2
Emergency Medicine Australasia (February 2005) 17, 293–294 Blackwell Science, LtdOxford, UKEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty LtdFebruary 2005173293294Miscellaneous Peer ReviewPeer Review PEER REVIEW Peer Review June 2005 Taylor D McD, Bennett DM, Cameron PA. A para- digm shift in the nature of care provision in emergency departments. Emerg. Med. J. 2004; 21: 681–4. This cross-sectional survey of ED directors and nurse unit managers in Melbourne, aimed to determine the extent of changes in care provision of EDs as a conse- quence of access block and government initiatives. The major new services have been care coordination teams, short-stay units and psychiatry services though the structure and function of these services vary consider- ably. Other initiatives such as nurse-initiated manage- ment and fast-tracking have also been increasingly employed. The authors conclude that there has been a paradigm shift in the care provided by EDs with greater emphasis on outpatient management, which has neces- sitated a restructuring of how EDs operate. Brooks S, Cicuttini FM, Lim S, Taylor D, Stuckey SL, Wluka AE. Cost effectiveness of adding magnetic resonance imaging to the usual management of sus- pected scaphoid fractures. Br. J. Sports Med. 2005; 39: 75–9. This study looks at the cost-effectiveness of an MRI scan within 5 days of suspected scaphoid fracture com- pared with usual therapy. The MRI group had fracture diagnosed significantly earlier and significantly less time in plaster if no fracture was present. There was no difference between the two groups in terms of days off work or disruption of daily activities. There was a non- significant increase in cost for the MRI group. The study only enrolled 28 patients and one of these was lost to follow-up. This paper raises one other interesting question. It is taught that ‘the fate of the scaphoid is sealed at the time of the fracture’ and yet we worry about avascular necrosis of occult injuries. My search of the Cochrane database can find only one trial on the management of clinically suspected scaphoid fractures. 1 In a prospective trial of 108 patients with clinically suspected scaphoid fracture and normal radiographs, patients were randomized to either plaster cast or crepe bandage. Seven fractures (noncomplete) were later con- firmed. The authors assert that these fractures nearly always heal and in this study the crepe bandage group had 10 less days of sick leave. Is anyone brave enough to do a bigger trial? Mackay MJ. A time to die. Med. J. Aust. 2004; 181: 667–8. This is a personal reflection on societal and medical attitudes to cardio-pulmonary resuscitation (CPR). The article also highlights the danger of media storms and how sound bites or headlines can gloss over the full story. The author particularly discusses the role of CPR in sick, elderly inpatients and the (often) lack of discus- sion about the subject between the medical team and the patient. Topical, given the recent NSW Health guidelines on end of life decisions. http:// www.health.nsw.gov.au/pubs/2005/endlifecare.html Taylor D McD, Bennett D, Carter M, Garewal D, Finch CF. Acute injury and chronic disability resulting from surfboard riding. J. Sci. Med. Sport 2004; 7: 429–37. This study sought to determine the incidence, nature and outcomes of acute surfing injuries and also the incidence of chronic health problems related to surfing. Information was gathered by interviewer-administered questionnaires at eight Victorian beaches. The acute injury rate was 0.26 injuries per surfer per year, mostly from striking things (other boards, other surfers and the sea-bed) or from ‘wiping out’. Lacerations, sprains, frac- tures and dislocations accounted for most injuries. Chronic problems mainly related to ear problems and musculoskeletal pain. Taylor D McD, O’Brien D, Ritchie P, Pasco J, Cameron PA. Propofol versus Midazolam/fentanyl for reduction of anterior shoulder dislocation. Acad. Emerg. Med. 2005; 12: 13–19. This prospective randomized trial found that propo- fol was at least as effective as midazolam/fentanyl in providing sedation for reduction of anterior shoulder dislocations. The propofol group had a shorter mean time to wakening, full consciousness, had easier shoul- der reduction and needed fewer reduction attempts but had more respiratory depression. Our department’s experience with propofol over a number of years, is that it is far better than midazolam and fentanyl in this setting, but one must take the approach that it is a general anaesthetic, albeit a short one, and should be treated as such. Fatovich DM/Rogers IR, Jelinek GA, Jacobs I/ Levi CR. Tissue plasminogen activator (tPA) in acute

