Sand aspiration: a case report and review of the radiological features and management.

We report a case of severe sand aspiration in association with near-drowning, which led to respiratory failure secondary to the acute respiratory distress syndrome, necessitating mechanical ventilation, repeated therapeutic bronchoscopic lavage, and a stay in the intensive care unit that exceeded one month.

Viral gastroenteritis--a danger to the patient, a danger to the staff.

Viral gastroenteritis is usually a mild, self-limiting illness. We report a case of a previously well 74-year-old woman who suffered a grave complication of this common condition, and caused a significant outbreak of illness amongst staff involved in her care. This case highlights the risks of Hospital Acquired Infection and raises important infection control issues. It illustrates the hazards associated with exposure to potentially infectious secretions and presents a clear message to medical and nursing staff involved in the care of the acute surgical emergency.

Survey of abuse and violence by patients and relatives towards intensive care staff.

A postal survey of senior nurses in intensive care units in England and Wales was conducted. The aim was to ascertain the frequency of abusive and violent behaviour by patients and relatives towards intensive care staff, discover the perceived causes, effects and documentation of such behaviour and define the current and proposed security arrangements for intensive care units. Response rate was 94%. During the study period, verbal abuse of nurses by patients and by relatives occurred in 87% and 74% of intensive care units, respectively. The relevant figures for doctors were 65% and 59%, respectively. Nurses experienced physical abuse by patients and by relatives in at least 77% and 17% of intensive care units, respectively (doctors 38% and 8%). Illness was the main perceived cause of offences by patients whereas 'distress' (45%), alcohol (24%), sociopathic behaviour (27%) were the main putative causes amongst relatives. Whilst 43% of intensive care units have no security system at the door, staff awareness, training and communication skills may be the principle tools in reducing the frequency and consequences of violent and abusive behaviour. This survey probably underestimates the problem.

Presentation of diaphragmatic herniae during pregnancy and labour.

We report two cases of pregnancy-related diaphragmatic hernia. Case one was a 36-year-old woman who presented in her ninth pregnancy, after eight vaginal deliveries. Eight months after a stab wound to the chest, she developed persistent vomiting. The diagnosis was made by chest X-ray after a contralateral central line had been inserted for parenteral nutrition. A 6 x 4 cm stab-induce defect in the diaphragm was repaired. Close by was a second healed diaphragmatic stab wound. Case two involved a 32-year-old woman with a history of repaired childhood diaphragmatic hernia. She developed atypical shoulder and precordial chest pain during labour. Delivery was achieved by the vaginal route, ventouse-assisted. Persistent pain and vomiting led to insertion of a nasogastric tube and the diagnosis was made on the subsequent chest X-ray. The omentum was very adherent to the lung and could only be mobilised via a thoracotomy, at which significant air leaks occurred but settled rapidly. The difficulties of diagnosis are discussed along with the embryology, mechanisms and management of this condition.