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Recent changes in medical training prompted by Modernising Medical Careers and the New Deal requires a more structured, competency based training programme. This paper describes the development of such a programme in an emergency medicine department of a teaching hospital. It describes the process of design and the various aspects incorporated to develop a balanced system of training, appraisal, and assessment.

To evaluate a system of prehospital thrombolysis, delivered by paramedics, in meeting the national service framework's targets for the management of acute myocardial infarction.Prospective observational cohort study comparing patients with suspected acute myocardial infarction considered for thrombolysis in the prehospital environment with patients treated in hospital.The catchment area of a large teaching hospital, including urban and rural areas.201 patients presenting concurrently over a 12 month period who had changes to the electrocardiogram that were diagnostic of acute myocardial infarction or who received thrombolysis for suspected acute myocardial infarction.Time from first medical contact to initiation of thrombolysis (call to needle time), number of patients given thrombolysis appropriately, and all cause mortality in hospital.The median call to needle time for patients treated before arriving in hospital (n=28) was 52 (95% confidence interval 41 to 62) minutes. Patients from similar rural areas who were treated in hospital (n=43) had a median time of 125 (104 to 140) minutes. This represents a median time saved of 73 minutes (P0.001). Sixty minutes after medical contact 64% of patients (18/28) treated before arrival in hospital had received thrombolysis; this compares with 4% of patients (2/43) in a cohort from similar areas. Median call to needle time for patients from urban areas (n=107) was 80 (78 to 93) minutes. Myocardial infarction was confirmed in 89% of patients (25/28) who had received prehospital thrombolysis; this compares with 92% (138/150) in the two groups of patients receiving thrombolysis in hospital.Thrombolysis delivered by paramedics with support from the base hospital can meet the national targets for early thrombolysis. The system has been shown to work well and can be introduced without delay.

In the Angus region of Scotland, we have used mobile telemetry to facilitate pre-hospital thrombolysis by paramedic staff. An initial survey demonstrated that connection could be achieved in all but three locations. In the first year of operation, 229 contacts were received. Communication between the ambulance and the base station failed on four occasions (2%). Problems with transmission of an electrocardiogram (ECG) were encountered on 37 occasions (16%). The median time for acquisition and transmission of an ECG was 22 min. This compares with a median time of 59 min for first ECG in a control group from similar locations, who were assessed in hospital. Telemetry offers essential back-up to paramedics adopting a challenging and extended role. Strategies can be developed to deal with signal strength and equipment failure.

Objectives: To determine the publication rate of abstracts presented by UK emergency physicians at major emergency medicine meetings, and to identify the site of publication of papers. Method: All abstracts presented to the annual scientific meetings of both the British Association of Emergency Medicine and the Faculty of Accident and Emergency Medicine between 2001 and 2002 were identified retrospectively from conference programmes. To identify whether the work relating to the abstract had been published in a peer-reviewed journal, the Medline database (Ovid interface) was searched using the first and last authors as well as key words from the abstract. Results: Of the 404 abstracts identified, 124 (30%) had been published as full articles. For abstracts presented in the oral sessions, 83 (57%) resulted in publication. A range of journals accepted papers for publication. Conclusion: The abstract-to-publication ratio for UK emergency medicine is lower than for other specialties, but broadly similar to emergency medicine in the US and Australia.

To investigate if triage nurses could safely apply a set of clinical criteria, removing hard collars and spinal boards at initial triage assessment.The Nexus clinical decision rules were applied by trained triage nurses to patients who attended the department with cervical collars and/or on spinal boards. Patients were excluded if they were felt to be in need of immediate medical assessment. Data were collected on the time to nursing assessment, time to medical assessment and time spent restrained. Patients were followed up until discharge and their radiological diagnosis confirmed. Hospital records were checked to ensure that no patients re-presented with injuries that had been missed at initial assessment.In total, 112 patients were included in the study. Clinical criteria were met in 59 patients and their collar removed at triage assessment. For low risk patients, this reflects a mean reduction in time spent restrained of 23.3 minutes (p0.005; 95% confidence interval 20.18 to 26.54). No patient who had a collar removed was found to have a significant injury.Simple criteria can be applied by accident and emergency triage nurses to allow safe removal of cervical collars and spinal boards. The reduced time patients spent immobilised represents an important improvement in patient care.

Objectives: To investigate the frequency and pattern of injury in front seat passengers as compared with drivers, in Scotland. Methods: Using the Scottish Trauma Audit Group (STAG) database from 1994 to 2000, a search for injuries to eight anatomical body regions was performed. Injuries were identified and selected by their abbreviated injury score code. A comparison of injury frequency between drivers and front seat passengers was then made. Results: There were 4189 drivers and 954 front seat passengers included in the study. Mortality was higher in the “front seat passengers” group (6.6% compared with 5.3% p = 0.13). Seven of the eight body regions selected showed higher rates of injury in front seat passengers. There were significantly more injuries to cervical spine (6.0% compared with 3.3% p⩽0.001), chest (41.4% compared with 29.0% p⩽0.001), and lumber spine (7.4% compared with 5.2% p⩽0.001) in front seat passengers. Conclusions: Front seat passengers are at increased risk of injury relative to drivers in actual road traffic accidents as recorded in the STAG database. This contradicts crash test data, which suggest drivers are less well protected than front seat passengers in laboratory conditions.