Efficacy of the presence of an emergency physician in prehospital major trauma care: Randomised control trial results are needed!
Correspondence / American Journal of Emergency Medicine 38 (2020) 1270–1294 1277
“severe sepsis”, “septic shock”,” Traditional Chinese Medicine“,” Chinese pat- ent medicine”, etc. should also be taken into account.
Second, it is generally acknowledged that I2 >> 50% indicates sub- stantial heterogeneity in Meta software analysis [2], while in Data Anal-
ysis part, Shi et al. adopted I2 N 30% to indicate the existence of heterogeneity, which may be more rigorous but affects the analysis re- sults. Moreover, as we known, the analysis model adopted after the test of heterogeneity is crucial to the reliability of the analysis results. If heterogeneity occurs, subgroup analysis, regression analysis or sensi- tivity analysis should be taken, and if it still cannot be processed, de- scriptive analysis should be conducted. But Shi et al, directly determined it was heterogeneous and analysis by a random-effects mode, which was obviously inappropriate.
Third, in my opinion, it is better for the article to list the basic character- istics of included studies, including the diagnostic criteria of sepsis, dosage and course of treatment of Xuebijing, etc., which may be beneficial to het- erogeneous analysis and can improve the credibility and persuasion of the article. Additionally, according to the guidelines [3], sepsis involves not only general physical conditions, inflammatory response, organ dysfunction but also tissue hypoperfusion, and tissue perfusion is closely related to lactic acid [4], so lactic acid is of great significance in evaluating the efficacy of Xuebijing on sepsis that is also better to be considered in outcomes.
Fourth, although Shi et al. had evaluated the quality of all the studies using the Jadad Scale, it still can’t ignore the analysis on the bias of the included studies to improve the credibility of the conclusion.
In recent years, there have been a lot of studies on the treatment of sepsis with Xuebijing. Although Shi et al. had mentioned some limitations of the study in the end, more accurate conclusions could be obtained if more complete and systematic analysis process can be carried out.
Declarations
Ethical approval and consent to participate Not applicable.
Consent for publication Not applicable.
Availability of supporting data Not applicable.
Funding
None.
Declaration of Competing Interest
The authors declare that they have no competing interests.
Acknowledgements
None.
Zhuang Jieqin
The Second Clinical Medical College of Guangzhou University of Traditional
Chinese Medicine, Guangzhou 510006, China
Dai Xingzhen Cai Hairong Chen Bojun*
Emergency Department, Guangdong Provincial Hospital of Chinese
Medicine, Guangzhou 510006, China
*Corresponding author at: Guangdong Provincial Hospital of Chinese Medicine, Guangzhou 510006, Guangdong Province, China. E-mail address: [email protected] (C. Bojun)
https://doi.org/10.1016/j.ajem.2019.11.031
References
- Shi Heng, Hong Yun, Qian Jianfang, et al. Xuebijing in the treatment of patients with sepsis: a meta-analysis. Am J Emerg Med 2017;35(2):285-91. https://doi.org/10. 1016/j.ajem.2016.11.007 PMID: 27852528.
- Chuanwei Mo, Qun Chen, Zhiwei Xu. The quantitative evaluation of medical research is completed by meta analysis of Stata software. Chinese Arch Trad Chinese Med 2008;26(5):947-9.
- Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit Care Med 2003;31:1250-6. https://doi.org/10. 1097/01.CCM.0000050454.01978.3B PMID: 12682500.
- Sablotzki A, Muhling J, Czesliek E. sepsis and multiple organ failure update of current therapeutic concepts. Anasthesiol Intensivmed Notfallmed Schmerzther 2005;40: 511-20. https://doi.org/10.1055/s-2005-870104 PMID: 16145638.
Efficacy of the presence of an emergency physician in prehospital major trauma care: Randomised control trial results are needed!To the editor,
In the 2019 September issue of the Journal, Hirano et al. [1] reported the lack of difference in mortality between care provided by non-physician staffed ambulances and physician-staffed ambulances after prehospital major trauma. Otherwise, despite the presence of a physician on scene al- lows rapid advanced life support and resuscitation, it delays in hospital ad- mission and definitive care. Firstly, we compliment the authors for this very interesting study related to the beneficial effect of an emergency physician in the prehospital setting after major trauma. We fully agree that the impact on outcome of a physician-staffed ambulance is controversial.
Nevertheless, in our opinion, some methodological issues deserve their attention.
