Warzone mentality in the ED, and finding balance with hospital pre-alerts - January 2025 Primary Survey

It's a celebration of qualitative research to start the new year, with a collection of papers offering new perspectives on emergency department issues. First is a pair of papers centred on the theme of pre-alerts to the emergency department. Setting the scene for a patient's arrival is a vital process, yet it can generate fear of criticism for getting the balance wrong, when it comes to over- and under-alerting. Following on is a paper taking a look at the human experience of working in the emergency department, and the war-like atmosphere that can be found there. This leads to the final paper on well-being interventions in the ED, with interviews having found real limitations to current approaches.   Read the issue highlights: January 2025 Primary Survey   How do emergency departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alerts in UK emergency departments What influences ambulance clinician decisions to pre-alert emergency departments: a qualitative exploration of pre-alert practice in UK ambulance services and emergency departments  It’s a battlefield! A thematic analysis of narratives shared in Cape Town emergency departments Well-being interventions for emergency department staff: ‘necessary’ but ‘inadequate’ – a phenomenographic study   The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

Subarachnoid haemorrhage is a diagnosis that can't be missed, but it is not a simple process to detect it. The first paper for discussion this month questions if a CT scan within 6 hours is sufficient for exclusion in patients with acute headache. Then there is a large-scale analysis of over 400 million ED visits in the USA, focussing in on the significant issue of self-harm in the homeless population. Next is a paper on a decision tool for suspected acute aortic syndrome, and to finish, a discussion on the change in ED culture around safety since the COVID pandemic.   Read the issue highlights: December 2024 Primary Survey   Articles discussed in this episode: Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study Suicide and self-injury-related emergency department visits and homelessness among adults 25–64 years old from 2016 to 2021 in the USA  Decision analytical modelling of strategies for investigating suspected acute aortic syndrome  Culture of safety in an adult and paediatric emergency department before and after the COVID-19 pandemic   The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

Upper limb injuries make up about three-quarters of the limb injuries to children seen in the emergency department. But when it comes to the elbow, just how good are clinicians at diagnosing based on radiography? The first paper this month is a study putting over 300 global participants to the test. There's also a practice review highlighting the concept of shared decision making with frail elderly patients, a discussion of biomarkers for aortic dissection detection, more on telephone triage, and an interesting questionnaire on patient experience. Read the issue highlights: November 2024 Primary Survey Articles discussed in this episode: Black and white: how good are clinicians at diagnosing elbow injuries from paediatric elbow radiographs alone? Person-centred decisions in emergency care for older people living with frailty: principles and practice Use of emergency departments by children and young people following telephone triage: a large database study The wisdom of elders: a new patient experience survey for older patients could tell us how to fix our emergency departments for everyone Psychometric validation of a patient-reported experience measure for older adults attending the emergency department: the PREM-ED 65 study Diagnostic accuracy of alternative biomarkers for acute aortic syndrome: a systematic review Links: Understanding escalation area and corridor care in UK emergency departments (UNCORKED) The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.  

There's a whole pile of blocks in this month's papers, with the first being a trial of Erector-Spinae Plane (ESP) blocks, not for rib fractures as you might expect but Hepato-Pancreato-Biliary (HPB) pain instead. Following on from that is a retrospective study comparing the resource utilisation of haematoma blocks, Bier’s blocks and procedural sedation for patients with forearm fractures. The next paper sets the performance of unassisted radiographers against those armed with artificial intelligence algorithms when diagnosing pneumothorax, and the results show an interesting demographic trend. Concluding the discussion topics this month is a letter regarding "on-scene time" for ambulances when assessing patients for suspected stroke - a situation where every minute counts. Read the issue highlights: October 2024 Primary Survey Articles discussed in this episode: EASIER trial (Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room) Haematoma block is the most efficient technique for closed forearm fracture reduction: a retrospective cohort study Evaluation of the impact of artificial intelligence-assisted image interpretation on the diagnostic performance of clinicians in identifying pneumothoraces on plain chest X-ray: a multi-case multi-reader study  On-scene times during ambulance assessment of suspected stroke patients across England from December 2021 to November 2022 The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

Being fallible was one of the most valued characteristics in a consultant, according to new doctors going through their induction - that's the subject of the first paper this month. Next up is a study on the impact of noise on hospital staff, which includes some simple interventions with measurable impact. There's also a discussion on pain relief for rib fractures, and how frailty scores are linked to 30-day mortality in patients. Read the issue highlights: September 2024 Primary Survey Articles discussed in this episode: Qualitative study of new doctor induction and socialisation Reduced noise in the emergency department: the impact on staff well-being and room acoustics The RELIEF feasibility trial: topical lidocaine patches in older adults with rib fractures Frailty is associated with 30-day mortality: a multicentre study of Swedish emergency departments The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

