McQuiston T. A. C. (1936) Poisoning with sodium nitrite. Lancet 2, 1153-1154. Polson C. J. & Tattersall R. N. (1969) Clinical Toxicology 2nd Ed, pp. 109-116. Pitman Medical, London. Shesser R., Mitchell J. & Edelstein S. (1981) Methaemoglobinaemia from isobutyl nitrite preparations. Annals of Emergency Medicine 10, 262-264. Walley T. & Flanagan M. (1987) Nitrite induced methaemoglobinaemia. Postgraduate Medical Journal 63, 643-644.
We agree with the authors that the inclusion of the accident and emergency (A&E) senior house officer's (SHO) radiological diagnosis on the X-ray request form facilitates the prompt identification of incorrect radiological diagnosis.We have been encouraging this practice in our department for some time, the princi- pal problem appears to be ensuring that all doctors comply.At St Peters Hospital radiographs of all patients discharged from A&E are reviewed daily at 8 a.m. by the A&E consultant or registrar.During a 2-month period we audited the effect of the radiological review by senior and middle grade A&E staff.A total of 3116 radiographs were reviewed (mean 51 radiographs per day).Of these, 2397 (79.6%) were normal and 604 (19.4%) were correctly diagnosed as abnormal by the doctor who first saw the patient.The review identified a further 38 (1.2%) missed positive radiological diagnoses.A further 75 (2.4%)abnormal radiological diagnoses that went identified by the review were reported by the radiologist.Although the number of abnormalities missed by the SHO and identified at the review were small, some potentialy serious abnormalities were identified including a depressed skull fracture and tibial platau fracture.By contrast, most of the abnormalities missed in A&E and detected only by the radiologist were not of immediate clinical significance.The daily review of radiographs by senior and middle grade A&E staff is considered to have other benefits.It provides an opportunity for teaching and for the audit of satisfactory completion of X-ray request forms.The review could be expanded easily to audit the use of radiology in A&E.However, it is dependent on the availability of senior and middle grade staff time for this purpose.We find that the review of radiographs in A&E can be completed in opproximately 30 min each morning.
deliberate self-harm (DSH), damage to property, verbal abuse, threatening behaviour and physical attacks on persons or on staff (Shader et al.
Assaults on women have been the subject of many studies. (Gayford, 1979; Steinmetz, 1980; Knopp, 1984; Tanne, 1992). The concept of the 'battered wife' is widely accepted (Gayford, 1979). Organizations exist to offer help, counselling and places of safety to victims. However, recent Chief Constables' reports have highlighted an increase in the number of violent crimes perpetrated by women. Therefore, a study was instigated to assess all female victims of assault that attended the Accident and Emergency Department (A&E) of St James' Hospital, to ascertain if violence to women, by women, is a significant problem.
During 1987 a system for the computer-aided diagnosis of abdominal pain was introduced on a trial basis in seven district health authorities in the North Western (NW) Region. Despite good reports of the system from other areas, by the end of a 12-month period only two of the seven districts continued to use it in the routine management of patients. A study was undertaken to determine the difficulties that had been encountered and the way in which these had hindered successful implementation of the system. Information was obtained by interview with key personnel involved in the trial, which included the chief executive in each district, a consultant designated as responsible for the system and clerical staff. The study identified three main factors undermining the implementation of the system: a lack of consultant support; the negative attitude of junior doctors; and inadequate clerical support.
Patients with haemorrhagic shock of all degrees present to accident and emergency (A&E) departments regularly. This study examined 43 such patients who presented to one department over a 14-week period. The adequacy of their fluid replacement was judged in comparison with Advanced Trauma Life Support (ATLS) recommendations according to the degree of shock they appeared to have on presentation. The study found that more training may be required on the appropriate recognition and treatment of haemorrhagic shock.
state that bony causes produced static winging which is present at rest and may be accentuated by certain passive shoulder movements.Cooley & Torg (1982) described what they termed 'pseudowinging' of the scapula produced by subscapular osteochondroma.They stressed that although subtle points of differentiation might allow the diagnosis to be suspected, the condition was liable to be confused with classical winging produced by serratus anterior paralysis.Indeed, in the case described, the latter diagnosis had initially been made by two specialists and spontaneous resolution predicted.In the case described above, radiology alone led to the correct diagnosis.The possibly misleading acute onset of symptoms was suggestive of a neurological cause.Also the winging was dynamic in that it was more prominent on asking the patient to push against a wall with both outstretched arms.A plea is made for considering X-rays as part of the basic assessment of the apparently winged scapula.
