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Preference: Emergency Medicine

202

More money to fight STDs, please Mr President

The United States of America has the highest sexually transmitted disease rate in the industrialised world, and health experts say it is only a lack of resources that prevents them getting on top of the problem.

Public health experts in America recently called on US President Donald Trump to declare a public health emergency over the rapid spike in STDs across the nation.

The rate of STDs has increased in the US four years in a row, with cases of gonorrhoea, syphilis, and chlamydia rising by 200,000 between 2016 and 2017, to a total of 2.3 million.

The National Coalition of STD Directors has said the results mean the US has the highest STD rates in the industrialised world.

It also said a fall in public health funding and resources is to blame.

The organisation has called on President Trump and Health and Human Services Secretary Alex Azar to intervene and to declare STDs in America a public health crisis.

“What goes along with that is emergency access to public health funding to make a dent in STD rates and to bring these rates down and make sure all American get access to the health care they need,” said the Coalition’s executive director David Harvey.

He added that $70 million in government funding was needed immediately, and $270 million needed for the 2019 financial year.

Michael Fraser, executive director of the Association of State and Territorial Health Officials, put it even more bluntly when calling for more government funding.

“We know what works for STD prevention,” he said. “We just don’t necessarily want to pay for it.”

 

AMA demands urgent fix to humanitarian emergency on Nauru

AMA demands urgent fix to humanitarian emergency on Nauru

The AMA has called on the Government to urgently transfer refugee families from Nauru, describing the situation there as a humanitarian emergency.

In a letter to Prime Minister Scott Morrison, AMA President Dr Tony Bartone urged a policy rethink and demanded that asylum seeker children and their families be removed from Nauru as a matter of priority.

Dr Bartone said deteriorating physical and mental health among refugee children and their families meant they should be relocated to more appropriate places, preferably in mainland Australia.

“Put bluntly, we want some urgent action to help these vulnerable people who find themselves in a hopeless, despairing situation,” Dr Bartone wrote in his letter to the PM.

“The AMA has been calling for a more humanitarian approach, including independent assessment of health care arrangements, for many years now.

“The medical situation for the children on Nauru has been described by health experts, including medical staff who have worked on Nauru, as critical and getting worse. It is a humanitarian emergency requiring urgent intervention.

“We have been given some hope at the bureaucratic level, but a slammed door at the political level.

“The AMA and the medical profession are demanding a change of policy – a change of policy that reflects community concern for the health of asylum seekers.”

Dr Bartone said the AMA wants to see a more compassionate Government approach to the health care of refugees and asylum seekers in the care of the Australian Government.

He said there had been a recent groundswell of concern and agitation across the AMA membership and the medical profession about conditions on Nauru and the escalation in reports of catastrophic mental and physical health conditions being experienced by the asylum seekers, especially children.

“As a suburban Melbourne GP for more than 30 years, and a grassroots Australian with strong community connections and Christian values, I passionately believe we can and must do more to look after the health of these people, many of whom have fled war, conflict, or persecution,” he wrote.

“There are now too many credible reports concerning the effects of long-term detention and uncertainty on the physical and mental health of asylum seekers.

“It is within the power of the Government to move on this issue and play its part in allowing traumatised people to begin rebuilding their lives.

“Australia is a caring nation with a long history of compassion and respect for human rights. We need to show the Australian people and the world that we are still a caring nation.

“The AMA believes that asylum seeker children and their families on Nauru must be removed and given access to physical and mental health care of an appropriate standard.”

Dr Bartone repeated the AMA’s call for the Government to facilitate access to Nauru for a delegation of Australian medical professionals to assess the health and welfare of child refugees and asylum seekers.

“This includes access to the children and their families and/or carers, the International Health and Medical Services (IHMS) medical professionals administering to the children, and any Nauruan Government officials administering to the children,” he said.

“Membership of the delegation would be determined in consultation with the AMA and the delegation would make public the findings of its inspections and interviews to assure the Australian public that the Australian Government has done all that is possible to protect the health and wellbeing of asylum seekers and refugees.”

