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LETTERS TO THE EDITOR
this study, but only 0.3% received electrical cardioversion, it suggests that synchronised cardioversion was underutilised. Ambulance Victoria should consider using synchronised cardioversion with less reservation and to apply this lifesaving electrical therapy in line with current recommendations, as electrical cardioversion is a very effective and the best treatment for unstable SVT.4 Furthermore, the authors state that overall, 438/ 882 (49.7%) patients remained in SVT on arrival at hospital, of which 116 patients were hypotensive. I contend that fewer patients would have remained in SVT if hypotensive and SVT-related chest pain were treated with synchronised cardioversion as per the ILCOR and other guidelines. In a recent study by the same authors, similar low rates of cardioversion were noted, with less than 1% receiving synchronised cardioversion. 5 It would be good
for the authors of this excellent study to investigate the reasons for the underutilisation of electrical cardioversion.
Competing interests None declared.
References 1. Smith G, McD Taylor D, Morgans A, Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: epidemiology and effectiveness of therapies. Emerg. Med. Australas. 2014; 26: 350–5. 2. Australian Resuscitation Council. Guideline 11.9 managing acute dysrythmias. 2009. [Updated November 2009; cited 27 Mar 2015.] Available from URL: http://resus .org.au/?wpfb_dl=59 3. Sinz E, Navarro K, Soderberg ES, Callaway CW. American Heart Association. Advanced Cardiovascular Life
Support. Provider Manual, Vol. VII. Dallas, TX: American Heart Association, 2011. 4. Morrison LJ, Deakin CD, Morley PT et al. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122(Suppl 2): S345– 421. 5. Smith G, McD Taylor D, Morgans A, Cameron P. Measuring the effectiveness of a revised clinical practice guideline for the pre-hospital management of supraventricular tachycardia. Emerg. Med. Australas. 2015; 27: 22–8.
Pieter F FOUCHE Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia doi: 10.1111/1742-6723.12390
Teaching medical students in the emergency department: A matter of survival Dear Editor, We read with great interest the Trainee Focus1–3 section of the February edition of Emergency Medicine Australasia. This topic is not just of passing interest, but one of survival for any ED. We are surprised it might require a debate. Even EDs of ‘excellence’ wane in their standing and performance when teaching, and education falls to a lower level of priority. It is our belief that, particularly for a regional hospital, providing an excellent medical student experience is a matter of necessity. As a large regional hospital, Bendigo Health ED was, until recently, almost entirely dependent on newly arrived international graduates, locum ‘registrars’ who were frequently not in a training programme, and seconded interns to provide the emergency medical workforce. From year to year,
we had no idea when our next crop of medical staff were coming, and the annual anxiety regarding the need to find someone capable of doing unsupervised night shifts was almost unbearable. Over the past 5–10 years, a concerted effort to develop the medical education programmes at Bendigo Health ED, at all levels of training, has produced a full complement of ACEM trainees, with an even spread of provisional and advanced trainees, and the next wave already identified from among the interns and residents. By doing so, we have seen good medical students return as interns and residents, and stay on to enter Emergency Medicine training, and we have seen others go away to major cities to spread the word about the education available at Bendigo, enticing others to come.
Under our model, the final year students take on the familiar role of junior intern, seeing and working up patients and reporting directly to the consultant on duty. This does increase the task load of the duty consultant; however, the duty consultant is otherwise discouraged from being directly responsible for patients, concentrating instead on close supervision of junior medical staff, early review of every patient to come through, and flow management as well as providing or delegating team leadership for critically ill and major trauma patients. Supervision of the medical student, therefore, is simply a graduated increase in supervision relative to supervising an intern. The medical student is responsible for writing the notes and the discharge letter, ensuring the pathology and imaging results
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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LETTERS TO THE EDITOR
are collated and ready for interpretation with the consultant, and for carrying out most referrals. In 2015, we have begun a new programme for the ‘foundation year’ students, in their first of three clinical years. These students rotate through the ED in pairs for 2 weeks each. Previously this has been a variably rewarding experience, very much dependent on the student, and seen as a drain on resources by the ED staff. Unable to take on the junior intern role, they tended to stay away from the consultant and would frequently attach themselves to a registrar, significantly slowing the registrar’s pace of work. Under the new model, a nurse educator will ‘concierge’ the students during their time in the ED, guiding them opportunistically to learning experiences as they arise and ensuring that they cover the key learning objectives for the term. For example, the nurse educator might take them to take
a history from a patient with chest pain and then to present that history to the clinician involved before taking them away to assess and irrigate a wound in fast track, ensuring an even spread of teaching work for all the staff in the ED, divided into short manageable segments. Crucial to the success of the programme will be the ability of the nurse educator to read the department, to recognise opportunities as they arise and to recognise who has 5 min to spare and who does not. Our department works faster now because we taught medical students well last year, and the years before that. To abandon medical student teaching entirely would be a false economy.
Competing interests
References 1.