The survey was undertaken in order to review the circumstances surrounding accidents that precipitated burn injuries which, presented to an inner city accident department. Figures are available of the number of bums seen in Plastic Surgical units (Bumcare Symposium, 1986), and of the number of burns occurring at home (Consumer Safety Unit, 1986), however, there is no published work documenting patients with bum injuries attending an A&E department in this country, except indirectly in articles dealing with injuries to particular regions of the body, e.g. the hand (Cutting et al., 1987), or with particular causes and types of burns (Bull et al., 1964).
Sir As a mild to moderate cyclist, (65 miles per week, mostly with a helmet!) I would like to question M. W. Cooke's suggestion that cycle helmet wearing should be compulsory. Firstly, consider accident cause. In a series of 394 cycle injuries presenting to an A&E department 63% were caused by the cyclist's inability to control the bike no vehicle or other factors were involved. We need to educate cyclists to ride properly, particularly the children. Secondly, in the above study only 26% were involved in a collision with a motor vehicle. In a separate study of head injuries to cyclists (Worrell, 1987) 38% were caused by collision with a motor vehicle, but 58% just fell off. Agreed, a collision will produce a more serious injury, but we must educate motorists to look out for cyclists, and also to enforce existing speed limits (E = 1 x 2 MV-2). Why should cyclists be compelled to protect themselves from the illegal acts of others? Thirdly, this law would be totally unenforceable, a fact recognized by a recent meeting of the House of Commons Select Committee on Transport, and surprisingly backed by the Department of Transport! Fourthly, he may not be aware that the BS for helmets is designed in such a way that the helmet must withstand an impact on an angled edge, which makes the helmet hot and heavy to wear. The 'comfort factor' is one of the most important points in helmet use; those which are poorly ventilated and heavy will not be worn. Even serious racers who agree helmets are needed do not always wear them, viz: on the mountain stages of the last Tour de France, where extremes of effort and heat are encountered. Yes, a helmet will help protect your head, but we should proceed by education rather than legislation.
Avulsion fractures involving the insertion of the tendo achilles into the calcaneus have been reported previously (Lowy, 1969; Protheroe, 1969). We wish to describe a case which presented clinically as a ruptured tendo achilles and the correct diagnosis was only made on the basis of a radiograph. We wish to stress the need for radiographic assessment of suspected tendo achilles ruptures in the elderly.
A summary of injuries sustained by 340 sportsmen over 9 successive weekends from 16 November 1991 to 12 January 1992 attending an accident and emergency (A&E) department is presented. Most injuries occurred in young males usually as a result of soccer or rugby. Sixty-seven per cent of patients were discharged with no further followed up in hospital. Seventy-two per cent of patients were X-rayed, 33% of X-rays showed a fracture or dislocation. A total of 193 attendees received minimal treatment, (defined as discharge with advice only, simple analgesia or strapping only with no hospital follow-up) and of these 152 were X-rayed. A total of 100 patients who received minimal treatment were selected randomly by computer to receive a follow-up letter asking about certain issues relating to their care in the A&E department. Most patients felt that the A&E Department was the most appropriate source of treatment for their sports injury, and over half attended specifically for an X-ray examination. Despite the doctors view that many of these minor injuries could have been self-treated, few patients felt able to treat future similar minor injuries themselves. They were, however, more likely to go elsewhere for treatment on subsequent occasions.
Over a 6-month period a record was kept of all patients presenting to the accident and emergency (A&E) department with nasal injuries. The results of the nasal radiographs were analysed to gauge their benefit. It was found that there was poor correlation between the radiological findings and the presence of external deformity, the latter determining the decision to carry out treatment. Routine radiographs of the nose are unnecessary in patients with nasal trauma.
Letters to the Editor 383 helicopter were for secondary missions, the helicopter being deployed after the land ambulance had arrived at the scene.It is clear from the work with the West Midlands that the best effective deploy- ment of an air ambulance is as a primary resource replacing a land-based ambulance resource.The only absolute measure of evaluating the emergency response care provided by the ambulance service will be a clearly demonstrated reduction in morbidity and mortality and this can only be shown with reference to formal trauma scoring in particular TRISS methodology.
