"Why haven't you taken any pain killers?" A patient focused study of the walking wounded in an urban emergency department.

OBJECTIVES: (1) To assess the proportion of patients of triage category 3-5 presenting to the minor side of an urban emergency department who present without taking prior pain relief, and (2) to describe the reasons why they do not take pain relief for their presenting complaint METHOD: By patient interview of a convenience sample of 60 adult patients in the setting of an urban emergency department. RESULTS: Fifteen of 60 patients had taken analgesia and 45 of 60 (75%) had not. Sixteen reasons were volunteered to the interviewer. Most patients offered one reason only 39 of 45 (87%). The three commonest single reasons cited for not taking pain relief were "don't like taking tablets" 10 (22%), "run out of tablets" 10 (22%), five (11%) said their "pain not bad enough". Six (13%) patients cited two reasons for not taking pain relief. Only three (6%) patients indicated that they "did not think about pain relief". Six (13%) of patients had inappropriate perceptions of how pain killers may interfere with their care. CONCLUSION: Most patients presenting with painful conditions to the minor side of an urban emergency department had not taken pain relief. The study highlights there are many different reasons for this and staff should not presume that it was because the patient "did not think about it". Ongoing education of staff and patients is needed.

A risk management audit: are we complying with the national guidelines for sedation by non-anaesthetists?

OBJECTIVES: To assess the effect of a preprinted form in ensuring an improved and sustained quality of documentation of clinical data in compliance with the national guidelines for sedation by non-anaesthetists. DESIGN: The process of retrospective case note audit was used to identify areas of poor performance, reiterate national guidelines, introduce a post-sedation advice sheet, and demonstrate improvement. SETTING: Emergency Department, Musgrove Park Hospital, Taunton. SUBJECTS: Forty seven patients requiring sedation for relocation of a dislocated shoulder or manipulation of a Colles' fracture between July and October 1996 and July and October 1997. MAIN OUTCOME MEASURES: Evidence that the following items had been documented: consent for procedure, risk assessment, monitored observations, prophylactic use of supplementary oxygen, and discharging patients with printed advice. Case note review was performed before (n = 23) and after (n = 24) the introduction of a sedation audit form. Notes were analysed for the above outcome measures. The monitored observations analysed included: pulse oximetry, respiratory rate, pulse rate, blood pressure, electrocardiography, and conscious level. RESULTS: Use of the form significantly improved documentation of most parameters measured. CONCLUSIONS: Introduction of the form, together with staff education, resulted in enhanced documentation of data and improved conformity with national guidelines. A risk management approach to preempting critical incidents following sedation, can be adopted in this area of emergency medicine.

Soccer players under regular training show oxidative stress but an improved plasma antioxidant status.

Physical activity is known to induce oxidative stress in individuals subjected to intense exercise. In this study, we investigated the lipoprotein profile and the plasma antioxidant status in a group of soccer players engaged in a regular training programme. As was expected for aerobic exercise, high-density lipoprotein-cholesterol (HDL-C) and HDL3-C levels were significantly increased in the sportsmen (P<0.05). Total plasma antioxidant capacity was 25% higher in sportsmen than in controls (P<0.005). Accordingly, plasma hydrosoluble antioxidant levels (ascorbic acid and uric acid) were found to be significantly elevated in the soccer players (P<0.005). In addition, these subjects showed high concentrations of alpha-tocopherol in plasma compared with controls (P<0.005). Furthermore, an increase in plasma superoxide dismutase activity was also observed in relation to exercise (P<0.01). The elevation in plasma activities of antioxidant enzymes and the higher levels of free radical scavengers of low molecular mass may compensate the oxidative stress caused by physical activity. High levels of high-density lipoprotein in plasma may offer additional protection by inhibiting low-density lipoprotein oxidation and thus liposoluble antioxidant consumption. Therefore, soccer players under regular training show an improved plasma antioxidant status in comparison to sedentary controls.

General practice: a secondment from emergency medicine--so what!

The Joint Committee for Higher Medical Training has issued a core curriculum for training in accident and emergency medicine. This article highlights some of the knowledge, skills, and attitudes one may usefully gain from a period of 6-12 months in general practice and how this can be integrated and adapted to a career in emergency medicine.

Variations in living donor graft rates by dialysis clinic: effect on outcome and cost of chronic renal failure therapy.

OBJECT: Examination of nephrology practice variations in living donor renal grafts to determine their influence on organ supply, quality, and cost of chronic renal failure therapy. MATERIALS: Saskatchewan chronic dialysis, cadaveric, and living donor renal grafts in 1983-1994 inclusive. RESULTS: Saskatchewan has three dialysis (I, II, III) and one transplant clinic. In the period the renal graft incidences/million population by these dialysis clinics by organ source were; Cadaveric: 23.1, 23.2, 21.1 (p = ns). Living: 5.4, 21.7, 8.3 (I or III vs II p < 0.000, I vs III p < 0.061). Total: 28.7, 44.7, 29.4. Living donor series A is 79 grafts in patients under age 60 with primary renal disease. Series B is 20 grafts in patients with secondary renal disease or over age 59. Series A ten-year actuarial patient survival is 92% and B 44%. Series A ten-year actuarial graft survival (including regrafts) is 77% and B 39%. Rehabilitation rate in patients with functioning grafts is 88.5%. Province-wide extension of the Clinic II living-donor graft rate in 1983-1994 would have produced 160 more renal grafts or 59% of those receiving chronic dialysis in 1994. The annual maintenance for a graft with the initial grafting cost taken over five years was $10,825 and the dialysis cost $40,100. CONCLUSIONS: (1) nephrology practice variations caused a 2.5-4.0-fold difference in living donor renal graft rates, indicating patient education by the attending nephrologist influences the living donor transplantation rate, (2) with such education the combined living donor and the cadaveric organ supply virtually meets graft demand, (3) living donor renal grafts yield a better quantity and quality of life and better cost control than dialysis with their annual cost being one-quarter that for dialysis.