The burden of head trauma in rural and remote North Queensland, Australia.

BACKGROUND: Head trauma is a leading cause of death and disability worldwide. Young males, Indigenous people, and rural/remote residents have been identified as high-risk populations for head trauma, however, Australian research is limited. Our aim was to define and describe the incidence, demographics, causes, prehospital interventions, and outcomes of head trauma patients transported by aeromedical services within North Queensland, Australia. We hypothesized that young, Indigenous males living remotely would be disproportionately affected by head trauma. METHODS: We conducted a retrospective study of all head trauma patients transferred by air to or between Townsville, Cairns, Mount Isa and Mackay Hospitals between January 1, 2016 and December 31, 2018. Patients were identified from the Trauma Care in the Tropics data registry and followed for a median 30-months post-injury. Primary endpoints were patient and injury characteristics. Secondary outcome measures were hospital stay and mortality. RESULTS: A total of 981 patients were included and 31.1 % were Indigenous. Sixty-seven percent of injuries occurred remotely and the median time from injury to hospital was 5.8-hours (range 67-3780 min). Eighty percent of severe head injuries occurred in males (p = 0.007). Indigenous and remote patients were more likely to sustain mild injuries. The most common mechanism of injury overall was vehicle accident (37.5 %), compared to assault in the Indigenous subgroup (46.6 %, p<0.001). The overall mortality rate was 4.9 %, with older age and lower initial Glasgow Coma Score significant predictors of in-hospital mortality. Prehospital intubation was associated with a 7-fold increased risk of mortality (p = 0.056), while patients that received tranexamic acid (TXA) were almost 5-times more likely to die. CONCLUSIONS: In North Queensland, young Indigenous males are at highest risk of traumatic head injuries. Vehicle accidents are an important preventable cause of head injury in the region. TXA administration is an important consideration for remote head trauma retrievals, in which time to emergency care is prolonged. Appropriate treatment and risk stratification strategies considering time to definitive care, severity of injury, and other prehospital patient factors require further investigation.

The TARGET pain study: Lessons from a painful marathon.

This perspective article summarises the experience of conducting a multicentre research project. We describe expected and unexpected hurdles we experienced as well as suggesting possible solutions for researchers embarking on multicentre studies.

Best-practice pain management in the emergency department: A cluster-randomised, controlled, intervention trial.

OBJECTIVES: We aimed to provide 'adequate analgesia' (which decreases the pain score by ≥2 and to <4 [0-10 scale]) and determine the effect on patient satisfaction. METHODS: We undertook a multicentre, cluster-randomised, controlled, intervention trial in nine EDs. Patients with moderate pain (pain score of ≥4) were eligible for inclusion. The intervention was a range of educational activities to encourage staff to provide 'adequate analgesia'. It was introduced into five early intervention EDs between the 0 and 6 months time points and at four late intervention EDs between 3 and 6 months. At 0, 3 and 6 months, data were collected on demographics, pain scores, analgesia provided and pain management satisfaction 48 h post-discharge (6 point scale). RESULTS: Overall, 1317 patients were enrolled. Logistic regression (controlling for site and other confounders) indicated that, between 0 and 3 months, satisfaction increased significantly at the early intervention EDs (OR 2.2, 95% CI 1.5 to 3.4 [P < 0.01]) but was stable at the control EDs (OR 0.8, 95% CI 0.5 to 1.3 [P = 0.35]). Pooling of data from all sites indicated that the proportion of patients very satisfied with their pain management increased from 42.9% immediately pre-intervention to 53.9% after 3 months of intervention (difference in proportions 11.0%, 95% CI 4.2 to 17.8 [P = 0.001]). Logistic regression of all data indicated that 'adequate analgesia' was significantly associated with patient satisfaction (OR 1.4, 95% CI 1.1 to 1.8 [P < 0.01]). CONCLUSIONS: The 'adequate analgesia' intervention significantly improved patient satisfaction. It provides a simple and efficient target in the pursuit of best-practice ED pain management.

Middle ear barotrauma in a tourist-oriented, condensed open-water diver certification course: incidence and effect of language of instruction.

