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Clinical researchers in acute emergency settings are commonly faced with the difficulty of satisfying the conventional ethical requirement of obtaining informed consent, whilst ensuring a representative group of patients is recruited into studies. We discuss our own experience in addressing institutional ethical requirements to obtain informed consent in a multi-centre trial, recruiting highly agitated patients in the emergency setting in Melbourne, Australia. We suggest that, through the application of existing ethical and legal frameworks and pre-emptive communication with the key stakeholders in ethics committees, hospital insurers and legal representatives, a balance can be struck between ethical and legal requirements on the one hand, and the integrity of the research question, on the other. [ABSTRACT FROM AUTHOR]

Aim: To compare the severity of paediatric pain as assessed by the triage nurse, child and parent. Methods: This was an analytical, observational study undertaken in a tertiary referral emergency department between January and June (inclusive) 2006. A convenience sample of children (aged 3–15 years) with painful conditions was enrolled. The triage nurse, child and parent were asked to assess the child's pain using the Wong–Baker FACES pain rating scale (young children) or a linear numerical pain rating scale (nurse, older children, parent). Each participant was blinded to the assessments of the others. Results: Eighty-six patients were enrolled: 52 (60.5%) male, mean age 9.1 (standard deviation 4.0) years. The median (inter-quartile range) pain scores recorded by the nurses, parents and children were 4.0 (3.0–6.0), 6.0 (5.0–7.5) and 6.5 (5.0–8.0), respectively. There were significant differences between the pain scores of the three groups ( P < 0.001, Kruskal–Wallis test). The nurses' score was significantly lower than both the parents' and the children's scores ( P < 0.001, Mann–Whitney U test). There was no significant difference between the parents and children's scores ( P = 0.11, Mann–Whitney U test). The nurses scored consistently lowest regardless of the cause of the pain or the child's age or gender. Conclusion: Relative to the children and parents, triage nurses assign significantly lower paediatric pain scores. The findings may have important implications for the management of paediatric pain which may need to be based upon the children's or parent's assessment rather than that of the nurse. [ABSTRACT FROM AUTHOR]

Success rates for the Valsalva manoeuvre (VM) in treatment of paroxysmal supraventricular tachycardia (SVT) vary with performance technique. This study aimed to assess whether ED doctors instruct their patients to perform the recommended VM technique (supine position for 15 s). A multicentre, observational study of 35 ED registrars and 17 emergency physicians. Each doctor was asked to describe how he/she would instruct a patient in SVT to perform the VM. Only five (9.6%) doctors would position their patient correctly and 31 (59.6%) would incorrectly instruct their patient to assume a sitting or semirecumbent position. Only five (9.6%) doctors would give specific instructions to blow for at least 15 s and 34 (65.4%) would instruct their patient to blow ‘as long as you can’. Only four (7.4%) doctors would use a sphygmomanometer to measure intrathoracic pressure during the VM. There were no significant differences ( P > 0.05) between the registrar and physician group responses for any study endpoint. Few ED doctors correctly instruct their patients in the VM technique recommended for management of SVT. Hence, maximal vagal tone and SVT conversion rates may not be achieved in many cases. The use of the recommended VM technique is encouraged. [ABSTRACT FROM AUTHOR]

There is anecdotal evidence that ACEM Fellows are reducing or planning to reduce their clinical workload. We investigated the extent of, and reasons for, these reductions. An anonymous, cross-sectional postal survey utilizing a study-specific questionnaire. Three hundred and twenty-three Fellows (63.5%) responded. Most were recently graduated males. In the last 5 years, the mean number of clinical hours worked per week has reduced significantly ( P < 0.001) for both junior (40.6–28.9 h) and senior Fellows (30.4–23.1 h). Further significant ( P < 0.001) reductions are planned. The most frequently reported reasons for reducing clinical workload were excessive workload, family life and emotional health effects, shift work and work stress. The most stressful aspects of work reported were access block, dealing with management, insufficient staffing, workload pressures and staff supervision. Clinical work reportedly impacts most upon family life, social life and emotional health. Fellows are significantly reducing their clinical workload largely in response to excessive workload and lack of resources. These findings have important implications for professional longevity and work force planning. Re-evaluation of workplace practice, especially identified stressors, is indicated. [ABSTRACT FROM AUTHOR]

