See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/24350218 Ethics and analgesia Article in Emergency Medicine Journal · June 2009 Source: PubMed CITATIONS READS 0 12 3 authors: Giles Cattermole Colin A Graham 54 PUBLICATIONS 175 CITATIONS 352 PUBLICATIONS 2,254 CITATIONS King's College Hospital NHS Foundation Trust SEE PROFILE The Chinese University of Hong Kong SEE PROFILE Timothy H Rainer The Chinese University of Hong Kong 296 PUBLICATIONS 5,216 CITATIONS SEE PROFILE All content following this page was uploaded by Timothy H Rainer on 16 December 2013. The user has requested enhancement of the downloaded file. Downloaded from emj.bmj.com on March 8, 2013 - Published by group.bmj.com PostScript LETTERS Harms of targets Emergency medicine as a specialty has had to embrace performance targets. Three years on, we feel a new pressure. ‘‘Two hour care’’ beckons. I think also that we are now seeing the harms of ‘‘target driven care’’, as I have recently written in the BMJ.1 Following this publication I have received emails from a variety of specialists from around the UK. All those from clinicians are supportive. I seem to reflect the mood of many. Some of my emergency department colleagues in the south-west of England have also written in support. Maybe others disagree, are too engaged in maintaining performance, or just didn’t see it. This is the strength of our specialty. Our challenge is to preserve and teach holistic care within the targets given to us. However, of most concern are the comments I have had from our trainees. Many agree, also feeling themselves the harms that targets are doing. Their clinical practice has changed and, for some, enjoyment has gone. They are concerned about where emergency medicine is going. With ‘‘target-driven care’’ the clock drives and the fulfilling practice of unusual diagnosis and holistic care can go. If this happens, they may go too. If we lose our trainees, we lose our future. How do we care for them? J N Rawlinson Correspondence to: Mr J N Rawlinson, Emergency Department, Bristol Royal Infirmary, Bristol BS2 8HW, UK; nigel.rawlinson@bristol.ac.uk accurate surgical diagnosis, therefore removing any ‘‘clinical equipoise’’ necessary ethically to justify a randomised placebo controlled clinical trial. The Declaration of Helsinki states ‘‘extreme care must be taken in making use of a placebo-controlled trial and that in general this methodology should only be used in the absence of existing proven therapy’’ and ‘‘considerations related to the well-being of the human subject should take precedence over the interests of science and society’’. The well-being of these subjects included the provision of adequate analgesia; they should not have been given placebo, and they should not have been studied to answer a question that has already largely been answered. Second, the study was powered only to detect a change in pain as measured by a visual analogue score, rather than to detect a change in diagnostic accuracy. No difference in clinical signs was found between the morphine and control groups, but this is likely to be a type II error as, with only 71 patients enrolled, it is unlikely that the study was powerful enough to detect such a difference. Patients were therefore subjected to a trial in which half suffered unnecessary pain, but which was sufficient only to assess whether morphine relieves pain or not. Even if some still believe—despite the evidence3— that morphine might mask physical signs, no one disputes that morphine relieves pain. Ethical approval by a local research ethics committee does not necessarily imply that a study really does meet the scientific and ethical standards demanded by the Declaration of Helsinki, nor therefore by readers of the Emergency Medical Journal. Competing interests: None. Accepted 29 October 2008 G N Cattermole, C A Graham, T H Rainer Emerg Med J 2009;26:389. doi:10.1136/emj.2008.067975 Accident and Emergency Medicine, Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China REFERENCE 1. Rawlinson N. The harms of target driven care. BMJ 2008;337:a885. http://www.bmj.com/cgi/content/full/ 337/jul17_3/a885. Correspondence to: Dr G N Cattermole, Accident and Emergency Medicine, Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China; gncattermole@cuhk.edu.hk Competing interests: None. Ethics and analgesia We were interested to read the article by Amoli et al1 confirming that morphine reduces pain in patients with acute appendicitis without affecting diagnostic accuracy. Although the trial was said to be carried out according to the Declaration