The major difference between the numbers of patients in the 2 studied groups may, by itself, explain the results observed in this study. As stated by the authors, in their cohort, first, trauma patients transported with an emergency physician were more severely in- jured and second, care delivered were not equivalent in the 2 groups. These 2 previous elements induce a selection bias; because severity
[2] as delivered care [3] directly influence the outcome, e.g. mortal- ity. Variables included in the multivariate logistic regression (age, sex, cause of injury, ISS, and pre-hospital vital signs), do not consider the potential cofounding effect of prehospital time duration, in hos- pital length of stay and decisions during the in-hospital phase, i.e. limitation of care, strongly affecting mortality [4]. Otherwise, the odd ratio reports the association and its strength between 2 variables not the direct causal link. Beyond this, from a statistical point of view, the absence of difference is not synonymous of equivalence. In this study, the authors should report the criteria used in the decision of dispatching a physician-staffed ambulance to the scene in case of major trauma. Beyond this, the authors do not report how the choose by the emergency service dispatch call centre between physician- staffed and basic life support team was done.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Romain Jouffroy* Benoit Vivien
SAMU de Paris, Service d‘Anesthesie Reanimation, Hopital Universitaire Necker – Enfants Malades, Assistance Publique – Hopitaux de Paris, and
Universite Paris Descartes – Paris 5, Paris, France
*Corresponding author.
E-mail address: [email protected] (R. Jouffroy).)
https://doi.org/10.1016/j.ajem.2019.11.033
1278 Correspondence / American Journal of Emergency Medicine 38 (2020) 1270-1294
References
Hirano Y, Abe T, Tanaka H. Efficacy of the presence of an emergency physician in prehospital major trauma care: a nationwide cohort study in Japan. Am J Emerg Med 2019;37(9):1605-10.
- Spaite DW, Tse DJ, Valenzuela TD, Criss EA, Meislin HW, Mahoney M, et al. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. Ann Emerg Med 1991;20:1299-305.
- Meizoso JP, Valle EJ, Allen CJ, Ray JJ, Jouria JM, Teisch LF, et al. Decreased mortality after Prehospital interventions in severely injured trauma patients. J Trauma Acute Care Surg 2015;79:227-31.
- Bohmer AB, Just KS, Lefering R, Paffrath T, Bouillon B, Joppich R, et al. Factors influenc- ing lengths of stay in the intensive care unit for surviving trauma patients: a retro- spective analysis of 30,157 cases. Crit Care 2014;7;18(4):R143.
A multidisciplinary educational curriculum for the management of orbital compartment syndrome
Correspondence
Orbital compartment syndrome is a time-sensitive, vision- threatening emergency due to elevated intraorbital pressure, resulting in decreased perfusion of the optic nerve and retina. Rapid diagnosis and management of OCS are vital for vision preservation as perfusion should be restored emergently to prevent permanent Vision loss [1]. Multiple studies have identified the need for educational initiatives to educate Emergency Medicine (EM) providers on the management of OCS [2,3]. However, lateral canthotomy and cantholysis, the primary management of OCS, is not identified by the Accreditation Council for Graduate Medical Education (ACGME) as an essential skill to the inde- pendent practice of an EM physician [4]. After encountering multiple cases of OCS which resulted in suboptimal outcomes at our institution, we were compelled to explore the recent cases of OCS at our institution in a brief retrospective review which identified a knowledge gap in the management of OCS. The purpose of our study was to evaluate the knowledge and confidence of residents encountering OCS and to share an educational curriculum to improve the diagnosis and management of OCS.
A small IRB-approved retrospective chart review was conducted in order to capture OCS cases seen in the Emergency Department (ED) at an academic Level 1 trauma center, University of Iowa Hospitals and Clinics, between 2016 and 2017. To identify cases of OCS, a query of the institution’s electronic medical records and billing records was per- formed for ICD-9 codes (376.31, 376.32, 376.33, 921.2) and ICD-10 codes (H05.221, H05.222, H05.223, H05.232, H05.231, H05.233) related
to OCS and for CPT(R) codes (67,715, 21,282) related to the LCC
procedure. Subsequently, cases were identified by reviewing the elec- tronic medical records. Nine of the 10 identified patients (Table 1) were transferred from outside hospitals, located 55.1 to 95.5 miles (mean, 75.1 miles) from the study ED. Lateral canthotomy and cantholysis was attempted prior to transfer for only 2 of the 9 patients presenting from an outside hospital. At our institution, the ED team suc- cessfully completed one of the 5 attempted LCC procedures on their own. With assistance from the ophthalmology service, a successful LCC was completed in 9 cases. The mean time from ED arrival to com- pletion of LCC was 63 min (range, 25-142 min), and the mean time from injury to completion of LCC for all patients was 299 min (range, 120-600 min). A LCC was not completed for any patient within the rec- ommended time window of 90-120 min after the presumed onset of OCS [1,5] (Fig. 1). Of the 8 surviving patients, three had a final vision of light perception or worse, one had a final vision of count fingers at 1 ft, and four hada final vision of 20/40 or better.
