Emergency medicine

Retrieval medicine

Noel R Eatough

Local health services should be prepared for a significant number of injuries

Sowmya Prabhakaran · Andrew W Silagy · Nicole A Campbell · Paul V Flanagan · Ian A Campbell

To the Editor: Cullen and colleagues are to be congratulated on their most recent contribution to the assessment of emergency department patients presenting with possible acute coronary syndrome.1 The ability to safely reduce length of stay for a larger proportion of patients compared with the ADAPT study, pending external validation, is promising.1 The timing of the article also presents an invaluable opportunity to remind all clinicians that despite the progressive improvements in accelerated diagnostic pathways for chest pain, not all chest pain is cardiac. Accelerated diagnostic pathways, when used incorrectly, run the risk of introducing cognitive dispositions to respond such as availability bias (where a clinician may choose a diagnosis that is more familiar, such as acute coronary syndrome), omission bias (doing something easy and omitting something hard, such as ordering serial troponins instead of a computed tomography aortogram) and Sutton’s slip (settling on the most obvious interpretation of the problem).2 The potential for error is further compounded by error-producing conditions inherent in busy emergency departments, such as overcrowding, narrow time windows for assessment, surge phenomena and multiple transitions of care (eg, movement to short stay).3 It is pleasing to see that additional features were utilised in stratifying patients compared with previous accelerated diagnostic pathways.1 High-risk features such as prolonged duration and recurrence of chest pain as well as syncope may also be present in aortic dissection.4 It is possible that a patient presenting with an aortic dissection could be deemed low risk with criteria such as those in the ADAPT accelerated diagnostic pathway.5 Troponin levels do not provide a safeguard, as evidenced in a previous case where a 75-year-old woman was discharged home after two normal troponin test results only to die later the same day from progression of a type A aortic dissection.4 Aortic dissection is a lethal cardiovascular emergency that boasts significant morbidity and mortality.4 It has been astutely described as the “subarachnoid haemorrhage of chest pain”.4 Although it is rare and sometimes difficult to diagnose compared with acute coronary syndrome, clinicians are urged to include aortic dissection in their initial assessment of chest pain before implementing an accelerated diagnostic pathway.

Joe-Anthony Rotella

To the Editor: We commend Cohen and colleagues1 on their recently published study, which is the largest randomised controlled trial (RCT) of acupuncture in the emergency department (ED). We recently completed a systematic review and meta-analysis on the role of acupuncture for analgesia in the emergency setting.2 Our meta-analysis incorporated 19 RCTs and included non-English language publications. The trial by Cohen and colleagues1 was not published at the time of our review; however, it strengthens our main conclusion that acupuncture was non-inferior to standard analgesia in the emergency setting. We also found similar evidence of improved patient satisfaction. It was interesting that the authors reported an adverse effects rate of 51% for acupuncture, whereas our study found an overall rate of 5%, with significant adverse effects being 1%. Our figures are consistent with other reviews3 and almost certainly highlight the difficulties in developing agreed definitions on adverse effects in acupuncture. Our review found that acupuncture in two out of four RCTs decreased pain medication requirements, whereas Cohen and colleagues’ study had the potential to inform this outcome, but did not report such data. The study by Cohen and colleagues1 illustrates many of the challenges in acupuncture trials, including having no sham comparator group. Some acutely painful conditions might resolve simply because of time or careful patient attention. Sham acupuncture is difficult to deliver as a control4 and needs to be plausible, realistic and, if possible, blinded. Our meta-analysis showed acupuncture to be superior, with clinically significant reductions in acute pain scores compared with sham. This latest significant RCT gives further impetus to carefully designed research on acupuncture in the emergency setting, which will require acupuncture techniques applicable to the time-constrained ED environment (eg, ear acupuncture), provision of a suitable sham acupuncture technique, and minimisation of assessment bias. We suggest that the specific outcomes to be assessed should include the impact of acupuncture as an adjunct to standard analgesia, side effects recorded using standard definitions, and reductions in medication use. Most importantly, the analgesic effect of acupuncture is unlikely to be equal for all pain presentations in the emergency setting and, therefore, the conditions for which its role is most beneficial need to be delineated.

