Low back pain presentations to rural, regional, and metropolitan emergency departments.

OBJECTIVE: To describe the context of low back pain (LBP) presentations to emergency departments (EDs) by remoteness areas, hospital delineation level and staffing portfolios. DESIGN: A retrospective observational study using routinely captured ED and admission data over a 5-year period (July 2014-June 2019). SETTINGS: Thirty seven EDs across a large health district in NSW, Australia, covering major cities, inner regional areas and outer regional areas. PARTICIPANTS: Emergency department (ED) presentations with a principal or secondary diagnosis of LBP based on ICD-10 code (M54.5). MAIN OUTCOME MEASURES: ED presentation and associated admission measures, including presentation rate, referral source, time in ED, re-presentation rate, admission details and cost to the health system. RESULTS: There were 26 509 ED presentations for LBP across the 5 years. Time spent in ED was 206 min for EDs in major cities, 146 min for inner regional EDs and 89 min for outer regional EDs. Re-presentation rates were 6% in major cities, 8.8% in inner regional EDs and 11.8% in outer regional EDs. Admission rates were 20.4%, 15.8% and 18.8%, respectively. CONCLUSIONS: This study describes LBP presentations across 37 EDs, highlighting the potential burden these presentations place on hospitals. LBP presentations appear to follow different pathways depending on the ED remoteness area, delineation level and staff portfolio.

Cardiac Arrest Nurse Leadership (CANLEAD) trial: a simulation-based randomised controlled trial implementation of a new cardiac arrest role to facilitate cognitive offload for medical team leaders.

BACKGROUND: Medical team leaders in cardiac arrest teams are routinely subjected to disproportionately high levels of cognitive burden. This simulation-based study explored whether the introduction of a dedicated 'nursing team leader' is an effective way of cognitively offloading medical team leaders of cardiac arrest teams. It was hypothesised that reduced cognitive load may allow medical team leaders to focus on high-level tasks resulting in improved team performance. METHODS: This randomised controlled trial used a series of in situ simulations performed in two Australian emergency departments in 2018-2019. Teams balanced on experience were randomised to either control (traditional roles) or intervention (designated nursing team leader) groups. No crossover between groups occurred with each participant taking part in a single simulation. Debriefing data were collected for thematic analysis and quantitative evaluation of self-reported cognitive load and task efficiency was evaluated using the NASA Task Load Index (NTLX) and a 'task time checklist' which was developed for this trial. RESULTS: Twenty adult cardiac arrest simulations (120 participants) were evaluated. Intervention group medical team leaders had significantly lower NTLX scores (238.4, 95% CI 192.0 to 284.7) than those in control groups (306.3, 95% CI 254.9 to 357.6; p=0.02). Intervention group medical team leaders working alongside a designated nursing leader role had significantly lower cognitive loads than their control group counterparts (206.4 vs 270.5, p=0.02). Teams with a designated nurse leader role had improved time to defibrillator application (23.5 s vs 59 s, p=0.004), faster correction of ineffective compressions (7.5 s vs 14 s, p=0.04), improved compression fraction (91.3 vs 89.9, p=0.048), and shorter time to address reversible causes (107.1 s vs 209.5 s, p=0.002). CONCLUSION: Dedicated nursing team leadership in simulation based cardiac arrest teams resulted in cognitive offload for medical leaders and improved team performance.

Laughter is the best medicine: A novel finding in the treatment of supraventricular tachycardia in a paediatric emergency patient.

We present a novel case of laughter induction that was noted to terminate an episode of supraventricular tachycardia (SVT) in a 10 year old girl who presented to a large metropolitan emergency department. In the initial management of this patient's SVT, traditional vagal maneuvers (including the valsalva maneuver and stimulation of the mammalian divers reflex) were attempted unsuccessfully. While awaiting further treatment, nursing staff presented the patient with an inflated examination glove that had been crafted into the shape of an elephant. This resulted in a fit of laughter that appeared to terminate the child's arrhythmia. Existing studies identified in the literature help to establish a correlation between the thoracic and cardiovascular physiology of laughter and the mechanics of the traditional Valsalva maneuver. Our patient's case highlights the potential positive impact of this physiology when applied in the context of the paediatric patient presenting in SVT. In the context of the available evidence, the case of our 10-year-old patient serves as a thought-provoking example of the real world relationship between laughter and the traditional Valsalva maneuver. The utility of laughter in the management of supraventricular tachycardia is an area that warrants further investigation.

Prehospital analgesic choice in injured patients does not impact on rates of vomiting: Experience from a New South Wales primary retrieval service.

OBJECTIVE: This study aimed to explore the analgesic regimes adopted in our contemporary retrieval practice and the incidence of vomiting in ED after prehospital analgesic use. METHOD: A retrospective review was conducted on trauma patients retrieved by the Hunter Primary Retrieval Service in the Hunter New England Local Health District, New South Wales, Australia, during 2015. RESULTS: Of the 379 patients attended by the service in 2015, 196 of them (mean age 38.6, SD 19.68, years) were selected for this review. Morphine was the most commonly used analgesic (mean 68.37%; 95% CI 61.36-74.81%), followed by fentanyl (mean 48.47%; 95% CI 41.29-55.70%) and ketamine (mean 34.18%; 95% CI 27.57-41.28%). Fourteen (7.14%, 95% CI 3.96-11.69%) patients vomited either prehospital or within the ED. Patients in both the emesis and the non-emesis group were comparable in demographics. None of the three studied analgesics were observed to be significantly associated with higher risk of vomiting than the others in this review, although a higher dose of fentanyl was given to the non-emesis group (P = 0.04). CONCLUSIONS: The frequency of vomiting in the retrieved patients observed in our study was less than previously reported in the literature. Opioids still prevailed over ketamine as the preferred initial analgesic, with ketamine most commonly used as an adjunct. Multi-centre trials in this field would be preferable in future in view of the relatively low incidence of vomiting in retrieved trauma patients.