In a separate letter to all MPs and Senators urging support and advocacy for the AMA position, Dr Bartone reminded politicians that, in April 2017, the Senate Legal and Constitutional Affairs Committee released the report of its inquiry into asylum seekers on Nauru.

The inquiry made two recommendations about the availability of medical services and medical transfers:

  • Recommendation 1: The committee recommends that the Department of Immigration and Border Protection, as a matter of urgency, commission an external review of its medical transfer procedures in offshore processing centres.
  • Recommendation 2: The committee recommends that the Australian Government undertake to seek advice in relation to whether improvements are required to the medical treatment options available to asylum seekers and refugees in the Republic of Nauru and Papua New Guinea, particularly mental health services.

The Government has not yet responded to the inquiry.

Dr Bartone praised the hard work and dedication of doctors and health workers who have been providing care with IHMS on Nauru.

“These health professionals and their employer have been doing their best in very trying conditions in isolation – and under a veil of secrecy not of their doing,” Dr Bartone said.

“The Government must get fair dinkum and give these long-suffering asylum seeker children, many of whom are extremely ill, and their families a fair go – bring them to Australia for proper care in the best possible environment for their severe mental and physical health conditions.”

There are about 100 children on Nauru. Many have been in detention long-term. Media reports suggest about 20 of the children are refusing food and fluids.

CHRIS JOHNSON 

 

4 hour rule successful in reducing ED overcrowding

A study has proven that the Australia-wide strategy to limit the time people spend in emergency departments (EDs) is helping to reduce chronic overcrowding.

Lead author of the study and senior research fellow at UNSW, Dr Roberto Forero, said the impact of the Four‐Hour Rule/National Emergency Access Target (4HR/NEAT) has been effective in decreasing access block – a symptom of ED overcrowding.

“At the beginning in 2002-2008, there was a 50-60% delay in patients waiting to be admitted to hospital in EDs, and these patients could end up spending more than 24 hours in the ED.”

He said the first change since implementing 4HR/NEAT has been a reduction in access block to 30-40%

ED trends across 16 hospitals were analysed

The longitudinal cohort study used data from 16 hospitals across WA, NSW, the ACT and QLD to assess the impact of 4HR/NEAT.

4HR/NEAT was introduced as a means of driving hospital performance by applying a time target. This target was set for all Australian EDs in response to evidence that ED overcrowding and prolonged length of stay was leading to increased in-hospital mortality.

The research team assessed data from before and after the introduction of the four-hour rule in Western Australia in 2009 and the four-hour National Emergency Access Target in participating states in 2012. Mortality trends were analysed using an interrupted time series technique.

From nearly 4 million visits to EDs, there were 952,726 emergency admissions and 40,281 deaths. All jurisdictions, except ACT, had improved flow and access block after the implementation of 4HR/NEAT. The ED flow recorded in ACT hospitals did improve but at a less pronounced rate.

Post-intervention, WA had a significant reduction of mortality rate of -0.28 per 1000 patients per quarter. However, QLD had mixed results and NSW/ACT mortality trends did not change significantly.

‘Whole-of-hospital’ approach is driving change

Dr Forero said that while the results varied from state to state due to differences between hospitals, the effect of 4HR/NEAT has been positive.

“In addition, the overall improvement was achieved by changing and innovating workplace practices in ED. This often involved improved clinical staffing in ED, and specific roles to address patient flow. We saw that hospitals changed the structure of the ED and involved the rest of the hospital in patient flow, looking at new ways to improve the process of discharging patients overall”

The implementation of 4HR/NEAT has generated a great deal of change within a relatively short period of time and Dr Forero says there is a clear reason for this.

“It was identified that the problem wasn’t an emergency department problem, but a whole-of-hospital problem, and required solutions at a health system level.”

Mortality link not as strong – but more analysis is needed

Dr Forero said there were potential explanations as to why the study did not find a strong link between the implementation of 4HR/NEAT and a reduction in mortality.