The recovery of laceration repair patients is the topic of this month's first paper, looking at behavioural disturbances in children following these difficult medical procedures. The second paper deals with pre-hospital use of tranexamic acid for trauma, and surfaces some demographic discrimination in its rates of application. Next there is an observational study which has developed a score for indirect signs of appendicitis on ultrasounds where the appendix is not visualised. Finishing off the episode is a "Best Evidence" report, dealing with the appropriate usage of CT scans on patients first presenting with a seizure.   Read the issue highlights: August 2024 Primary Survey   Articles discussed in this episode: Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound Best Evidence Topic report: Is a CT head required for patients who present to the emergency department with a first seizure?    The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

What might yawning and sneezing be signs of in a patient? This month's podcast features new RCEM and NPIS guidance on acute opioid toxicity, outlining a number of symptoms to stay alert to. Before getting to that there's a paper on bypassing hospitals for patients needing mechanical thrombectomy, a study on how austerity affected emergency admissions across a range of UK local authorities, and some research on the immune-related adverse affects that can arise in the ED amongst oncological patients. Read the issue highlights: July 2024 Primary Survey Articles discussed in this episode: Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study. Day J, Simmonds RL, Shaw L, et al Are local public expenditure reductions associated with increases in inequality in emergency hospitalisation? Time-series analysis of English local authorities from 2010 to 2017. Castro-Ávila AC, Cookson R, Doran T, et al Management and outcome of oncological patients under immune checkpoint inhibitors presenting at the emergency department. Pini F, Grigoriu B, Lieveke A, et al Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Blundell M, Gill R, Thanacoody R, et al   The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

How well do patients in the emergency department judge the severity of their situation? Some may fear the worst for any hospital visit, and others not realise that their lives are in danger. This month's first paper is a review of the accuracy of self-prognostication and its relation to admission, severity, and length of stay. Then there's a trio of publications on the challenges of pain in various forms. Starting with a study on the links between red flags in headache assessment, and serious secondary headaches. Next there is a letter, questioning how well pain management is done in the ED. To finish, a new scale has been developed to assess ultrasound-guided fascia iliaca block. Read the issue highlights: June 2024 Primary Survey Articles discussed in this episode: Can acutely ill patients predict their outcomes? A scoping review. Mols EM, Haak H, Holland M Safer@Home Research Consortium, et al Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study. Chu K, Kelly A, Kuan WS HEAD and HEAD-Colombia study groups, et al Pain in the ED: does anyone manage it well? Wilson S, Dainty J, Quinlan J, et al Development and validation of an assessment tool for adult simulated ultrasound-guided fascia iliaca block: a prospective monocentric study. Guyader F, Violeau M, Guenezan J, et al The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.  

Should we be bringing preventative medicine into the emergency department, or is it just using up valuable time? Our first paper this month looks at the "Cessation of Smoking Trial in the Emergency Department (COSTED)" trial, which presents the case for opportunistic smoking cessation intervention. Next up is a topical research paper on interpreting CT scans with artificial intelligence, and how machine assessment measures up against experienced physicians. Then there's a trio of troponin papers, discussing high-sensitivity testing. The final paper this time is not a paper but a guideline from the Royal College of Emergency Medicine, setting out best practices for dealing with suspected cannabinoid hyperemesis syndrome. Articles discussed in this episode: Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial. Pope I, Clark LV, Clark A, et al Using an artificial intelligence software improves emergency medicine physician intracranial haemorrhage detection to radiologist levels. Warman P, Warman A, Warman R, et al External validation of a rapid algorithm using high-sensitivity troponin assay results for evaluating patients with suspected acute myocardial infarction. Cullen L, Greenslade JH, Stephensen L 2022 SAMIE study group, et al High-sensitivity troponin testing at the point of care for the diagnosis of myocardial infarction: a prospective emergency department clinical evaluation. Curran JM, Mergo A, White S, et al Determination of a whole-blood single-test low-risk threshold for a point-of-care high-sensitivity troponin assay. Pickering JW, Hamill L, Aldous S, et al RCEM best practice guideline: suspected cannabinoid hyperemesis syndrome in emergency departments. Humphries C, Gillings M   The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

“Social distancing is a privilege,” is the core message underlying the first paper brought by Sarah to this month’s roundup, as it unpacks the stark differences in COVID-19 outcomes across the spectrum of racial and ethnic groups in the United States. A second paper examines the returning rates of COVID patients across a large group of emergency departments in Canada, and the factors at play there. The final topic is one of Rick’s favourites, focusing on troponin testing in ambulances. Articles discussed in this episode: Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA. Khosla S, Del Rios M, Chisolm-Straker M, et al.  Characteristics and outcomes of patients with COVID-19 who return to the emergency department: a multicentre observational study by the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). Rosychuk RJ, Khangura JK, Ortiz SS, et al.  Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study. Daniels J, Robinson E, Jenkinson E, et al. Prehospital T-MACS and HEART scores in the prediction of myocardial infarction: a prospective evaluation. Cooper JG, Donaldson LA, Coutts AJ, et al.   The EMJ podcast is hosted by: Dr. Richard Body, EMJ Deputy Editor, University of Manchester, UK (@richardbody) Dr. Sarah Edwards, EMJ Social Media Editor, Leicester Royal Infirmary, UK (@drsarahedwards) You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast iTunes (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.