INTRODUCTION: In Professional Association of Diving Instructors (PADI) Open Water Diver certification courses that cater to tourists, instruction is often condensed and potentially delivered in a language that is not the candidate's native language. OBJECTIVE: To assess the incidence of middle ear barotrauma (MEBt) in open-water diver candidates during a condensed four-day certification course, and to determine if language of instruction affects the incidence of MEBt in these divers. METHOD: The ears of participating diving candidates were assessed prior to commencing any in-water compression. Tympanic membranes (TM) were assessed and graded for MEBt after the confined and open-water training sessions. Tympanometry was performed if the candidate had no movement of their TM during Valsalva. Photographs were taken with a digital otoscope. RESULTS: Sixty-seven candidates participated in the study. Forty-eight had MEBt at some time during their course. MEBt was not associated with instruction in non-native language (adjusted odds ratio = 0.82; 95% confidence intervals 0.21-3.91). There was also no significant association between the severity of MEBt and language of instruction. CONCLUSION: Open-water diver candidates have a high incidence of MEBt. Education in non-native language does not affect the overall incidence of MEBt.

Grommets in HBOT patients: GA vs LA, unanswered questions.

We read with interest the article on grommet procedures for patients undergoing hyperbaric oxygen therapy (HBOT), and have a number of comments. It appears the authors may have missed a number of cases. In a previous paper from The Townsville Hospital Hyperbaric Unit (TTH HMU), Commons et al presented 14 of 106 patients (13%) who required grommets over the period between June 2009 and May 2010. These patients are included in the Lamprell et al data set. Figure 1 shows an apparent spike in their cases in 2010 (n = 13, part of the period covered in the previous paper) when compared to the remaining four years of their study (mean number of cases 4.5 per year, for an incidence of 3%). This difference in incidence is statistically significant (chi square = 8.336, df = 1, P = 0.004). We suspect the difference may be the result of missed cases rather than a true spike; however, it is not possible to determine this from the paper. Lamprell et al describe identifying cases using the TTH HMU patient database. Did the authors also consider using the operating theatre database and/or ENT clinic records to ensure all cases were captured? We also have concerns regarding Lamprell's primary outcome measure: time from ENT referral to date of re/commencement of HBOT. These data are presented as median values with the associated ranges, rather than an interquartile range (IQR), the traditional measure of dispersion in non-parametric data. We believe the data sets contain a number of outliers that should be excluded, e.g., 98 days. We ask to see the IQRs and box-and-whisker plots for both data sets, and suspect the statistically significant difference in medians might not remain with outliers excluded from the analysis. There is also no discussion about the clinical relevance of this difference of seven days. Based on the most common indications for HBOT listed, most patients would have received at least 30 daily sessions of HBOT. What impact does a delay of seven days have on their treatment? As doctors who have worked at this HMU, we know patients preferentially received their grommets under GA prior to 2012 at the request of the ENT surgeon, who believed that insertion under LA was poorly tolerated. The authors do not describe whether the insertion of grommets under LA was associated with patient discomfort; a limitation of this retrospective paper, but a clinically relevant factor in the decision-making process of which form of anaesthesia to use. The paper by Lamprell et al has shown us that patients may experience a more rapid insertion of grommets and return to HBOT, if inserted under LA versus GA, but this difference may not be important clinically. We believe the authors may have failed to collect all cases and exclude outliers and this, coupled with the lack of documentation about patient satisfaction with insertion under LA, leaves us with more questions than answers.

'Sea legs': sharpened Romberg test after three days on a live-aboard dive boat.

INTRODUCTION: The sharpened Romberg test (SRT) is commonly used by diving and hyperbaric physicians as an indicator of neurological decompression illness (DCI). People who spend a prolonged time on a boat at sea experience impairment in their balance on returning to shore, a condition known as mal de debarquement ('sea legs'). This conditioning of the vestibular system to the rocking motion of a boat at sea may impact on the utility of the SRT in assessing a diver with potential DCI after a live-aboard dive trip. AIM: To assess the impact 'sea legs' has on the SRT after three days on a live-aboard dive trip. METHODS: Thirty-nine staff and passengers of a three-day, live-aboard dive trip performed a SRT before and after their journey, with assessment of potential variables, including middle ear barotrauma, alcohol consumption, sea-sickness and occult DCI. RESULTS: There was no statistically significant impact on SRT performance, with 100% completion pre-trip and 35 out of 36 divers (97.2%) post-trip. There were trends towards more attempts being required and time needed for successful SRT post-trip, but these were not statistically significant. There was a small, but noteworthy incidence of middle-ear barotrauma, with seven people affected pre-trip, and 13 post-trip. There was a higher incidence in student divers. Middle-ear barotrauma did not appear to have a direct impact on SRT performance. CONCLUSION: There was no significant impact on SRT performance resulting from 'sea legs' after three days at sea. Recreational divers, especially dive students, have a substantial incidence of mild middle ear barotrauma.