Issue 45 / 1 December 2014

DURING the tense wait for updates on the status of critically injured cricketer Phillip Hughes who died last week, the media looked for angles to report, finding one in whether the time it took an ambulance to arrive had jeopardised the young player’s outcome.
    
Time is of the essence when responding to trauma, where even the long-heralded “golden hour” might be too long in some cases.

Time also has a vital role in other areas of medicine — when to take preventive measures in slowly developing problems, when to operate on a degenerating joint or when to start treatment for a chronic disease.

In this week’s issue of MJA InSight several articles touch on time, and the timing of medical interventions.

The time taken to receive emergency attention after out-of-hospital cardiac arrest is inversely correlated with survival, yet even for witnessed arrests mortality is high. A recent study from the US found that in 2012, despite improvements in the previous decade, only 8.3% of patients survived to hospital discharge.

Another US study, reported in one of our news stories this week, reveals some of the complexity in the timing of management for this most critical of emergencies. Based on the belief that early delivery of interventions such as endotracheal intubation, intravenous drugs and defibrillation would improve outcomes, paramedics have been trained and equipped to deliver these.

However, when the researchers compared survival and neurological outcomes for patients receiving these advanced techniques with the outcomes for those receiving only basic life support (chest compressions, bag valve mask ventilation and automated external defibrillation with rapid transport to hospital), the latter group did better. In response, an editorialist questioned whether the time taken to initiate and deliver advanced support might be better spent transporting the patient to hospital for definitive care.

For some diseases, there is a “window of opportunity” for treatment. It seems such is the case for optimal response to antiretroviral treatment for HIV. Our News in brief includes a summary of a study that found starting antiretroviral therapy within 12 months of HIV seroconversion provided the best chance of achieving a normal CD4+ count.

In a lively comment to mark World Aids Day (1 December) immediate past president of the Australian Society for HIV Medicine, Professor Edwina Wright, says one of the barriers to Australia’s goal of “virtual elimination of HIV transmission by 2020” is a reluctance to seek early diagnosis and treatment because of ongoing stigma associated with HIV and its risk factors.

Services such as Australia’s headspace, the National Youth Mental Health Foundation, have been established because of evidence that timely management of anxiety and depression in young people can minimise long term morbidity — another case of the window effect.

Another of our news stories indicates that we are missing the window for an important group of young people.

A longitudinal study of youth who had been in juvenile detention in the US found substantially elevated rates of psychiatric problems such as substance abuse and behavioural disorders 5 years later.

Experts told MJA InSight that the high prevalence of psychiatric disorders in youth detention centres was “a universal trend observed across the developed world” and that, in Australia, the fragmentation of health, community and criminal systems meant that young people get lost in the system, rather than accessing timely, ongoing and coordinated care.

This is reflected in the increased risk of death from substance abuse, risk-taking behaviour and suicide in young Australians who have been in contact with the criminal justice system.

When Phillip Hughes died late last week, the doctors who treated him reassured a shocked and saddened public that his injury was “catastrophic” and his emergency care had been competent and timely.

It’s a stark reminder that, even with the earliest application of great skill, some injuries and illnesses will be swift and savage.

These events make it all the more important that when we know we have a chance to make a difference with a timely intervention, we should seize it with both hands.

 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

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