Senior Emergency Physicians Research Articles

Young–Burgess classification: Inter-observer and inter-method agreement between pelvic radiograph and computed tomography in emergency polytrauma management

Background: While there are intrinsic differences in the pros and cons between plain radiographs and computer tomography, the role of pelvic radiographs in polytrauma management is diminishing as computer tomography scans are becoming more accessible. Previous studies found varying results in the inter-observer agreement in pelvic radiograph interpretations. Objectives: To evaluate inter-observer agreement of classifying pelvic fractures in major trauma patients by emergency physicians, and the inter-method agreement between plain radiographs and computer tomography scans. Methods: Three hundred sixty-nine patients with pelvic trauma were recruited from the trauma registries of four designated trauma centres in Hong Kong, each having one set of anteroposterior pelvic radiographs and pelvic computer tomography scans. Pelvic radiographs were classified by two emergency physicians using Young–Burgess classification, and pelvic computer tomography scans classified by an experienced radiologist. Disagreed pelvic radiographs were evaluated by a senior emergency physician to make a final decision before comparing with computer tomography scans. Cohen’s kappa was used to measure the inter-observer and the inter-method agreements, in the groups ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’. Results: Inter-observer agreements of plain radiograph classification for ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’ were moderate to substantial (κ = 0.72, 0.60 and 0.55, respectively). Inter-method agreement for the three groups between plain radiographs and computer tomography were fair to moderate (κ = 0.42, 0.59 and 0.38, respectively). Conclusion: The inter-method agreement between plain pelvic radiographs and computer tomography scans was fair in classifying pelvic fractures, and moderate in detection of unstable pelvic fractures. If the patient is haemodynamically unstable or when computer tomography is unavailable, it is reasonable to obtain plain radiographs to screen for unstable pelvic fractures to expedite early intervention. A review in the education approach and material of Young–Burgess classification may improve inter-observer agreement.

Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine.

BackgroundTo treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses.ObjectiveIn this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one.MethodsA specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact.ResultsA total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds.ConclusionsTriage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage.

Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study

ObjectivesConfirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber-optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time-consuming, and not always practical. Inexpensive endoscopic USB-cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB-camera. MethodsThis study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB-endoscopy. We have prepared a randomized intubation list (n=96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB-endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2cm wide ostium on the proximal trachea. ResultsIn this study, all intubations (n=96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB-camera. Both the sensitivity and specificity of TUS and USB-endoscopy for the CoETP were 100.0%. ConclusionThe perfect accuracy of TUS and USB-endoscopy, have placed those techniques in a unique position as an alternative in resource-poor situations.

What Factors Determine the Use of an Electronic Test Result Acknowledgement System? - A Qualitative Study Across Two EDs.

Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part in determining the nature of change that an electronic result acknowledgement system is likely to produce.

Preclinical use of mild therapeutic hypothermia after cardiac arrest by the emergency services in Baden-Württemberg, Germany

During the last decade target temperature management has become an integral part of postresuscitation care. Within recent years there was astrong debate about the optimal target temperature, which might have effects on the preclinical induction of hypothermia. The present investigation focuses on the use of mild therapeutic hypothermia by emergency services in the state of Baden-Württemberg (Germany) and compares it to results of aprior study in 2008. Between April and August 2014 aquestionnaire was sent to all senior emergency physicians of emergency services in Baden Württemberg. The survey period was April to August of 2014. Parts of the questionnaire were similar to aprevious one in 2008, to ensure comparability to the former data; other parts were added to set new focuses. The data were analyzed in anonymized form. The response rate was 72.4% (97/134). Of the 97sites which responded to the questionnaire significantly more use preclinical hypothermia, compared to 2008 (72.2% [70/97] vs. 41.7%); 62.9% (44/70) declare cooling resuscitated patients routinely (vs. 17.7% in 2008). Cold infusions (85.7%), icepacks (64.3%), passive cooling (37.1%), nasal cooling (2.9%) and cooling caps (1.4%) are used (multiple naming was possible). Sites that did not use mild therapeutic hypothermia stated the following reasons: lack of equipment, short transport time and missing data for the intervention. Four sites reported on complications with therapeutic hypothermia. The present investigation shows an increased use of preclinical cooling after cardiopulmonary resuscitation as compared to 2008. Therefore, recent discussions concerning the optimal target temperature in postresuscitation care did not result in awaiving of preclinical therapeutic strategies in Baden-Württemberg. The emergency services sites/locations estimated the complication rates of mild therapeutic hypothermia as very low. Lack of equipment seems to be the main reason to refuse the preclinical use of therapeutic hypothermia. In conclusion, preclinical mild therapeutic hypothermia has become an integral part in the standard care of resuscitated patients in Baden-Württemberg.