Couser G. Teaching medical students in emergency departments: time to reinvent a core activity. Emerg. Med. Australas. 2015; 27: 69–71. 2. Ilancheran A. Should emergency medicine registrars focus on seeing patients and leave the teaching of medical students to others? Yes. Emerg. Med. Australas. 2015; 27: 76–7. 3. Osborne R. Should emergency medicine registrars focus on seeing patients and leave the teaching of medical students to others? No. Emerg. Med. Australas. 2015; 27: 78–9.
Mark PUTLAND and Ben MCKENZIE Emergency Medicine, Bendigo Health Care Group, Bendigo, Victoria, Australia doi: 10.1111/1742-6723.12388
None declared.
Do ambulance paramedics administer too much oxygen to patients with acute exacerbations of chronic obstructive airways disease? Dear Editor, The COPD-X guidelines (2014) 1 recommend that for patients with chronic obstructive pulmonary disease (COPD) treated in emergency settings (including the prehospital setting), oxygen flow should be carefully titrated to achieve arterial oxygen saturations between 88% and 92%. The rationale is that there is evidence that high-flow oxygen administered prehospital may increase mortality (number needed to harm 14), based on work by Austin et al.,2 and is associated with an increased risk of of death, assisted ventilation or respiratory failure.3 We aimed to determine what proportion of patients with COPD arriving at the ED by ambulance is over-oxygenated.
This was an unplanned sub-study of retrospective cohort by medical record review of patients presenting to ED by ambulance with final hospital diagnosis of COPD. The parent study aimed to compare mortality for those receiving controlled versus uncontrolled oxygen therapy. Inclusion criteria were age ≥18 years and ED discharge diagnosis of COPD. Exclusion criteria were: did not arrive by ambulance; did not receive oxygen prehospital; did not receive oxygen after initial ED assessment; failure to confirm COPD as the principal hospital discharge diagnosis; discharged from ED; was receiving assisted ventilation on ED arrival; and missing records. Patients were identified from the ED data management system for the period 1 January 2012
to 31 March 2013. There were 864 potentially eligible patients. A convenience sample of 642 patients, based on record availability, was screened for inclusion representing approximately 74% of all potentially eligible patients. Data collected included demographics, use of home oxygen, prehospital oxygen delivery method, last recorded SpO2 prehospital, primary hospital discharge diagnosis and in-hospital mortality. The outcome of interest was the proportion of patients with SpO2 ≥93% at last prehospital reading. Analysis is descriptive with 95% confidence intervals (CIs). Ethics approval as a quality assurance project was obtained. Patient consent was not required.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
274
LETTERS TO THE EDITOR
this study, but only 0.3% received electrical cardioversion, it suggests that synchronised cardioversion was underutilised. Ambulance Victoria should consider using synchronised cardioversion with less reservation and to apply this lifesaving electrical therapy in line with current recommendations, as electrical cardioversion is a very effective and the best treatment for unstable SVT.4 Furthermore, the authors state that overall, 438/ 882 (49.7%) patients remained in SVT on arrival at hospital, of which 116 patients were hypotensive. I contend that fewer patients would have remained in SVT if hypotensive and SVT-related chest pain were treated with synchronised cardioversion as per the ILCOR and other guidelines. In a recent study by the same authors, similar low rates of cardioversion were noted, with less than 1% receiving synchronised cardioversion. 5 It would be good
for the authors of this excellent study to investigate the reasons for the underutilisation of electrical cardioversion.
Competing interests None declared.
References 1. Smith G, McD Taylor D, Morgans A, Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: epidemiology and effectiveness of therapies. Emerg. Med. Australas. 2014; 26: 350–5. 2. Australian Resuscitation Council. Guideline 11.9 managing acute dysrythmias. 2009. [Updated November 2009; cited 27 Mar 2015.] Available from URL: http://resus .org.au/?wpfb_dl=59 3. Sinz E, Navarro K, Soderberg ES, Callaway CW. American Heart Association. Advanced Cardiovascular Life
Support. Provider Manual, Vol. VII. Dallas, TX: American Heart Association, 2011. 4. Morrison LJ, Deakin CD, Morley PT et al. Part 8: advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122(Suppl 2): S345– 421. 5. Smith G, McD Taylor D, Morgans A, Cameron P. Measuring the effectiveness of a revised clinical practice guideline for the pre-hospital management of supraventricular tachycardia. Emerg. Med. Australas. 2015; 27: 22–8.
Pieter F FOUCHE Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia doi: 10.1111/1742-6723.12390
Teaching medical students in the emergency department: A matter of survival Dear Editor, We read with great interest the Trainee Focus1–3 section of the February edition of Emergency Medicine Australasia. This topic is not just of passing interest, but one of survival for any ED. We are surprised it might require a debate. Even EDs of ‘excellence’ wane in their standing and performance when teaching, and education falls to a lower level of priority. It is our belief that, particularly for a regional hospital, providing an excellent medical student experience is a matter of necessity. As a large regional hospital, Bendigo Health ED was, until recently, almost entirely dependent on newly arrived international graduates, locum ‘registrars’ who were frequently not in a training programme, and seconded interns to provide the emergency medical workforce. From year to year,
we had no idea when our next crop of medical staff were coming, and the annual anxiety regarding the need to find someone capable of doing unsupervised night shifts was almost unbearable. Over the past 5–10 years, a concerted effort to develop the medical education programmes at Bendigo Health ED, at all levels of training, has produced a full complement of ACEM trainees, with an even spread of provisional and advanced trainees, and the next wave already identified from among the interns and residents. By doing so, we have seen good medical students return as interns and residents, and stay on to enter Emergency Medicine training, and we have seen others go away to major cities to spread the word about the education available at Bendigo, enticing others to come.
