Casualty Officer Research Articles

Doctors' reported knowledge on how to deal with a front tooth which has been knocked out

A study was conducted to determine the medical profession's knowledge about dental trauma. Postal questionnaires were sent to 220 general medical practitioners (GMPs) and 65 casualty officers to investigate three key elements in the emergency care of avulsed permanent incisor teeth. Almost one fifth of the GMPs (18.5%) were unaware that it was possible to replant an avulsed tooth. Sixty-eight per cent of doctors would store the injured tooth in a way that would severely compromise the success of replantation. Over two-thirds of doctors (66%) would clean a dirty, avulsed tooth in a manner that would harm the periodontal ligament and jeopardise the success of replantation.This study has identified a need to improve the knowledge of doctors about dental injuries and their emergency management.

Audit of a multi-disciplinary assessment unit for deliberate self-harm patients in a general hospital

Abstract This paper describes a joint departmental audit of a multidisciplinary assessment unit for patients with deliberate self-harm. Our results indicated a significant gap in service delivery for this client group. Recommendations made include improvement of teaching for casualty officers, closer liaison with Accident & Emergency, on-call psychiatrists and substance misuse services. With the recent U.K. Royal College of Psychiatrists consensus statement on the general hospital management of adult deliberate self-ham patients, the need for future cross-depamnental audit is emphasised.

Misdiagnosis of acute angle closure glaucoma.

When acute glaucoma presents in its classical form, the diagnosis is fairly simple to make. However, atypical presentations are not uncommon and the diagnosis can be missed. This inevitably leads to a delay in treatment which can permanently compromise visual function. We have studied which doctors are most likely to make a misdiagnosis and calculated the resulting delay in treatment. All patients with acute glaucoma attending Whipps Cross eye unit between 1991 and 1994 were identified and their notes obtained. Thirty-eight patients were found to have a had diagnosis of acute closed angle glaucoma. In only 39.5% was the diagnosis correctly made by the referring practitioner and a misdiagnosis resulted in a mean delay of treatment of 5.8 days. General practitioners were the most likely group to have difficulty making the diagnosis, while casualty officers were most likely to make the correct diagnosis. Because acute glaucoma can present without its typical features, there needs to be a high index of suspicion for this diagnosis. This diagnosis does not require expensive equipment or a high level of training--all our patients had a significant reduction in vision. Any patient who has a red eye and a subjective reduction in vision should be referred to an ophthalmologist the same day.

Chart helps with calculation of dose of adrenaline for children

EDITOR,--In the report of a case of anaphylaxis that prompted Malcolm Fisher's review the casualty officer had difficulty in determining the correct dose of adrenaline for a …

The health belief model and use of accident and emergency services by the general public.

There has been much debate about the use made by the general public of accident and emergency services. A strong element of professional disapproval has been present, as shown by phrases such as 'inappropriate attender'. This paper examines the reasons why people attend accident and emergency and the factors that delay or accelerate attendance, utilizing a framework espoused in the medical sociology literature, i.e. the Health Belief Model. This predicts that individuals carry out a treatment cost-benefit analysis when making decisions about seeking medical assistance. A sample of 200 adult, ambulatory accident and emergency patients was interviewed whilst waiting to see the casualty officer for this study. The data demonstrated that much of the medical, sociological literature concerning patient consultation with doctors is applicable to the accident and emergency situation, in particular the Health Belief Model. A range of factors was shown to make statistically significant differences to the delay times involved in deciding to attend accident and emergency and the time it took to then subsequently attend and register as a patient. These factors also fit the cost-benefit analysis which the Health Benefit Model predicts takes place. Accident and emergency attendance therefore needs to be seen as a logical decision-making process that requires hospitals to provide appropriate services, rather than merely labelling the patients as inappropriate.

Ethical Debate: Providing treatment against a patient's wishes

A patient who presents voluntarily at an emergency department should be assumed to want treatment. If relatives or friends bring in a patient we can again assume that they want the person in their care to receive attention. The situation is more difficult if a patient is brought in by the police or by a carer from an institution. However, in the two cases reported here the casualty officer would have known that friends or relatives were responsible for each patient's presentation. In such cases the doctor must therefore take into account the broader perspectives of each case rather than the short term demands of a patient. Decisions must be taken on the basis of previously agreed, evidence based protocols and should …

Come home to a real fire

Conversation overheard: “Anyway the referral letter to the casualty SHO was in Welsh. So the casualty officer, who was Indian, wrote back in Urdu. Ho, ho. Serve the GP right.“ “Clever dick. Probably a cottage burner on his nights off. Come home to a real fire, eh? Bet he dresses up as a druid and prances about with a trumpet at the Eisteddfod.“ “And all that money they spend putting up the signs around the hospital in Welsh as well - people get even …

A survey of new attenders at a paediatric accident and emergency department.