What do emergency physicians in charge do? A qualitative observational study

IntroductionThe emergency physician in charge role has developed in many large EDs to assist with patient flow. We aimed to describe and classify the problem-solving actions that this role requires.MethodsWe...

What is the impact of an electronic test result acknowledgement system on Emergency Department physicians’ work processes? A mixed-method pre-post observational study

ObjectiveTo examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians’ test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED). MethodsThe impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system. ResultsThe eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA. ConclusionsGiven that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results.

VALIDATION OF THE SHORT FORM OF THE INTERNATIONAL CROWDING MEASURE IN EMERGENCY DEPARTMENTS (ICMED): INTERNATIONAL STUDY

Objectives & BackgroundThere is little consensus on the best way to measure emergency department crowding. We have previously developed a consensus based measure, the International Crowding Measure in Emergency Departments...

P021: Impact of emergency department surge and end of shift on patient workup and treatment prior to referral to internal medicine

Introduction: The goal of this study was to determine if emergency department (ED) surge and end of shift assessment of patients affect the extent of diagnostic tests, therapeutic interventions performed and accuracy of diagnosis prior to referral of patients to Internal Medicine as well as the impact on patient outcomes. Methods: This study was a health records review of consecutive patients referred to the internal medicine service with an ED diagnosis of heart failure, COPD or sepsis, at two tertiary care EDs. We developed a scoring system in consultation with senior emergency and internal medicine physicians to uniformly assess the treatments and investigations performed for patients diagnosed in the ED with heart failure, COPD or sepsis. These scores were then correlated with surge levels and time of day at patient assessment and disposition. Rate of admission and diagnosis disagreements were also assessed. Results: We included 308 patients (101 with heart failure, 101 with COPD, 106 with sepsis). Comparing middle of shift to end of shift, the overall weighted mean scores were 92.2% vs. 91.7% for investigations and 73.5% vs. 70.0% for treatments. Comparing low to high surge times, the overall weighted mean scores were 89.9% vs. 92.6% for investigations and 68.6% vs. 71.7% for treatments. Evaluating each condition separately for investigations and treatments according to time of shift or surge conditions, there were no consistent differences in scores. We found overall high admission rates (93.1 % for heart failure, 91.1% for COPD, 96.2% for sepsis patients), and low rates of diagnosis disagreement (4.0 % heart failure, 10.9% COPD, 8.5% sepsis). Conclusion: We found that surge levels and end of shift did not impact the extent of investigations and treatments provided to patients diagnosed in the emergency department with heart failure, COPD or sepsis and referred to internal medicine. Admission rates for the patients referred were above 90% and there were very few diagnosis disagreements or diversion to alternate service by internal medicine. We believe this supports the emergency physician's ability to adapt to time and surge constraints, particularly in the context of commonly encountered conditions.

Exploring the influence of gender, seniority and specialty on paper and computer-based feedback provision during mini-CEX assessments in a busy emergency department

The mini-clinical evaluation exercise (mini-CEX) is a well-established method of assessing trainees’ clinical competence in the workplace. In order to improve the quality of clinical learning, factors that influence the provision of feedback are worthy of further investigation. A retrospective data analysis of documented feedback provided by assessors using the mini-CEX in a busy emergency department (ED) was conducted. The assessors comprised emergency physicians (EPs) and trauma surgeons. The trainees were all postgraduate year one (PGY1) residents. The completion rate and word count for each of three feedback components (positive feedback, suggestions for development, and an agreed action plan) were recorded. Other variables included observation time, feedback time, the format used (paper versus computer-based), the seniority of the assessor, the gender of the assessor and the specialty of the assessor. The components of feedback provided by the assessors and the influence of these contextual and demographic factors were also analyzed. During a 26-month study period, 1101 mini-CEX assessments (from 273 PGY1 residents and 67 assessors) were collected. The overall completion rate for the feedback components was 85.3 % (positive feedback), 54.8 % (suggestions for development), and 29.5 % (agreed action plan). In only 22.9 % of the total mini-CEX assessments were all three aspects of feedback completed, and 7.4 % contained no feedback. In the univariate analysis, the mini-CEX format, the seniority of the assessor and the specialty of the assessor were identified as influencing the completion of all three components of feedback. In the multivariate analysis, only the mini-CEX format and the seniority of the assessor were statistically significant. In a subgroup analysis, the feedback-facilitating effect of the computer-based format was uneven across junior and senior EPs. In addition, feedback provision showed a primacy effect: assessors tended to provide only the first or second feedback components in a busy ED setting. In summary, the authors explored the influence of gender, seniority and specialty on paper and computer-based feedback provision during mini-CEX assessments for PGY1 residency training in a busy ED. It was shown that junior assessors were more likely to provide all three aspects of written feedback in the mini-CEX than were senior assessors. The computer-based format facilitated the completion of feedback among EPs.