“We were expecting to find a strong association between the decreased mortality and the decreased levels of access block and overcrowding, but this relationship was not as strong.”

“Basically, we couldn’t compare the same periods of time after the policy was implemented across the states because the data wasn’t available”, Dr Forero said.

“We only had 2 years after the implementation policy in eastern states, and 4 years after the implementation of policy in WA, so that may explain why there wasn’t a significant association.”

Dr Forero said this could be a measuring error, “but it will probably just require more time.”

“One of the things we need to do now is get more data and have more years for the analysis. And we also need to have more states involved – the states we didn’t have in this study.”

[Correspondence] Treatment modalities for pregnant women with opioid use disorder

In his first year of term, President Trump declared the opioid crisis a national emergency. This declaration allowed state and federal agencies to allot more resources to confront the epidemic by using recommen-dations from the final report of the President’s commission on combatting drug addiction and the opioid crisis,1 such as increased treatment capacity and better access to medication-assisted treatment (MAT) programmes. These recommendations are rather vague and could leave the most vulnerable people behind.

Clinical chemistry score versus high-sensitivity cardiac troponin I and T tests alone to identify patients at low or high risk for myocardial infarction or death at presentation to the emergency department [Research]

BACKGROUND:

Testing for high-sensitivity cardiac troponin (hs-cTn) may assist triage and clinical decision-making in patients presenting to the emergency department with symptoms of acute coronary syndrome; however, this could result in the misclassification of risk because of analytical variation or laboratory error. We sought to evaluate a new laboratory-based risk-stratification tool that incorporates tests for hs-cTn, glucose level and estimated glomerular filtration rate to identify patients at risk of myocardial infarction or death when presenting to the emergency department.

METHODS:

We constructed the clinical chemistry score (CCS) (range 0–5 points) and validated it as a predictor of 30-day myocardial infarction (MI) or death using data from 4 cohort studies involving patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome. We calculated diagnostic parameters for the CCS score separately using high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT).

RESULTS:

For the combined cohorts (n = 4245), 17.1% of participants had an MI or died within 30 days. A CCS score of 0 points best identified low-risk participants: the hs-cTnI CCS had a sensitivity of 100% (95% confidence interval [CI] 99.5%–100%), with 8.9% (95% CI 8.1%–9.8%) of the population classified as being at low risk of MI or death within 30 days; the hs-cTnT CCS had a sensitivity of 99.9% (95% CI 99.2%–100%), with 10.5% (95% CI 9.6%–11.4%) of the population classified as being at low risk. The CCS had better sensitivity than hs-cTn alone (hs-cTnI < 5 ng/L: 96.6%, 95% CI 95.0%–97.8%; hs-cTnT < 6 ng/L: 98.2%, 95% CI 97.0%–99.0%). A CCS score of 5 points best identified patients at high risk (hs-cTnI CCS: specificity 96.6%, 95% CI 96.0%–97.2%; 11.2% [95% CI 10.3%–12.2%] of the population classified as being at high risk; hs-cTnT CCS: specificity 94.0%, 95% CI 93.1%–94.7%; 13.1% [95% CI 12.1%–14.1%] of the population classified as being at high risk) compared with using the overall 99th percentiles for the hs-cTn assays (specificity of hs-cTnI 93.2%, 95% CI 92.3–94.0; specificity of hs-cTnT 73.8%, 95% CI 72.3–75.2).

INTERPRETATION:

The CCS score at the chosen cut-offs was more sensitive and specific than hs-cTn alone for risk stratification of patients presenting to the emergency department with suspected acute coronary syndrome. Study registration: ClinicalTrials.gov, nos. NCT01994577; NCT02355457

[Clinical Picture] Re-expansion pulmonary oedema

A 46-year-old man presented to the emergency department with moderate dyspnoea and a 4-day history of cough. His medical history also included alcoholic cirrhosis with portal hypertension and ascites. On admission, a chest x-ray showed complete white-out of the right hemithorax with contralateral mediastinal deviation compatible with a large pleural effusion—presumed to be hepatic hydrothorax (figure). A chest drain was inserted into the right pleural cavity under ultrasound guidance and 2 L of clear fluid were rapidly drained over approximately 2 min.

