Emergency Medicine Australasia最新文献

The current ANZCOR guidelines for first aid management of life-threatening bleeding from a limb, where bleeding cannot be controlled with direct pressure, recommends the use of an arterial tourniquet. However, tourniquets required specialised training and equipment, which may not be accessible in all emergencies. This systematic review evaluated the effectiveness of arterial pressure point techniques (APPT) as a first aid measure for controlling life-threatening, non-compressible bleeding from limbs and anatomical junctions. A comprehensive literature search was conducted following the PRISMA guidelines. The search was used in five databases: PubMed, CINAHL, SportDiscuss, Proquest Central and Embase. Eligible studies included adult participants in and out of hospital settings, focusing on extremities and junctional areas. Studies assessing APPT alone or compared with other first aid techniques were included. The review included nine quasi-experimental articles, with eight having low levels of evidence. Although most reported high success rates (87.5-100%) for APPT achieving blood flow cessation, its effectiveness compared to alternative methods, such as arterial tourniquets, remains inconclusive because of methodological heterogeneity and differing success benchmarks. APPT shows promise in external haemorrhage control. Additional research with higher levels of evidence, standardised protocols and larger sample sizes is needed. Investigation in real-world scenarios is crucial to compare methods like tourniquets. Future research will determine APPT's effectiveness and its potential role as a bridging technique before tourniquet application or medical assistance.

Objective: Our study aimed to explore the experience of attaining higher education among women in medicine at the largest national hospital in Fiji, focusing on barriers and enablers to completing training, and to explore women's perception of gender-based discrimination in the world of medicine. Findings subsequently informed evidence-based recommendations on enablers and barriers at the hospital and medical university to improve experiences of women in medicine.

Methods: We conducted a mixed-method study, emphasising the phenomenological qualitative component. All women doctors working at the national hospital were invited to complete a survey, and those with past or present engagement in postgraduate specialty medical training participated in semi-structured interviews. Survey data were analysed using descriptive statistics. Interviews were transcribed, coded then organised using thematic analysis. Reflexivity and triangulation were employed at all levels of the research to ensure rigour.

Results: Four distinct themes were found to illuminate women's enablers and barriers. Participants described work-life stress, absence of advocacy, coercion-control-power and inflexible systems as barriers. For enablers, they described inner strength, social circles, work culture and mentors/role models/advocates. Participants had mixed perspectives on gender-based discrimination in the workplace, with unanimity in calling for protected maternity leave entitlements.

Conclusions: Challenges only become true barriers when enablers are eclipsed by them. Institutional support helps mitigate these barriers especially for those women who lack social support. Gender based discrimination continues in the Pacific, commonly covertly, especially in terms of policy gaps regarding maternity leave during training.

Objective: The Broset Violence Checklist (BVC) can stratify the risk of violence and aggression in EDs. The aim of the present study was to report the initial uptake of introducing this checklist and associations with unplanned alerts to potential or actual violence in two EDs.

Methods: The BVC was recommended in all patient care episodes. This retrospective review included routinely collected data from an adult tertiary referral hospital and a suburban mixed paediatric and adult ED over a 12-month period. The primary outcome variable was completion of at least one BVC score and the secondary outcome was unplanned alerts to potential or actual violence episodes within the EDs.

Results: There were 121 330 presentations, of which 108 274 were included in the present study. The BVC was completed for 42 675 (39.4%) presentations. Using a cut-off score of 3, BVC had a specificity of 99.2% (95% confidence interval [CI] 99.1-99.2) and a sensitivity of 15.6% (95% CI 12.5-19.3) for unplanned alerts to potential or actual violence events. Completion of a BVC was independently associated with more unplanned alerts to potential or actual violence events (adjusted odds ratio 1.37; 95% CI 1.12-1.66).

Conclusions: The BVC was highly specific for violence and aggression but had low sensitivity. Completion of the BVC was associated with more frequent unplanned alerts to potential or actual violence events, suggesting that high-risk patients might be identified intuitively, without formal scoring. Further exploration of the utility of the BVC in the ED is indicated with a focus on strategies to prevent violence and aggression.