Ultrasound-Guided Reduction of Distal Radius Fractures.

Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures.

Seniority of Emergency Physician, Patient Disposition and Outcome Following Disposition

ObjectivesThe relationship between the seniority of emergency physicians (EPs) and disposition decision-making is not well defined. As most responsibility by EPs involves developing an appropriate disposition plan, this study aimed to examine the influence of EP seniority on decisions regarding patient dispositions in the emergency department (ED). Materials and MethodsThis retrospective, 1-year, cohort study was conducted in 3 EDs including all day-shift nontraumatic adult patients. The outcome involves patient dispositions at the end of the shift, patient final dispositions and patient 72-hour ED return. The EPs were categorized into the following 3 groups according to seniority: junior group (≤5 years of work experience), intermediate group (6-10 years) and senior group (>10 years). ResultsThe dispositions of 68,333 ED patients as determined by the 59 full-time EPs were studied. Compared to junior and intermediate EPs, senior EPs kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they had the lowest patient mortality rate especially in first triage patients (3.4% fewer than junior EP, 1.3% fewer than intermediate EP); they took more time for patient discharge (0.2 more hours than junior EP, 0.1 more hours than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP). ConclusionsSenior EPs had the best quality of care (lowest mortality, fewest 72-hour returns). This best quality of care is accompanied with a slightly longer length of stay.

The Impact of Emergency Physician Seniority on Clinical Efficiency, Emergency Department Resource Use, Patient Outcomes, and Disposition Accuracy

The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs).The purpose of this study was to investigate the impact of EP seniority on clinical performance.A retrospective, 1-year cohort study was conducted across 3 EDs in the largest health-care system in Taiwan. Participants included 44,383 adult nontrauma patients who presented to the EDs. Physicians were categorized as junior, intermediate, and senior EPs according to ≤5, 6 to 10, and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. Emergency department resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests, and computed tomography scans. Discharge and mortality rates were used as patient outcomes. Disposition accuracy was evaluated by ED revisit rate.Senior EPs were found to have longer door-to-order (11.3, 12.4 minutes) and door-to-disposition (2, 1.7 hours) time than nonsenior EPs in urgent and nonurgent patients (junior: 9.4, 10.2 minutes and 1.7, 1.5 hours; intermediate: 9.5, 10.7 minutes and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs, and computed tomography scans in nonurgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted odd ratios, 1.5 and 1.6, respectively).Compared with EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for nonurgent patients, and are associated with a lower ED mortality rate.

Fluid resuscitation for paediatric sepsis: A survey of senior emergency physicians in Australia and New Zealand.

It is unclear whether emerging evidence for harm from aggressive fluid resuscitation for paediatric sepsis has altered clinical practice. We surveyed senior emergency physicians to see if their fluid resuscitation practices conformed to published clinical guidelines. This is a cross-sectional, Internet-based survey of senior emergency medical staff in any of 12 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network centres in Australia and New Zealand. There were 110 of 120 (92%) senior medical staff who responded. Ninety-eight per cent of respondents used 0.9% saline as their primary resuscitation fluid. Sixty-two per cent of respondents used 20 mL/kg fluid bolus for every bolus, 30% used 20 mL/kg for the first bolus and 10 mL/kg subsequently. Response to fluid bolus administration was based on clinical parameters in 92% of respondents (heart rate, BP, skin perfusion/mottling and central capillary refill), conscious state in 80% and venous lactate in 75%. Harm from fluid bolus administration was routinely monitored for by 81% of respondents. In those assessing for harm, clinical parameters were reported to be most commonly used (respiratory rate and effort in 60%, SpO2 in 55%, presence of crackles on lung auscultation in 50% and hepatomegaly in 42%). Invasive or ultrasound-based monitoring was used infrequently. Paediatric sepsis is reported to be managed by senior emergency physicians largely according to published guidelines. At this time, evidence for potential harm from fluid bolus resuscitation has not altered practice.