Peer Review June 2005

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Page 1: Peer Review June 2005

Emergency Medicine Australasia

(February 2005)

17

293ndash294

Blackwell Science LtdOxford UKEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty LtdFebruary 2005173293294Miscellaneous

Peer ReviewPeer Review

P

EER

R

EVIEW

Peer Review June 2005

Taylor D McD

Bennett DM

Cameron PA

A para-digm shift in the nature of care provision in emergencydepartments

Emerg Med J

2004

21

681ndash4This cross-sectional survey of ED directors and nurse

unit managers in Melbourne aimed to determine theextent of changes in care provision of EDs as a conse-quence of access block and government initiatives Themajor new services have been care coordination teamsshort-stay units and psychiatry services though thestructure and function of these services vary consider-ably Other initiatives such as nurse-initiated manage-ment and fast-tracking have also been increasinglyemployed The authors conclude that there has been aparadigm shift in the care provided by EDs with greateremphasis on outpatient management which has neces-sitated a restructuring of how EDs operate

Brooks S Cicuttini FM Lim S

Taylor D

StuckeySL Wluka AE Cost effectiveness of adding magneticresonance imaging to the usual management of sus-pected scaphoid fractures

Br J Sports Med

2005

39

75ndash9

This study looks at the cost-effectiveness of an MRIscan within 5 days of suspected scaphoid fracture com-pared with usual therapy The MRI group had fracturediagnosed significantly earlier and significantly lesstime in plaster if no fracture was present There was nodifference between the two groups in terms of days offwork or disruption of daily activities There was a non-significant increase in cost for the MRI group Thestudy only enrolled 28 patients and one of these waslost to follow-up This paper raises one other interestingquestion It is taught that lsquothe fate of the scaphoid issealed at the time of the fracturersquo and yet we worryabout avascular necrosis of occult injuries My searchof the Cochrane database can find only one trial on themanagement of clinically suspected scaphoid fractures

1

In a prospective trial of 108 patients with clinicallysuspected scaphoid fracture and normal radiographspatients were randomized to either plaster cast or crepebandage Seven fractures (noncomplete) were later con-firmed The authors assert that these fractures nearlyalways heal and in this study the crepe bandage grouphad 10 less days of sick leave Is anyone brave enoughto do a bigger trial

Mackay MJ

A time to die

Med J Aust

2004

181

667ndash8

This is a personal reflection on societal and medicalattitudes to cardio-pulmonary resuscitation (CPR) Thearticle also highlights the danger of media storms andhow sound bites or headlines can gloss over the fullstory The author particularly discusses the role of CPRin sick elderly inpatients and the (often) lack of discus-sion about the subject between the medical team andthe patient Topical given the recent NSW Healthguidelines on end of life decisions httpwwwhealthnswgovaupubs2005endlifecarehtml

Taylor D McD

Bennett D Carter M Garewal D FinchCF Acute injury and chronic disability resulting fromsurfboard riding

J Sci Med Sport

2004

7

429ndash37This study sought to determine the incidence nature

and outcomes of acute surfing injuries and also theincidence of chronic health problems related to surfingInformation was gathered by interviewer-administeredquestionnaires at eight Victorian beaches The acuteinjury rate was 026 injuries per surfer per year mostlyfrom striking things (other boards other surfers and thesea-bed) or from lsquowiping outrsquo Lacerations sprains frac-tures and dislocations accounted for most injuriesChronic problems mainly related to ear problems andmusculoskeletal pain

Taylor D McD OrsquoBrien D Ritchie P Pasco J

Cameron PA

Propofol versus Midazolamfentanyl forreduction of anterior shoulder dislocation

Acad EmergMed

2005

12

13ndash19This prospective randomized trial found that propo-

fol was at least as effective as midazolamfentanyl inproviding sedation for reduction of anterior shoulderdislocations The propofol group had a shorter meantime to wakening full consciousness had easier shoul-der reduction and needed fewer reduction attempts buthad more respiratory depression Our departmentrsquosexperience with propofol over a number of years is thatit is far better than midazolam and fentanyl in thissetting but one must take the approach that it is ageneral anaesthetic albeit a short one and should betreated as such