A prospective study of one week's new attendances (sampled over three consecutive weeks) at the A&E Department of the National Children's Hospital (NCH) was undertaken. A total of 310 children attended over the composite week. Of these, 307 took part in the study, all but three of which were accompanied by an adult. Almost three-quarters (72%) of the children attended without medical referral. Most children (80%) resided within two miles of the hospital. While 46% of respondents claimed they had used the hospital at least once during the previous twelve months, frequent attendance did not appear to be a problem. The majority of children (83%) were seen by a casualty officer within one hour of arrival. Injuries accounted for over half (53%) of the conditions presented. A fifth (21%) of the attenders were admitted, half (54%) of whom were discharged within 24 hours. The study provides baseline data on paediatric A&E services in Dublin and should assist planning of future services.

Asthma: audit of peak flow rate guidelines for admission and discharge.

A two part 8.5 month study was undertaken to see if peak expiratory flow rate (PEFR) could be used to guide casualty officers deciding whether to admit or discharge children with asthma. In part 1 PEFR, immediate treatment, and admission or discharge of all children attending because of asthma were recorded. In part 2 the same information was recorded after the introduction of admission and discharge guidelines based on PEFR. After the introduction of guidelines the proportion of children admitted with a PEFR > or = 40% expected after casualty treatment fell from 43% to 26% (part 1 44/101, part 2 38/145). For a PEFR > 60% the rate fell from 23% to 5% (part 1 12/52, part 2 4/80). There was no significant change in the reattendance rate. PEFR can help to reduce unnecessary admissions, provided appropriate normal values and guidelines are supplied.

The utility of nasal bone radiographs in nasal trauma

A prospective study was performed to assess the value of nasal bone radiographs taken in the accident and emergency department. The study population consisted of 100 consecutive patients who had nasal bone radiographs in our accident and emergency (A&E) department following trauma. We looked at the casualty officers', radiologists' and ENT surgeons' assessment of the cases. Thirty months later we reviewed the patients' notes to identify the number who sought medico-legal reports on their injury in that interval. We found sporting injuries to be the commonest mechanism of injury, followed closely by accidental falls. The remaining third was made up predominantly of cases of personal assault and road traffic accidents. Only two patients had a naso-pharyngeal history recorded on their visit to A&E. Thirty-five patients were referred to ENT out-patients, only 24 kept their appointment. Thirty-one of the 35 ENT referrals were felt to have a fracture demonstrated on their radiographs. However, 19 of those discharged were also thought to have an X-ray-proven fracture. Thirty months later only two patients had requested a medico-legal report. We demonstrate that the decisions regarding treatment of nasal trauma are based on clinical findings and that nasal bone radiography has no place in the decision making process and should therefore be abandoned.

A study of the attitudes of A & E staff towards patients

Many nursing and medical staff frequently wonder why some patients attend Accident & Emergency (A & E). People with conditions which seem trivial to experienced eyes present alongside the serious injuries and acute emergencies. A & E staff can be forgiven for thinking that many of their patients should either have gone to their General Practitioner (GP), or just used a bit of common sense and basic first aid, to deal with a problem themselves. This view that many patients should not be attending A & E has found expression in the medical literature as the concept of ‘inappropriate attendance’. Suggestions for deterring ‘inappropriate’ patient utilisation of A & E services have been made, ranging from education campaigns to renouncing one of the basic principles of the NHS and charging a booking-in fee. behind these ideas lurks the possibility of staff harbouring negative attitudes to some groups of patients as they become labelled ‘inappropriate’. The worry is that attitudes are usually associated with beliefs and actions (Atkinson et al, 1987), and so negative attitudes may lead to lower standards of service delivery. It is important, therefore, to review the recent literature which supports this notion of ‘inappropriate’ A & E attendance, and to start with the work of Davison et al (1983) whose study looked at a sample of 607 patients attending a London A & E unit. Casualty officers were required to state in their view whether each patient was an accident, emergency or neither. Overall the authors found that 39% of patients were neither accidents nor emergencies and were therefore ‘misusing’ the A & E service, although 12% of the sample had no GP at all. Other similar papers have followed. Myers (1982) reviewed a sample of 1000 A & E case notes and concluded that 54.2% could have been dealt with by a GP. A similar smaller scale study was conducted by Davies (1986). He looked at 92 patients from his own practice who attended A & E, and concluded that 63% could have been dealt with by the practice rather than A & E. Another large scale study by Driscoll et al (19&V), including 835 A & E patients, produced a figure of 35% of A & E attenders who should have gone to their GP. A more recent study was undertaken by Hobday (1988) who looked at a sample of 606 of his own patients who attended A & E during a 6-month period in 1986. He concluded

Ophthalmology

A comprehensive textbook of ophthalmology, which presents all the relevant information needed for examinations. The authors have produced a coherent summary of this often demanding speciality, the text is well-expressed, logically organized and uses clear diagrams, photographs and lists of key points to make complex issues easier to understand and revise. The authors explain, step-by-step, the practical ophthalmological procedures that all GPs and Casualty Officers need which, with the practical checklist, makes this a useful everyday reference. Following a concise description of anatomy and physiology assessment and refraction, the book takes a problem-solving approach to the major ophthalmological signs and symptoms: squint or strabismus, glaucoma, red eye, sudden painless loss of vision, gradual painless loss of vision, neuro-ophthalmological problems, diabetes, trauma. Supplementing these core clinical problems are comprehensive chapters on tropical ophthalmology, genetics and the epidemiology of visual loss.