of Helsinki,2 we were concerned that patients in the emergency department with a clinically convincing presentation of acute appendicitis sufficient to warrant booking for appendicectomy were randomised to receive morphine or placebo normal saline. It may be that standard practice in the study institution currently is not to give any analgesia to patients waiting for appendicectomy, but this was not stated in the paper. Even so, the authors make reference to the wealth of published evidence demonstrating that morphine does not hinder Emerg Med J May 2009 Vol 26 No 5 Accepted 29 October 2008 effectiveness of ketamine for procedural sedation in the emergency department.1 A point of concern was that 77% of patients in their sample received propofol, midazolam or ketamine at a dose that depressed their conscious level such that they were unresponsive to verbal stimulus (scoring ‘‘P’’ or ‘‘U’’ on the AVPU scale). Furthermore, 15. 9% of all patients experienced some form of complication. They concede a high complication rate but do not appear to consider that the level of ‘‘sedation’’ administered in the majority of all cases is equivalent to a general anaesthetic. The ‘‘P’’ of the AVPU scale is considered to correspond to a Glasgow Coma Score (GCS) of 8,2 at which a patient is at risk of loss of airway reflexes. The recommendation put forward by the Intercollegiate Working Party on safe sedation practice considers deep sedation as a state where a patient does not respond to verbal or simple physical stimuli, with consensus that its supervision requires the same level of training and skill as general anaesthesia.3 We therefore have to question whether the degree of depression of consciousness achieved in this cohort might adversely affect the level of care offered. It would be interesting to ascertain the level of anaesthetic and life support training undertaken by those staff performing the sedation for these procedures, given that a proportion of the SHO workforce will constitute FY2 doctors and around 50% of those who are ACCS ST doctors will be ST1. Neither of these groups can be assumed to have achieved basic anaesthetic competencies.4 There is a clear case for further regulating procedural sedation in the emergency department rather than simply introducing new and alternative agents. N M Sibbald,1 M J Jackson,2 L A Howie2 1 Department of Intensive Care Medicine, Salford Royal NHS Foundation Trust, Salford, UK; 2 Department of Anaesthesia, Trafford General Hospital, Urmston, Manchester, UK Correspondence to: Dr N M Sibbald, Department of Intensive Care Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK; nataliesibbald@ doctors.net.uk Competing interests: None. REFERENCES 1. 2. 3. Amoli HA, Golozar A, Keshavarzi S, et al. Morphine analgesia in patients with acute appendicits: a randomised double-blind clinical trial. Emerg Med J 2008;25:586–9. World Medical Association (WMA). Declaration of Helsinki. Ethical principles for medical research involving human subjects. Ferney-Voltaire: WMA, 2004. Brewster GS, Herbert ME, Hoffman JR. Medical myth: analgesia should not be given to patients with an acute abdomen because it obscures the diagnosis. West J Med 2000;172:209–10. How deep is your sedation? We read with interest the paper by Vardy et al on the audit of the safety and Accepted 4 November 2008 REFERENCES 1. 2. 3. 4. Vardy JM, Dignon N, Mukherjee N, et al. Audit of the safety and effectiveness of ketamine for procedural sedation in the emergency department. Emerg Med J 2008;25:579–82. McNarry AF, Goldhill DR. Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma Scale. Anaesthesia 2004;59:34–7. Academy of Medical Royal Colleges. Implementing and ensuring safe sedation practice for healthcare procedures in adults. Report of an Intercollegiate Working Party chaired by the Royal College of Anaesthetists. London: Academy of Medical Royal Colleges, 2001. McGowan A. Modernising medical careers: educational implications for the emergency department. Emerg Med J 2006;23:644–6. 389 Downloaded from emj.bmj.com on March 8, 2013 - Published by group.bmj.com Ethics and analgesia G N Cattermole, C A Graham and T H Rainer Emerg Med J 2009 26: 389 Updated information and services can be found at: http://emj.bmj.com/content/26/5/389.2.full.html These include: References This article cites 2 articles, 1 of which can be accessed free at: http://emj.bmj.com/content/26/5/389.2.full.html#ref-list-1 Email alerting service Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article. 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