To evaluate the psychological health of ACEM Fellows and the important factors that impact on this health. A cross-sectional, mail survey utilizing validated psychological instruments. Three hundred and twenty-three (63.5%) of 510 physicians responded. Most were recently graduated males. Compared to a general population sample, their psychological health was good with greater optimism and mastery ( P < 0.001), less anxiety, depression and physical symptoms ( P < 0.001), better life satisfaction ( P = 0.04) and similar perceived stress ( P = 0.20). The mean work stress score (1 = low, 10 = high) was 5.6 ± 2.1 (moderate stress) although 63 (19.5%) had very high scores (8–10). The mean work satisfaction score was 6.3 ± 2.1 (moderate satisfaction) although 43 (13.3%) had very low scores (1–3). Perceptions of control over hours worked and mix of professional activities were positively associated with work and life satisfaction ( P < 0.001) and negatively associated with work stress and measures of wellbeing ( P < 0.001). Most employed adaptive coping strategies. However, maladaptive strategies (alcohol/drugs, denial, disengagement) were positively associated with anxiety, depression and stress ( P < 0.001). Most physicians are psychologically healthy. However, there appears to be a subgroup that is not thriving. Workplace stress should be addressed promptly and greater flexibility provided over hours worked and mix of professional activities. [ABSTRACT FROM AUTHOR]

Abstract Objective: To assess the adequacy of continuity of care for patients who are discharged to home or admitted to hospital from the emergency department. Methods: Questionnaire survey of emergency department communication practices. Results: Seventy-five of 86 emergency departments (87.2%) participated. Emergency departments failed to communicate with general practitioners upon disposition of many patients. For patients discharged to home, significantly more private emergency departments contacted general practitioners directly by telephone (P < 0.01) or by letter (P < 0.001). Significantly more public emergency departments gave patients a letter to take to their general practitioners (P < 0.01). Overall, emergency departments gave the patient a general practitioner letter some (33.3% of emergency department) or most (40.0%) of the time. Few letters were posted or faxed and little use of Email was made. Pre-formatted letters were used less than was expected. On patient admission, the telephone was used most frequently to advise general practitioners. Conclusions: Continuity of patient care may be inadequate in many emergency departments. Emergency departments should establish a check system to ensure that a communication is made with the general practitioners of all patients. Telephone or facsimile communication is recommended on patient admission. Other modes may be more appropriate on patient discharge to home. Structured, pre-formatted letters/facsimiles are recommended. Emergency department–general practitioner communications should be used as a performance indicator of emergency department practice. [ABSTRACT FROM AUTHOR]

Abstract Objective: To determine why some patients refuse consent for their general practitioner to be notified, by facsimile, of their admission to hospital from the emergency department. Methods: Descriptive, questionnaire-based study of patients refusing consent for general practitioner notification, over a 7 month period was performed. Results: Forty-eight patients (1.5%) refused consent and 47 patients completed the questionnaire. Thirty-five patients (74.5%) did not think it was necessary for their general practitioner to know of their admission and seven patients (14.9%) did not want their general practitioner to know. No refusal was related to the mode of notification (facsimile). The patients who refused consent had no defining characteristics related to gender, general practitioner or diagnosis but tended to be young, with 31 patients (64.6%) aged under 38 years. Conclusions: It is likely that most refusals were related to a lack of understanding of the importance of general practitioner notification, although some refusals may have reflected the patient–general practitioner relationship. Patients appeared to have confidence that their faxed information would not be misdirected or accessed by unauthorized personnel. Medico-legal action is conceivable if non-urgent information is faxed without patient consent. We recommend the use of facsimile notification of patient admission from the emergency department, provided that informed, signed consent is obtained. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about various classes of drugs use for acutely agitated patients in the previous issue.