Wet cement: a poorly recognized cause of full-thickness skin burns

Cement is a rare cause of full-thickness burms. We have examined the aetiology, frequency and severity of these burns, and assessed public awareness of the potential of cement as a caustic agent. Of patients, 95 per cent were unaware of the potential of cement to cause burms, and none had seen precautionary warnings on cement bags or delivery dockets. Factors important in burn production appear to be alkalinity, duration of contact and the abrasive nature of the cement particles. It is concluded that doctors, especially casualty officers, should know of the potential of progressive full-thickness burns from wet cement. General public awareness should be increased. The cement manufacturers were asked to comment on the content of this paper.

Sparing of deep rectal sensation after spinal cord injury

A 38-year-old unemployed chef fell down a flight of stairs while inebriated. He claimed to be able to stand, but was put to bed by friends. On waking the next morning he noticed that he was unable to move his arms and legs and an ambulance was called. On arrival in the casualty department the patient was assessed by the casualty officer. It was documented that the patient had sensory deficit (to light touch) from the sixth dermatome distally, and motor loss from the sixth cervical myotome distally. There was no sparing of perineal or sacral sensation. On rectal examination there was complete loss of anal tone, but the patient reported the presence of deep sensation to the examining finger. Radiographs and a computed tomography scan revealed a burst fracture of the sixth cervical vertebra. There was no malalignment of the cervical spine on plain radiographs. The patient was admitted to hospital and appropriate care instituted before transfer to a spinal injuries unit. Over the 5 days following the injury the patient recovered sensation down to the level of TlO, and from L5 to S3 bilaterally. He also regained plantar flexion of his left ankle and toes (MRC IV) and a flicker of movement in both triceps (MRC I). At 18 months after the injury the patient had recovered MRC V power in many arm muscles, but there was little further improvement in his legs. The patient was able to walk with a brace and crutches, and lived in his own flat. He continued to drink heavily and this was a cause for some concern.

Burns in children: do casualty officers get it right?

It is often said that casualty officers are unable to assess burns accurately. This prospective study examines this, proving the point and offering basic suggestions for improvements.

Effect of an algorithm on the treatment of knee injuries

An audit was performed of the treatment of patients presenting with acute knee injuries to the accident and emergency department of a district general hospital. This showed that for patients requiring follow-up the majority were reviewed by the casualty officers themselves in the accident department, with the result that definitive diagnosis and treatment for patients with continuing symptoms was often delayed. Once the current treatment had been discussed at an audit meeting, a protocol (in the form of an algorithm) of the treatment of knee injuries was produced. A further audit was performed after the protocol had been in use. This demonstrated that the protocol was effective in encouraging the casualty officers to seek the help of more senior members of staff and also reduced the time taken to definitive diagnosis and treatment.

Hyperventilation syndrome – not to be dismissed

Hyperventilation reduces arterial PCO2 and can cause many symptoms due to neuronal hyper-excitability, and vasoconstriction. It has always been recognised as a psychosomatic condition, but has proved very difficult to define clearly. Nevertheless, patients severely disabled from chronic hyperventilation have been well documented. Casualty officers often see patients presenting with dramatic acute hyperventilation, and GPs and physicians in most specialities see occasional patients in whom presenting complaints are due to the effects of hypocapnia.

Chest pain in the accident and emergency department: is chest radiography worthwhile?

Four per cent of patients attend the Accident and Emergency Department (A&E) present with chest pain. In this prospective study of 297 patients the value of chest radiography is assessed. Overall, 23% of chest X-rays (CXRs) had an abnormality which influenced management of the patient, rising to 40% in those patients admitted to Coronary Care. Twenty-nine per cent of CXRs were misinterpreted by Casualty Officers but resulted in the mismanagement of only six patients (3.3%). Potentially serious errors were averted by early CXR audit by a Radiologist.

How well can radiographers triage x ray films in accident and emergency departments?

To assess the ability of radiographers to identify abnormal radiographs of patients attending accident and emergency departments. Prospective study over six weeks. Teaching hospital casualty x ray department. 3394 consecutive patients referred for radiography. Radiographs were assessed by radiographers who were offered a four point triage scheme: normal, abnormal, insignificantly abnormal, or further advice required. Comparison of radiographers' assessments with an assessment made independently by the reporting radiologists. Overall disagreement between the radiographers and radiologists was 9.4%. There were 7% false positives and 14% false negatives. Most errors occurred in assessing radiographs of the skull, facial bones, chest, abdomen, and soft tissues. Unselected radiographers can offer useful advice on radiographs to casualty officers, but their high rate of false positive diagnoses indicates that they cannot triage casualty radiographs sufficiently accurately to allow them to extend their current reporting role.

Rectal examination in patients with pain in the right lower quadrant of the abdomen.

To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen. Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital. District general hospital. 1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission. Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis. Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination. If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.