BMJ  2005;331:E381 (17 September), doi:10.1136/bmj.331.7517.E381

Following are excerpts from Rapid Responses generated by this article, all of which can be read in their entirety at http://bmj.bmjjournals.com/cgi/eletters/330/7506/1475.—Editor

BMJ USA: Letter

RAPID RESPONSES FROM BMJ.COM

... The circumstance/conditions when treatments and diagnosis decisions were made in emergency care department and the circumstance when treatments diagnosis decisions were made by `panel members' who were not under heavy workload, nor having limited time for decision making, while even noticing the kind of diseases which they were evaluating, are significant different, and this is very likely to worsen the image of the emergency practice on diagnosis and on providing treatment for meningococcal disease (the health care professionals may have sufficient training but, for example, they may not have enough time to look after the patients).

The outcome/difference between original decisions on diagnosis and treatments and the `standard' decisions on diagnosis and treatments is at least due to 1) the skill of the emergency professionals on diagnosis and treatment of the disease, 2) the circumstance affects the diagnosis methods in an emergency health care department—with limited time to consult/observe the patients as children especially young children always could not express their feelings, and high workload.

As been described in the article, meningococcal disease may develop fast, and correct diagnosis the disease and the stage of the disease on time is crucial for the outcome of the patients. However there are many factors may affect the diagnosis and treatments provided by the health care professionals, thus in order to improve the health care service it is necessary to identify the key factors which influence the practice—are there enough doctors or now it is already the most cost-effective way to run the health care system?

Curtin University of Technology

Letter

The points raised are important. Reviewing clinical data on patients after the event cannot be the same as being there and of course there are many pressures on those at the coal face that we could not appreciate as we were not there. However our panel was not asked only to diagnose meningococcal disease, a relatively rare condition. They were asked to diagnose the time that children met the criteria for disease complication/organ failure. These criteria were very basic (as shown in table 1, full text, online) and for the following organ failures; shock, respiratory failure, coma, raised intracranial pressure, and a non-blanching rash. All these disease complications other than the rash are not only seen in meningococcal disease but are seen in other life threatening pediatric conditions. This is important; the lessons from this study are likely to be important for all acute pediatrics. It seems unlikely that the increased risk of death we found associated with children being looked after by non-pediatric trained doctors or junior doctors was simply due to medical staff being too busy to act appropriately. During this study we saw cases that were intensively monitored and had plenty of time lavished on them but inappropriate therapy delivered by those unfamiliar with managing sick children. Improved training and supervision would lead to better recognition of problems in less time, after all that is what experience is.

Great Ormond Street Hospital

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