Medical education, by necessity, frequently emphasizes the resuscitation and relief of life-threatening conditions in the severely injured patient. The increased use of seat-belt retraints has meant that high speed automobile collisions may not necessarily result in major external injury if the occupants are well supported (Dudley, 1986). In such instances, trauma may be sustained as a result of the spine and viscera continuing to move forward following impact. Examples of such injuries are mesenteric detachment of the gut, ruptured solid organs and distraction fractures of the lumbar spine (Dudley, 1986). A case history illustrating several features which may alert the attending clinician to the presence of underlying, initially occult, clinically significant injury is described.
A 30-year-old man sustained a dirty irregular V-shaped laceration to the vertex of his scalp on diving head first into a freshwater pond. There was no associated injury or loss of conciousness. No fracture or foreign bodies were seen on the initial skull X-ray. The wound was cleaned and sutured at a nearby accident and emergency (A&E) department. Two days later he returned complaining of pain over the scalp wound. He was admitted to hospital and antibiotic treatment begun. Forty-eight hours later he was transferred to the local neurosurgical unit. By this time his scalp had become extensively cellulitic with surgical emphysema. The wound was oozing purulent material. He was pyrexial at 39 celsius, with cervical and occipital lymphadenopathy. He was neurologically intact. A CT head scan confirmed marked soft-tissue swelling of the scalp and face, with extensive sub-galeal air and foreign material. There was no skull fracture. (Fig. 1) At operation a thorough debridement was performed excising necrotic galea and periosteum to healthy margins. Post-operatively his chemotherapy included penicillin 2 g 4 hourly, gentamicin and metronidazole. Bacteriological culture indi-
To assess whether an accurate diagnosis of pneumothorax can be made on a single chest film, 233 pairs of inspiratory (I) and expiratory (E) chest films taken in an accident and emergency (A&E) department for suspected pneumothorax were reviewed by two A&E officers and three radiologists. The films were assessed for the presence of pneumothorax by viewing the I film in isolation and, after an interval, by viewing the paired I and E films together. Fifty-four of the patients had a pneumothorax. The five observers missed 23 pneumothoraces (8.5% of total) on the I film alone which were correctly diagnosed on the paired I and E films, the three radiologists missed 10/162 pneumothoraces on the I film alone which were correctly identified on the I and E films (6%) and the two A&E officers 13/108 (12.5%). The use of a single inspiratory chest film for suspected pneumothorax could result in pneumothoraces being missed, particularly by less experienced observers and therefore we believe that paired I and E films should continue to be used routinely for suspected pneumothorax.
Despite the frequency with which whiplash injuries present to accident and emergency (A&E) departments, there lacks an objective investigation to define the severity of the initial injury or the morbidity that may ensue. Following reports on the effectiveness of isotope bone scanning for soft tissue and ligament injuries a study was undertaken of isotope scanning of whiplash injuries. The objectives of the study were to isolate the anatomic site of the injury and to quantify the severity of the injury with relation to the concentration of isotope uptake and subsequent morbidity.
Anaesthesia of an entire finger is a routinely performed procedure at the General Practice and the emergency room, and by many surgical disciplines. The method according to Oberst is the most-performed procedure to do this. The transthecal digital block is a new method that can be easily learned. This technique results in less discomfort for patients and doctors and leads to few complications.
The purpose of this study was to assess the ability of work-related stress, and other work environment characteristics that might affect stress, to predict work satisfaction among senior house officers (SHOs) during accident and emergency (A&E) training. Questionnaires were returned by 365 SHOs, who indicated their year in training, the number of hours worked per week, the type of training hospital, the number of new A&E attendances per year, the ratios of patients and consultants to SHOs at their training hospitals and their likelihood of specializing in A&E. They also completed inventories measuring work-related stress, task and role clarity, work group functioning and work satisfaction. Scores on the satisfaction scale served as the dependent variable in a multiple regression equation. Using an alpha level of 0.05, a significant relationship was detected between satisfaction and the 10 independent variables (P = 0.0001). Direct relationships between task and role clarity (P = 0.0001) and work group functioning (P = 0.0002) were significant, as were inverse relationships between stress (P = 0.0001) and the number of new attendances (P = 0.0321). Management practices, such as orientation sessions, that define tasks and roles, enhance work group cohesiveness and mitigate against stress, should result in increased satisfaction among SHOs.