Fatovich DMRogers IR Jelinek GA Jacobs I

Levi CR Tissue plasminogen activator (tPA) in acute

Peer Review

et al

294

ischaemic stroke time for collegiate communication andconsensus

Med J Aust

2005

182

44ndash5These letters in the

MJA

present some spirited debateon the use of thrombolytics in stroke and consider therisk versus harm benefits of this therapy The lettersalso highlight the need for collegiate collaboration ininitiatives that are cross-disciplinary

Kelly A-M

Kerr D Dietze P Patrick I Walker TKoutsogiannis Z Randomised trial of intranasal versusintramuscular naloxone in prehospital treatment ofsuspected opioid overdose

Med J Aust

2005

182

24ndash7

This prospective randomized unblended trial com-pared 2 mg of naloxone intramuscularly (im) versus2 mg intranasally (in) for respiratory depression in sus-pected opiate overdose in the prehospital setting Theadvantage of intranasal use is that no needles arerequired reducing the risk of needle-stick injury andthat it would be easier for lay people (eg family mem-bers) to administer The im group had a more rapidresponse The in route while not as effective was stillsufficient at reversing the respiratory depression of opi-ate toxicity in 74 of cases Given that 67 were inthe company of a friend or family member before para-medics arrived it does raise the possibility of widercommunity availability of naloxone

Holland J

Cooksley DG

Safety of helicopter aeromed-ical transport in Australia a retrospective study

MedJ Aust

2005

182

17ndash19This study sought to look at the risk of helicopter

emergency medical services (HEMS) over an 11-yearperiod There were only three accidents or one accidentevery 16 721 missions with one patient death (but fivetotal fatalities) ndash after the study period another threecrew members died in a separate accident The one riskthis paper doesnrsquot examine and one that I believe is agreater risk is inappropriate tasking of HEMS whichdelays definitive care This though would be a difficultsubject to study

Garner A

Keetelaar DM Konermann J Safety of emer-gency medical service helicopters

Med J Aust

2005

182

12ndash13This editorial accompanies the article by Holland and

Cooksley and discusses the complexities of aircraftsafety Unlike other countries Australian helicopteremergency medical services are usually multitaskedoperations undertaking search and rescue work as wellas retrieval and scene work It is argued that safety

margins are lower crew training and experience lessand funding insufficient

Ting JYS Humphrey KJ

After hours medical wardduties in a teaching hospital

Aust Health Rev

2005

29

37ndash42

This study looked at the reasons for 10 523 nurse-initiated requests for out-of-hours medical review ofinpatients over a 2-year period Of these calls 275 werefor cannula resites or venesection 245 were for med-icationfluid charts and 7 were for review of pathol-ogy In total two-thirds of the calls were consideredinappropriate or non-essential Increased training of non-medical staff in phlebotomy and cannulation and poli-cies to ensure day staff completed routine ward workwould greatly reduce unnecessary out-of-hours calls

Papadopulos-Eleopulos E

Turner VF

PapadimitriouJ

et al

A critique of the Montagnier evidence for theHIVAIDS hypothesis

Med hypotheses

2004

63

597ndash601

What diverse interests emergency physicians haveThis paper questions the widely held belief that a ret-rovirus HIV is the cause of AIDS The authors arguethat the HIV hypothesis does not explain the clinicalobservations that manifest as AIDS Furthermore theyargue that the HIV theory predicted heterosexual trans-mission vaccine development and the development ofan animal model none of which they argue hasoccurred They also question the three strands of evi-dence originally used to prove the existence of the newvirus known as HIV Despite at times getting a bitbaffling with the lsquolanguage of virologyrsquo the article ismostly quite readable and interesting

Reference

1 Sjolin SU Andersen JC Clinical fracture of the carpal scaphoidndash supportive bandage or plaster cast immobilization

J HandSurg [Br]

