Objectives-To investigate how well junior doctors in accident and emergency (A&E) were able to diagnose significant x ray abnormalities after trauma and to compare their results with those of more senior doctors. Methods-49 junior doctors (senior house officers) in A&E were tested with an x ray quiz in a standard way. Their results were compared with 34 consultants and senior registrars in A&E and radiology, who were tested in the same way. The quiz included 30 x rays (including 10 normal films) that had been taken after trauma. The abnormal films all had clinically significant, if sometimes uncommon, diagnoses. The results were compared and analysed statistically. Results-The mean score for the abnormal x rays for all the junior doctors was only 32% correct. The 10 junior doctors with more experience scored significantly better (P < 0.001) but their mean score was only 48%. The mean score of the senior doctors was 80%, which was significantly higher than the juniors (P < 0.0001). Conclusions-The majority of junior doctors misdiagnosed significant trauma abnormalities on x ray. Senior doctors scored well, but were not infallible. This suggests that junior doctors are not safe to work on their own in A&E departments. There are implications for training, supervision, and staffing in A&E departments, as well as a need for fail-safe mechanisms to ensure adequate patient care and to improve risk management.
Significant adverse effects of propofol in this case series were uncommon (12/98 patients) and readily countered. This case series suggests that propofol is a safe and effective sedative for relocating hip prostheses.
The intervention was effective at achieving nearly universal early assessment and documentation of pain. This did not translate to an improvement in analgesic provision. Other means of changing behaviour need to be studied, possibly using the computerised record again to obligate analgesia provision.
Our large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg(-1) propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies.
Problems associated with breaking bad news in cases of trauma * Death or severe injury is sudden and unexpected Coping with major trauma is stressful for both staff and the relatives. * The victim is often young Handling distressed relatives is an underemphasised part of the work, and * The prognosis is often unsure medical staff may have had no training and little experience of it. It is a time * Staff are often very busy that the relative will always remember and, if handled badly, will leave * Relatives may already have been notified lasting scars. in an unskilled manner * The victim may have committed suicide * Alcohol intoxication may have been a BMJ VOLUME 301
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