INTRODUCTION Postoperative urinary retention requiring urethral catheterisation increases the risk of joint sepsis following arthroplasty. Spinal anaesthesia with opiate administration is used widely in lower limb arthroplasty. We sought to establish whether the choice of opiate agent had any effect on the incidence of postoperative retention and therefore the risk of joint sepsis. METHODS A total of 445 consecutive patients who underwent primary elective lower limb arthroplasty were reviewed retrospectively. Patients had general anaesthesia and femoral nerve block (GA+FNB), spinal anaesthesia and intrathecal fentanyl (SA+ITF) or spinal anaesthesia and intrathecal morphine (SA+ITM). RESULTS Urinary retention was observed in 14% of male and 2% of female patients with GA+FNB, 9% of male and 3% of female patients with SA+ITF, and 60% of male (p=0.0005) and 5% of female patients with SA+ITM. Men who experienced retention were older (68 vs 64 years, p=0.013) and had longer inpatient stays (6.7 vs 4.6 days, p=0.043). Fewer patients in the SA+ITM group required breakthrough analgesia (28% vs 58%, p=0.004). CONCUSIONS The use of ITM in men significantly increases the incidence of urinary retention requiring urethral catheterisation and subsequently increases the risk of deep joint sepsis. Its use should be rationalised against the intended benefits and alternatives sought where possible.

Non-anaesthetic practitioners have a higher tracheal intubation failure rate during pre-hospital RSI. This likely reflects a lack of training opportunities and infrequency of clinical experience. Strategies to improve pre-hospital airway management are required.

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Climbing incidents present a myriad of challenges to prehospital teams. Management decisions are often influenced by factors including difficulties in accessing patients, limited available resources and safe egress from scenes. This case illustrates the importance of an adaptable and innovative approach to scene management and clinical decision making in such cases.

The experiences of an Emergency Medicine trainee in pilot programme at a regional Air Ambulance in the UK compared favourably with the results of formal pilots of the IBTPHEM programme conducted at other centres. The IBTPHEM assessment tools are appropriately designed and sufficient in number to ensure that fulfilment of the curriculum elements can be recorded and trainee development monitored. Areas for future developments in training and support, notably in curriculum areas regarding the management of obstetric prehospital emergencies, are suggested.