Andrew L Jan · Ian Rogers · Eric J Visser

To the Editor: The conclusions made by Cohen and colleagues1 can be challenged on the basis of study design and results. A significant flaw in the design is that of all patients not excluded due to additional medical problems, 38% of potential study participants declined to be included, possibly because they were not prepared to be assigned to the acupuncture-only arm. This flaw introduces a critical bias when analysing the 62% who did participate, as it is reasonable to assume that they are statistically more inclined to experience a placebo benefit from acupuncture and more likely to be positive at 48 hours about repeating this therapy. Even with this bias, however, the results of the study do not support a broad interpretation of non-inferiority, given that 39% of acupuncture-only patients required rescue therapy at or after one hour, compared with 22.5% of pharmacotherapy-only patients. In the context of an emergency department (ED) and patients with mean verbal numerical rating scale score of 8.5 at presentation, this difference in pain reduction and satisfaction with the initial therapy during the first hour of treatment should render the acupuncture-only option unacceptable. The authors have selectively and speculatively interpreted their data to support their enthusiasm for acupuncture. Results for patients with migraine are given minimum discussion or reference in the conclusions. The inferior performance of acupuncture-only patients’ willingness to repeat the therapy at one hour is dismissed as being influenced by patients’ concerns about length of stay and transport arrangements, whereas they indicate that the same parameter at 48 hours is more meaningful. I suggest that the results at one hour more accurately reflect a patient’s experience of their pain and desire for abatement, whereas the improved satisfaction at 48 hours is the result of shifted perspective following self-resolution — in a selected patient population with an existing positive bias for acupuncture. The authors’ suggestion that acupuncture use in EDs would reduce opioid addiction is an opportunistic grab at exploiting popular sentiment among people who do not understand the causes and parameters of this serious problem. This article does not support diversion of resources towards acupuncture use in EDs or a change in evidence-based treatment protocols in emergency medicine.

Anitra J Wenden

In reply

Marc M Cohen · Michael Ben-Meir · Nick Andrianopoulos

To the Editor:The recent tragic suicides of young doctors have highlighted concerns regarding the welfare of trainees in our profession. The Trainee Committee of the College of Intensive Care Medicine of Australian and New Zealand (CICM) met in Melbourne in March 2017, and the recent results of the survey1 into bullying and harassment, in addition to the deaths of several junior medical officers to suicide, provided for a solemn meeting. The committee wants to highlight the factors that adversely affect intensive care medicine trainees: bullying, discrimination and sexual harassment;1 staffing and intensity as, while patients’ needs are more complex, staffing has not increased with this intensity of practice; rapid response teams, which are often under-resourced, poorly trained and undersupported; and poor workforce planning and tenuous future job security, compelling junior doctors to pursue increased non-clinical commitments without an allocated time to do so. A consequence of these factors is burnout, which disproportionately affects intensivists and is an increasingly significant risk in trainees.2 Changes in work practices, severity of illness, increased demand for limited resources and increasing intensive care unit size — problems that have recently been addressed by Corke3 — have all played a part in burnout rates. The Trainee Committee welcomes the approach of the CICM to tackle these issues.4 The college is steadfast in its zero tolerance to bullying, discrimination and harassment, and remains committed to fair and equitable access to training. The college also values the need for a reasonable balance between provision of clinical services and time for professional development, and recognises the importance of work–life balance, including part-time training and the provision of parental and other forms of leave. However, the CICM has limited ability to enforce these needs at hospital level. Finally, the CICM embraces rapid response teams, recognising the importance of an appropriately supported service, but hospitals need to respond to this need, and lack of planning and matching training with lifetime workforce demands have to be a priority for the government at all levels. Our specialty will change significantly in the next decade or so. We chose intensive care because we enjoy the work we do and find the challenge it provides rewarding. We must ensure that the next generation of intensivists can meet this challenge too.

Alun T Ellis · Sandra Lussier · Sarah A Yong

To the Editor:I congratulate Isbister and colleagues1 for performing a first aid randomised controlled trial on box jellyfish stings (a rarity in toxinology). The result is at variance with other studies on this topic (although they mainly involved North American jellyfish stings).2 I agree with the authors and the accompanying editorial3 that the major weakness in the study was the up to 4-hour delay for treatment with hot water. Unlike the earlier bluebottle stings first aid study performed on the beach,4 this study is performed in the emergency department of the Royal Darwin Hospital, when the pain severity was lessening. Pain severity was the primary study outcome: 25% of the study group had pain scores of less than 26 (hot water) or 20 (ice), which is minimal pain. Only 10% of the study group received opioid analgesia, compared with the results obtained by Currie and Jacups5 in a 14-year prospective observational study of box jellyfish stings in Darwin, where 48% of patients received analgesia, including 30% of patients receiving narcotic analgesia. The article by Currie and Jacups5 also reported that 71% of patients received ice. The current trial1 does not detail if ice (or heat) was applied to patients before enrolling in the study. Moreover, Currie and Jacups5 also reported that 84% of stings occurred in less than 1 m of water and most of the stings occurred on the legs. I am not sure how the temperature of the water in the bucket used for distal limb stings was controlled to maintain a temperature of 45°C. If not well regulated, then this would lessen the benefits of the heat. In addition, I am surprised that the authors have not attempted to use their findings to push for a standardised approach to jellyfish stings in Australia. The Australian Resuscitation Council currently has different first aid advice for stings in the tropics compared with southern Australia.3,6 These results would suggest that heat is equally effective as ice for box jellyfish stings. The authors were concerned about the difficulty in providing hot water as first aid, which is the same problem for southern Australia, where hot water is recommended. Surely, it is time to standardise first aid for jellyfish stings in Australia.

Mark Little

In reply

Geoffrey K Isbister · Bart J Currie