Under our model, the final year students take on the familiar role of junior intern, seeing and working up patients and reporting directly to the consultant on duty. This does increase the task load of the duty consultant; however, the duty consultant is otherwise discouraged from being directly responsible for patients, concentrating instead on close supervision of junior medical staff, early review of every patient to come through, and flow management as well as providing or delegating team leadership for critically ill and major trauma patients. Supervision of the medical student, therefore, is simply a graduated increase in supervision relative to supervising an intern. The medical student is responsible for writing the notes and the discharge letter, ensuring the pathology and imaging results
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
bs_bs_banner
275
LETTERS TO THE EDITOR
are collated and ready for interpretation with the consultant, and for carrying out most referrals. In 2015, we have begun a new programme for the ‘foundation year’ students, in their first of three clinical years. These students rotate through the ED in pairs for 2 weeks each. Previously this has been a variably rewarding experience, very much dependent on the student, and seen as a drain on resources by the ED staff. Unable to take on the junior intern role, they tended to stay away from the consultant and would frequently attach themselves to a registrar, significantly slowing the registrar’s pace of work. Under the new model, a nurse educator will ‘concierge’ the students during their time in the ED, guiding them opportunistically to learning experiences as they arise and ensuring that they cover the key learning objectives for the term. For example, the nurse educator might take them to take
a history from a patient with chest pain and then to present that history to the clinician involved before taking them away to assess and irrigate a wound in fast track, ensuring an even spread of teaching work for all the staff in the ED, divided into short manageable segments. Crucial to the success of the programme will be the ability of the nurse educator to read the department, to recognise opportunities as they arise and to recognise who has 5 min to spare and who does not. Our department works faster now because we taught medical students well last year, and the years before that. To abandon medical student teaching entirely would be a false economy.
Competing interests
References 1.
Couser G. Teaching medical students in emergency departments: time to reinvent a core activity. Emerg. Med. Australas. 2015; 27: 69–71. 2. Ilancheran A. Should emergency medicine registrars focus on seeing patients and leave the teaching of medical students to others? Yes. Emerg. Med. Australas. 2015; 27: 76–7. 3. Osborne R. Should emergency medicine registrars focus on seeing patients and leave the teaching of medical students to others? No. Emerg. Med. Australas. 2015; 27: 78–9.
Mark PUTLAND and Ben MCKENZIE Emergency Medicine, Bendigo Health Care Group, Bendigo, Victoria, Australia doi: 10.1111/1742-6723.12388
None declared.
Do ambulance paramedics administer too much oxygen to patients with acute exacerbations of chronic obstructive airways disease? Dear Editor, The COPD-X guidelines (2014) 1 recommend that for patients with chronic obstructive pulmonary disease (COPD) treated in emergency settings (including the prehospital setting), oxygen flow should be carefully titrated to achieve arterial oxygen saturations between 88% and 92%. The rationale is that there is evidence that high-flow oxygen administered prehospital may increase mortality (number needed to harm 14), based on work by Austin et al.,2 and is associated with an increased risk of of death, assisted ventilation or respiratory failure.3 We aimed to determine what proportion of patients with COPD arriving at the ED by ambulance is over-oxygenated.
This was an unplanned sub-study of retrospective cohort by medical record review of patients presenting to ED by ambulance with final hospital diagnosis of COPD. The parent study aimed to compare mortality for those receiving controlled versus uncontrolled oxygen therapy. Inclusion criteria were age ≥18 years and ED discharge diagnosis of COPD. Exclusion criteria were: did not arrive by ambulance; did not receive oxygen prehospital; did not receive oxygen after initial ED assessment; failure to confirm COPD as the principal hospital discharge diagnosis; discharged from ED; was receiving assisted ventilation on ED arrival; and missing records. Patients were identified from the ED data management system for the period 1 January 2012
to 31 March 2013. There were 864 potentially eligible patients. A convenience sample of 642 patients, based on record availability, was screened for inclusion representing approximately 74% of all potentially eligible patients. Data collected included demographics, use of home oxygen, prehospital oxygen delivery method, last recorded SpO2 prehospital, primary hospital discharge diagnosis and in-hospital mortality. The outcome of interest was the proportion of patients with SpO2 ≥93% at last prehospital reading. Analysis is descriptive with 95% confidence intervals (CIs). Ethics approval as a quality assurance project was obtained. Patient consent was not required.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