Objective: Radiological evaluation of cervical spine injury with computed tomography (CT) scanning is a fundamental component of the assessment of major trauma. Accurate interpretation of scans is essential for safe clearance or diagnosis of injuries. However, delays in radiologist reporting often result in prolonged spinal immobilisation. The aim of the present study was to evaluate a simple, structured reporting tool to improve assessment of CTs of the cervical spine by emergency medicine trainees.

Methods: A prospective pre- and post-intervention cohort study was undertaken within a major metropolitan ED. Participants in the pre-intervention phase interpreted a set of randomly selected cervical spine CTs. The post-intervention phase presented the same task with the additional provision of a structured cervical spine CT reporting template designed in collaboration with radiologists and emergency physicians. Interpretation by trainees was evaluated for concordance with the final radiology report by two blinded assessors.

Results: A total of 155 cervical spine CT scans were reported by the 46 participants. Participants in the cohorts were similar with regards to experience and country of primary medical degree. Concordance with the radiology report in the pre-intervention phase was 60% (95% CI 0.48-0.71), compared with a concordance of 54% (95% CI 0.42-0.65) in the post-intervention phase (P = 0.46).

Conclusions: Interpretation of cervical spine CT scans by trainees was inferior compared to radiologists and did not improve with a structured reporting template. Other innovative strategies towards timely reporting of CT scans by radiologists of the cervical spine are indicated for earlier definitive diagnosis.

Objective: To evaluate gender authorship trends in the official journal of the Australasian College for Emergency Medicine (ACEM), Emergency Medicine Australasia (EMA).

Methods: A bibliometric review of author gender in EMA during the 10-year period 2013-2022. The gender of first/last authors were determined by www.genderize.io, or a manual internet search where gender was not determined with at least 90% certainty. Descriptive statistics were used with percentages of women as first and last author compared to current percentages of ACEM Fellows (FACEMs) who identify as women.

Results: The final analysis included 1703 articles. Women accounted for 27.4% fewer authors than men (36.3% vs 63.7%). Women were outnumbered by men by 20.0% among first authors (40% vs 60%), and 36.2% (31.9% vs 68.1%) for last authors. When the last author was a woman, there was a similar rate of women (49.2%) and men (50.8%) as first authors. However, when the last author was a man, first authors were 37.1% women versus 62.9% men. If the last author was a woman, there was a 60% greater probability that the first author was also a woman (odds ratio 1.6, 95% CI 1.3-2.1). First authorship rate by women was equal to or exceeds the proportion of women FACEMs, however, last authorship by women still lags behind.

Conclusion: The emergency medicine community in Australasia must continue to tackle existing gender disparities which exist in our specialty. A creative and active strategy on the part of publishers, editors, academics and authors is needed to redress this balance.

Objective: Our primary aim was to identify a low-risk subgroup of older adults (aged 65 and older) presenting to ED with minor head trauma which can be safely managed without a cranial CT (cCT).

Methods: This was a single-site, prospective, observational, cohort study conducted at a major-referral ED. Alert, haemodynamically stable, older adults with suspected head trauma were eligible. This included both community dwellers and residential aged care facility (RACF) residents. Primary outcome was the proportion of patients who had a clinically important traumatic brain injury (ciTBI) within 42 days of index ED presentation. Secondary outcomes included proportion investigated with a cCT, and proportion needing neurosurgical intervention.

Results: Two hundred seventy-six patients (mean age 80.5 years; 53.6% female) were enrolled. The most common mechanism of injury was ground-level fall (93.8%). One in four patients was from RACFs, 30.1% had dementia and 52.2% were on blood thinners. 80.8% had a cCT during the index ED visit. Seven (2.5%) patients had ciTBI within 42 days of index ED presentation. Patients with ciTBI had either external signs of head injury or abnormal neurological exam. All patients with ciTBI were treated conservatively after shared decision-making.