2018 AMSA National Convention: Welcome to Perth-fect engagement

 BY ALEX FARRELL, PRESIDENT, AUSTRALIAN  MEDICAL  STUDENTS’ ASSOCIATION

 

In early July this year, the Australian Medical Students’ Association held our 59th National Convention in Perth. As the world’s largest student-run conference, it hosted more than1000 medical student delegates from across Australia and New Zealand. It was a week of innovative academic and social programs, enhanced by intervarsity competitions, field trips, and workshops. A team of over 100 student volunteers from universities in Western Australia worked for two years to make this huge undertaking possible.

As always, the National Convention was an opportunity for students to showcase their talents, ranging from research with poster presentations and 3 Minute Thesis, Sports Day competitions, debating (won by Monash University), and the Emergency Medical Challenge (won by University of Western Australia).

The academic program was full of motivational Australian and international plenary speakers showcasing contemporary health issues.

The program opened with Burns Specialist, Prof Fiona Wood, speaking to students about harnessing the power of science and technology to strive towards excellence in health care. We were fortunate to be joined by former AMA Presidents, A/Prof Rosanna Capolingua, who spoke on navigating leadership in the medical community, and Dr Michael Gannon, who reflected on his experiences within both AMSA and the AMA, and the advocacy that both groups drive forward. Dr Nikki Stamp spoke on paying attention to detail while not becoming overwhelmed by the minutiae.

There was the opportunity to hear from doctors about working in every context imaginable, from Dr Jeff Ayton’s experiences in Antarctica, Dr Nick Coatsworth travelling from Congo to Darwin with Medecins Sans Frontieres, and A/Prof Gordon Cable’s work in aerospace medicine.

There was also an array of fantastic speakers bringing their expertise from outside the medical world. Steven Bradbury’s recollections of his remarkable Olympic victory included messages that are applicable to all of our daily lives; memory athlete, Daniel Kilov, shared the techniques that make his work possible; and social advocate, Yasmin Abdel-Magied, spoke on challenging stereotypes through personal interactions and navigating a hyper politicised world.

Students left with increased clinical understanding, having battled it out against the hosts of the ‘IM Reasoning’ podcast run by Dr Nic Szecket and Dr Art Nahill in an interactive case reasoning session; heard from Prof Nick Talley on negotiating OSCEs and clinical examination; and participated in workshops on everything from reading ECGs to performing rhomboid skin flaps.

From doctors’ mental health to social issues and innovative medical practice, students learnt about the prominent issues of today’s medical landscape, as well as seeing the endless pathways and opportunities medicine can lead to. Perth Convention 2018 aspired for delegates to discover parts of life and medicine they never knew about before, engage in important issues, meet incredible, like-minded people, and be inspired to leave a lasting positive impression on the field of medicine in Australia.

[Correspondence] End immigration detention: an open letter

To the Honourable Ginette Petitpas Taylor, Minister of Health; the Honourable Ralph Goodale, Minister of Community Safety and Emergency Preparedness; the Honourable Ahmed D Hussen, Minister of Immigration, Refugees, and Citizenship; and the Right Honourable Prime Minister Justin Trudeau,

[Perspectives] Dutch dynamo

15 years after George W Bush created the multibillion dollar US President’s Emergency Plan for AIDS Relief (PEPFAR) to treat HIV infections worldwide, it can be hard to recall the horrors of bearing witness to AIDS carnage. In the absence of effective treatment, there was a time of walking corpses, of young adults and their babies staggering through final days in terrible pain. The hopelessness of the time, from 1981 to 1996 in high-income countries and another 6 years in Africa, often weighed on the souls of scientists, physicians, nurses, activists, and chroniclers in its maelstrom.