowledge of the pharmacology of analgesic drugs. To evaluate such a knowledge a study by questionnaire was conducted. Fourteen accident and emergency departments participated and one hundred senior house officers answered the questionnaire. A large percentage of the respondents would use an inappropriate route of administration (intramuscular 50% rather than intravenous 50%), some would use an inappropriate drug and often wait too long (90 min) before giving a further dose of analgesic should the patient continue to be in severe pain after the initial dose. These results suggest that there is need for further teaching on pain relief at medical schools, casualty officers need to be taught about analgesia when they start working in accident and emergency departments, and it may be beneficial for accident and emergency departments to have an analgesic policy.