1988

1

75ndash6

Associate Professor Steven Doherty MB BS FACEM

Emmergency Physician

Tamworth Base Hospital

Associate Professor

University Department of Rural Health

Tamworth

Research Fellow

National Institute of Clinical Studies

Tamworth New South Wales Australia

Page 2: Peer Review June 2005

Peer Review

et al

294

ischaemic stroke time for collegiate communication andconsensus

Med J Aust

2005

182

44ndash5These letters in the

MJA

present some spirited debateon the use of thrombolytics in stroke and consider therisk versus harm benefits of this therapy The lettersalso highlight the need for collegiate collaboration ininitiatives that are cross-disciplinary

Kelly A-M

Kerr D Dietze P Patrick I Walker TKoutsogiannis Z Randomised trial of intranasal versusintramuscular naloxone in prehospital treatment ofsuspected opioid overdose

Med J Aust

2005

182

24ndash7

This prospective randomized unblended trial com-pared 2 mg of naloxone intramuscularly (im) versus2 mg intranasally (in) for respiratory depression in sus-pected opiate overdose in the prehospital setting Theadvantage of intranasal use is that no needles arerequired reducing the risk of needle-stick injury andthat it would be easier for lay people (eg family mem-bers) to administer The im group had a more rapidresponse The in route while not as effective was stillsufficient at reversing the respiratory depression of opi-ate toxicity in 74 of cases Given that 67 were inthe company of a friend or family member before para-medics arrived it does raise the possibility of widercommunity availability of naloxone

Holland J

Cooksley DG

Safety of helicopter aeromed-ical transport in Australia a retrospective study

MedJ Aust

2005

182

17ndash19This study sought to look at the risk of helicopter

emergency medical services (HEMS) over an 11-yearperiod There were only three accidents or one accidentevery 16 721 missions with one patient death (but fivetotal fatalities) ndash after the study period another threecrew members died in a separate accident The one riskthis paper doesnrsquot examine and one that I believe is agreater risk is inappropriate tasking of HEMS whichdelays definitive care This though would be a difficultsubject to study

Garner A

Keetelaar DM Konermann J Safety of emer-gency medical service helicopters

Med J Aust

2005

182

12ndash13This editorial accompanies the article by Holland and

Cooksley and discusses the complexities of aircraftsafety Unlike other countries Australian helicopteremergency medical services are usually multitaskedoperations undertaking search and rescue work as wellas retrieval and scene work It is argued that safety

margins are lower crew training and experience lessand funding insufficient

Ting JYS Humphrey KJ

After hours medical wardduties in a teaching hospital

Aust Health Rev

2005

29

37ndash42

This study looked at the reasons for 10 523 nurse-initiated requests for out-of-hours medical review ofinpatients over a 2-year period Of these calls 275 werefor cannula resites or venesection 245 were for med-icationfluid charts and 7 were for review of pathol-ogy In total two-thirds of the calls were consideredinappropriate or non-essential Increased training of non-medical staff in phlebotomy and cannulation and poli-cies to ensure day staff completed routine ward workwould greatly reduce unnecessary out-of-hours calls

Papadopulos-Eleopulos E

Turner VF

PapadimitriouJ

et al

A critique of the Montagnier evidence for theHIVAIDS hypothesis

Med hypotheses

2004

63

597ndash601

What diverse interests emergency physicians haveThis paper questions the widely held belief that a ret-rovirus HIV is the cause of AIDS The authors arguethat the HIV hypothesis does not explain the clinicalobservations that manifest as AIDS Furthermore theyargue that the HIV theory predicted heterosexual trans-mission vaccine development and the development ofan animal model none of which they argue hasoccurred They also question the three strands of evi-dence originally used to prove the existence of the newvirus known as HIV Despite at times getting a bitbaffling with the lsquolanguage of virologyrsquo the article ismostly quite readable and interesting

Reference

1 Sjolin SU Andersen JC Clinical fracture of the carpal scaphoidndash supportive bandage or plaster cast immobilization

J HandSurg [Br]

1988

1

75ndash6

Associate Professor Steven Doherty MB BS FACEM

Emmergency Physician

Tamworth Base Hospital

Associate Professor

University Department of Rural Health

Tamworth

Research Fellow

National Institute of Clinical Studies

Tamworth New South Wales Australia