In order to increase awareness of OCS management, an educational curriculum on the management of OCS was subsequently developed through a joint effort between the Departments of Ophthalmology and Emergency Medicine at the University of Iowa Hospitals and Clinics. (Supplementary material 1) To gauge baseline knowledge and under- standing of OCS, an initial 18-question electronic survey was adminis- tered prior to the implementation of the educational curriculum (Supplementary material 2). Participants were instructed to complete this self-directed study and pre-assessment (https://eyerounds.org/ tutorials/ocs/), and subsequently, ophthalmology residents and an oph- thalmology faculty member conducted a didactic session reviewing or- bital anatomy, the clinical signs of OCS including instructions on how to measure Intraocular pressure, and the management of OCS including a video of the LCC procedure. A post-assessment electronic survey includ- ing identical questions to those of the pre-assessment was administered 3-4 months after the didactic session (Fig. 2).
Forty-one residents (23 EM, 7 trauma surgery, 5 ENT, 3 OMFS, and 3
unspecified) completed the pre-assessment survey, and 28 residents (16 EM, 6 trauma surgery, 4 ENT, 2 OMFS) completed the post- assessment survey. Confidence in the ability to identify OCS increased from 24.4 to 82.1% (p b 0.0001), and confidence in the ability to perform lateral canthotomy and cantholysis increased from 19.5 to 67.9% (p b 0.0001) from the pre-assessment to the post-assessment. In the post-assessment, 23 residents (82.1%) were able to correctly identify signs of OCS, compared to 65.9% in the pre-assessment (p = 0.18). Fif- teen residents (53.6%) were able to correctly identify risk factors for OCS, compared to 36.6% in the pre-assessment (p = 0.22) (Table 2).
Despite the first case report of OCS being described in the liter- ature almost 70 years ago [6], management of OCS in the emer- gency setting is often suboptimal, and there remains room for improvement. While emergency medicine residency programs
Table 1 Orbital compartment syndrome patients seen in the ED between 2016 and 2017 Key: RAPD: relative Afferent pupillary defect; LCC: lateral canthotomy and cantholysis; M: male; F: Female; NLP: No light perception; LP: Light perception; HM: Hand motion; OSH: Outside hospital.
Pt
Age
Initial
Intervention
Final
#
(yrs)/Sex
RAPD
IOP
(mmHg)
Procedure
Service(s) Performing
Time from injury to LCC completion (minutes)
IOP
(mmHg)
Visual acuity
1
70/M
+
90
LP
LCC & Superior lid splitting
OSH ED, Level 1
231
18
NLP
2
60/M
+
87
NLP
LCC
ED, Ophtho
Ophtho
600
30
LP
3
89/F
+
86
NLP
LCC
Ophtho
450
46
NLP
4
44/M
+
86
20/250
LCC
Level 1 ED & Ophtho
390
24
20/15
5
83/F
+
58
20/40
LCC
Ophtho
335
21
20/30-2
6
92/F
+
Not checked
CF at 1 ft
LCC
OSH ED & Ophtho
255
19
CF at 1 ft
7
46/F
Not checked
Not checked
Not checked
LCC
Level 1 ED
120
29
20/25
8
53/M
Minimally reactive
98
Unable
LCC & Superior lid splitting
Level 1 ED, ENT, Ophtho
220
26
20/25
9
56/F
Fixed
49
Unable
LCC
Ophtho
225
19
Deceased
10
33/M
Fixed
65
Unable
LCC
Level 1 ED & Ophtho
165
40
Deceased
Efficacy of the presence of an emergency physician in prehospital major trauma care: Randomised control trial results are needed!
A multidisciplinary educational curriculum for the management of orbital compartment syndrome