Introduction: We aimed to identify the possible chain of events leading to fatal scuba diving incidents in Australia from 2001-2013 to inform appropriate countermeasures., Methods: The National Coronial Information System was searched to identify scuba diving-related deaths from 2001-2013, inclusive. Coronial findings, witness and police reports, medical histories and autopsies, toxicology and equipment reports were scrutinised. These were analysed for predisposing factors, triggers, disabling agents, disabling injuries and causes of death using a validated template., Results: There were 126 known scuba diving fatalities and 189 predisposing factors were identified, the major being health conditions (59; 47%), organisational/training/experience/skills issues (46; 37%), planning shortcomings (29; 23%) and equipment inadequacies (24; 19%). The 138 suspected triggers included environmental (68; 54%), exertion (23; 18%) and gas supply problems (15; 12%) among others. The 121 identified disabling agents included medical-related (48; 38%), ascent-related (21; 17%), poor buoyancy control (18; 14%), gas supply (17; 13%), environmental (13; 10%) and equipment (4; 3%). The main disabling injuries were asphyxia (37%), cardiac (25%) and cerebral arterial gas embolism/pulmonary barotrauma (15%)., Conclusions: Chronic medical conditions, predominantly cardiac-related, are a major contributor to diving incidents. Divers with such conditions and/or older divers should undergo thorough fitness-to-dive assessments. Appropriate local knowledge, planning and monitoring are important to minimise the potential for incidents triggered by adverse environmental conditions, most of which involve inexperienced divers. Chain of events analysis should increase understanding of diving incidents and has the potential to reduce morbidity and mortality in divers., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

Introduction: A scuba diving fatality usually involves a series of related events culminating in death. Several studies have utilised a chain of events-type analysis (CEA) to isolate and better understand the accident sequence in order to facilitate the creation of relevant countermeasures. The aim of this research was to further develop and better define a process for performing a CEA to reduce potential subjectivity and increase consistency between analysts., Methodology: To develop more comprehensive and better-defined criteria, existing criteria were modified and a template was created and tested using a CEA. Modifications comprised addition of a category for pre-disposing factors, expansion of criteria for the triggers and disabling agents present during the incident, and more specific inclusion criteria to better encompass a dataset of 56 fatalities. Four investigators (raters) used both the previous criteria and this template, in randomly assigned order, to examine a sample of 13 scuba diver deaths. Individual results were scored against the group consensus for the CEA. Raters' agreement consistency was compared using the Index of Concordance and intra-class correlation coefficients (ICC)., Results: The template is presented. The index of concordance between the raters increased from 62% (194⁄312) using the previous criteria to 82% (257⁄312) with use of this template indicating a substantially higher inter-rater agreement when allocating criteria. The agreement in scoring with and without template use was also quantified by ICC which were generally graded as low, illustrating a substantial change in consistency of scoring before and after template use., Conclusion: The template for a CEA for a scuba diving fatality improves consistency of interpretation between users and may improve comparability of diving fatality reports.

Introduction: This is the second report based on a survey of Divers Alert Network Asia-Pacific (DAN AP) members who dive with cardiovascular and respiratory conditions and diabetes. It examines the medical management of the divers' conditions, any diving modifications used to mitigate the risk and outcomes., Methodology: An online cross-sectional survey was sent to 833 divers who had declared a targeted medical condition when applying for DAN AP membership between July 2009 and August 2013., Results: Two-hundred-and-sixty-eight respondents (32%) provided sufficient information on their conditions to be included in the analyses. These included ischaemic heart disease (31), arrhythmias (20), cardiac septal defects (31), other cardiac conditions (10), hypertension (127), diabetes (25), asthma (40) and pneumothorax (5). Forty-nine per cent had sought specialist diving medical advice about their condition and 23% reported modifying their diving practices to mitigate their risk. The cohort had completed 183,069 career dives, 57,822 of these since being diagnosed with their medical condition. There were 27 individuals who reported having decompression illness (25 of whom were subsequently diagnosed with a persistent foramen ovale), and two individuals who experienced an arrhythmia during diving., Conclusions: Some DAN AP members are diving with medical conditions which could potentially impact the safety of their diving. A minority modified their diving practices to mitigate the risk of their condition and approximately half sought specialist diving medical advice. The incidence of diving-related problems precipitated by known and managed pre-existing health conditions seems low but further studies of larger cohorts and incorporating fatality data would be necessary to confirm this. These results are limited by the 32% response rate and potential for bias towards selection of those most careful with their health.