Conclusions: Alert, haemodynamically stable, older ED adults with suspected head trauma had a low incidence of ciTBI in the present study. Abnormal physical examination findings were consistently present in patients with ciTBI. Shared decision-making prior to cCT may be the pragmatic way ahead in the management of this patient cohort, especially among those from RACFs.

Over recent years, emergency telehealth has developed rapidly in Australasia. From the patient's perspective, establishing trust with a healthcare provider is uniquely challenging when using the audio and video modalities commonly used in telehealth. It is crucial to consider how we may improve the delivery of care through this emerging pathway if high-quality care is to be delivered. Several simple techniques have been identified in the literature and can be employed to create trust and improve the patient-provider relationship. These include ensuring privacy and an appropriate setting for the consultation; considering how eye contact and expressions are best used; providing alternative options to telehealth; and clearly identifying names, roles and qualifications. We describe how these methods can best be employed in the virtual emergency care setting.

Objective: The serratus anterior plane block (SAPB) is a regional anaesthesia technique with increasing use as an analgesic adjunct in patients with rib fractures. The present study aimed to generate consensus of the requirements of education, training and credentialing for the use of a 'single shot' SAPB in the management of rib fractures.

Methods: A modified Delphi process was designed using online questionnaires. Expert panellists from Australian and Aotearoa New Zealand were invited from the fields of Emergency Medicine and Anaesthesia and were asked to rate the importance of different components of SAPB education, training and credentialling on a 9-point Likert scale. Consensus was achieved if ≥70% of experts provided a score of seven or greater on this scale for any given statement.

Results: Thirty specialists (60% FACEM, 40% FANZCA) representing New Zealand plus all states and territories of Australia formed the expert panel. Participant response rates were 100% (first round), 83% (second round) and 63% (final round). At the end of three survey rounds, 59 consensus statements were formed (27 for education, 5 for training and 17 for credentialing).

Conclusions: This series of expert statements provides consensus on the education, training and credentialling of the SAPB for the management of rib fractures. These serve as the minimum standard by which this procedure should be taught while providing clinicians with a syllabus for the development of training programmes.

Ambulance ramping, the delay to transfer of a patient arriving at an ED by ambulance into an ED treatment space and handover of care to ED clinicians, is a problem in all Australian states and territories and New Zealand. It is a symptom of ED overcrowding and access block and has been associated with adverse health outcomes for some patient groups. The questions arise, who might be legally responsible for the care of patients who are ramped and does their physical location matter? The short answers are 'everyone' and 'no', however, whether there will be a breach of duty depends on the reasonableness of responses and resource allocation considerations.

Objectives: To determine the frequency and clinical consequences of discrepancies in skeletal radiograph interpretation between emergency and radiology doctors in an Australian ED.

Methods: We reviewed the records of adult and paediatric patients assessed with skeletal radiography in an ED in Victoria, Australia over 3 months (January to March 2022). Epidemiological data, the interpretation of the radiograph by ED and radiology doctors, and clinical management of the patient were recorded to determine interpretation discrepancies and the consequences of these.

Results: There were 2359 unique skeletal radiographs in 1576 patient presentations during the study period. Of these, 140 (6%) had a discrepancy. Where a discrepancy existed, 47% of the ED interpretation reported a fracture and/or dislocation which was not present in the radiology interpretation (false positive), whereas the remaining (53%) were attributed to a missed fracture and/or dislocation (false negative). Thirty-five discrepancies (2%) required a change in patient management and were therefore clinically significant. The most commonly affected body region was the elbow, where 15% of radiographs were discrepant. Pathology was more often missed when multiple abnormalities were present on the same radiograph (odds ratio = 4.2, 95% confidence interval = 2.5-6.8).

Conclusion: The rate of clinically significant discrepancies in the interpretation of skeletal radiographs by emergency medicine doctors is low. This data support using the ED interpretation of radiographs to guide initial management as safe practice.