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the Internet: a multisite survey.

BackgroundPatients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions.ObjectiveThe aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results.MethodsA cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification.ResultsThe response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61).ConclusionsAlthough patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Management of children with possible appendicitis: a survey of emergency physicians in Australia and New Zealand.

To describe current practice in managing children with possible acute appendicitis in EDs in Australia and New Zealand as the basis for a clinical practice guideline (CPG). An anonymous survey was distributed to consultant emergency physicians working at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand in April 2013. A second, site-based survey was distributed to the PREDICT representatives at each of the 13 sites. The response rate was 100% (13/13) for the site-based survey and 82% (145/176) for the physician survey. Most respondents agreed that right lower quadrant (RLQ) tenderness (94%), anorexia (92%), migration of abdominal pain to the RLQ (86%), rebound tenderness in the RLQ (60%) and RLQ tenderness produced on coughing, hopping or percussion (63%) were valuable symptoms and signs in diagnosing appendicitis. The responses regarding nausea and vomiting and fever were less consistent. Less than 50% regarded blood tests (C-reactive protein, white cell count) as relevant for the diagnosis of appendicitis. Most physicians (61%) agreed there was a role for a validated CPG for possible appendicitis in children, although only 3/13 sites reported use of such a CPG. This survey of senior emergency physicians across Australia and New Zealand demonstrated congruence in several clinical markers and disagreements in others in the approach to diagnosing children with possible appendicitis. Whereas emergency physicians would like a validated CPG, this survey has highlighted some critical issues. Particularly, the low regard for blood tests, integral to published diagnostic scoring systems, will be a challenge for the development and introduction of such a CPG in Australia and New Zealand.

A Comparative Assessment of Adverse Event Classification in the Out-of-hospital Setting

Objectives. We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. Methods. The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). Results. For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI −0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58–68%) and NPV (63–76%) was moderately dissimilar between clinicians, while sensitivity (25–80%), specificity (43–97%), and PPV (48–83%) varied. Conclusions. We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.

From little things: How it all started

When Stephen Lock retired from editing the British Medical Journal in 1991 after a quarter of a century with the journal, I was just in my third year of editing Emergency Medicine Australasia (or Emergency Medicine as it was then). I remember thinking how long that period of Lock’s journal editing was, and realising how diametrically opposed were the requirements of being an emergency physician (rapid decision-making, short concentrated attention span, time periods measured in minutes to hours) and those of a journal editor (strategic long-range planning, judgements considered over months to years and time periods measured in years to decades). I was an unabashed fan of Stephen’s and of his successor Richard Smith, and the wonderful, eclectic, human medical journal they put together over all those years. Balancing journalism and science became their journal’s hallmark, presenting a human and sometimes humorous face to medicine, ensuring that art, music, history and personal reflection were given equal stand

‘Out of hours’ adult CT head interpretation by senior emergency department staff following an intensive teaching session: a prospective blinded pilot study of 405 patients

AimCranial CT is the gold standard for the investigation of intracranial emergencies. The aim of this pilot study was to audit whether senior emergency physicians were able to report CT...

Triggers for head computed tomography following paediatric head injury: Comparison of physicians' reported practice and clinical decision rules

To compare head computed tomography (CT) triggers for paediatric head injury as reported by senior paediatric emergency physicians in Australia and New Zealand with triggers in published evidence-based clinical decision rules (CDRs). A survey of CT triggers after head injury was distributed to senior emergency physicians at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand. Results were compared with recommendations for CT scans in CATCH, CHALICE and PECARN CDRs. Clinical practice guidelines (CPGs) from each site were also reviewed. The response rate was 93% (130/140). No published trigger for head CT was identified by 100% of survey participants and each CDR included several triggers not identified by many respondents. Abnormal examination findings, including depressed skull fracture and base of skull fracture, were most likely to prompt respondents to order a head CT (>90%). A concerning mechanism of injury, such as a fall greater than 3 feet or five stairs, triggered a CT response only in approximately 10% of respondents. Eight different head injury CPGs were used across the 13 PREDICT sites. These were highly variable between sites and CPGs were not explicitly based on published CDRs. High-quality, published CDRs exist for head CT use after paediatric head injury. Physician-reported CT triggers differ from CDR-recommended triggers. The major published head injury CDRs should be prospectively validated in the Australasian setting before incorporating them into local practice and CPGs.