The need for undergraduate education in critical care. (Results of a questionnaire to year 6 medical undergraduates, University of New South Wales and recommendations on a curriculum in critical care)

One hundred and fifteen final year medical students of the University of New South Wales (UNSW) who were gathered together for mid-year lectures were asked to respond to a questionnaire which sought their perceptions of their knowledge of and competence in those skills required to prevent loss of life of patients with acute reversible life-threatening illnesses. There were 101 responders (88% response rate). A high proportion of students lacked practical experience of many of the skills or had not witnessed some procedures. They lacked confidence in their ability to manage acute emergencies. The results were similar to those in a separate study of the perceptions of New South Wales interns and resident medical officers of their competencies at the beginning of their intern year. The authors concluded that undergraduate education in critical care had not kept pace with the rapid evolution of critical care practice and describe the development and implementation of an explicit vertical and horizontal curriculum of critical care in the undergraduate curriculum of the UNSW.

Open air rock concert: an organised disaster.

OBJECTIVE: To describe the planning and implementation of health care provision at a mass gathering, and to describe the conditions treated at such an event. SETTING: When approximately 93,000 fans gathered outdoors in Sydney's Centennial Park, a natural reserve, for Australasia's largest ever outdoor rock concert, there was an obvious potential for medical disaster. PATIENTS: At most disasters or mass gatherings, accurate patient numbers and details are not available, but an organised patient data collection system allowed the case load at this event to be clearly defined. This showed that 450 patients were attended to by the first aid teams. Triage identified 36 of these as having conditions serious enough to require admission to the medical area. Seven of these patients were ultimately transferred to hospital. RESULTS: A brief practical outline is provided of the medical planning for the concert, detailing the staff and equipment, how to avoid potential problems, the use of voluntary organisations, and specific site organisation. Key points in the medical planning, organisation and practicalities, especially those which are vital to any disaster response, are highlighted. CONCLUSION: Solutions to recurrent problems experienced by medical personnel involved with mass gatherings or disasters are suggested. The lack of practice in implementing a multiple casualty or disaster plan may be remedied by organised responses to mass events.

Aminophylline in the emergency department. Maximizing safety and efficacy.

An experimental technique designed to predict theophylline doses needed to attain therapeutic theophylline concentrations in 43 emergency department (ED) patients was compared with a standard conventional regimen in 46 ED patients. The experimental protocol utilized a computer-assisted dosage prediction program that incorporated baseline theophylline concentration rapidly obtained using a bedside assay. The standard protocol used conventional loading and infusion rates, as well as an estimate of time of last theophylline dose based on patient history. Plasma theophylline concentrations, estimated 1 and 6 hours after commencement of aminophylline therapy in each regimen, were compared. The experimental protocol was equally rapid but much more accurate in achieving targeted theophylline concentrations. Experimental dosage prediction was associated with a higher proportion of theophylline concentrations in the therapeutic range at 1 (81 percent vs 26 percent; p less than 0.001) and 6 hours (91 percent vs 37 percent; p less than 0.001). There was a trend toward fewer toxic concentrations recorded at 1 (0 percent vs 7 percent; p = 0.27) and 6 hours (0 percent vs 10 percent; p = 0.08). This protocol, which was performed quickly and without difficulty by residents in a busy hospital ED, offers an opportunity to improve the efficacy and decrease the toxicity of theophylline use in asthma emergencies.

Fat embolism--a review.

The subject of fat embolism is of recurring interest to those managing trauma. This article covers the topic of fat embolism in general, and presents a case of fulminant fat embolism syndrome which highlights the importance of clinical expertise, and whatever technological aids are available to diagnose and appropriately treat this relatively rare, but highly significant form of the syndrome. Fulminant fat embolism syndrome has a very high mortality and should be watched for in patients who have experienced major trauma.

Successful limb salvage with prostaglandin infusion: a review of ergotamine toxicity.

OBJECTIVE: A case of severe acute peripheral arterial insufficiency secondary to ergotamine toxicity treated successfully with intravenously administered prostaglandin is presented to highlight the features of this condition and to demonstrate the efficacy of treatment with prostaglandin infusion. CLINICAL FEATURES: A 35-year-old unemployed Caucasian woman with a background of polypharmacy abuse and recurrent migraines presented to St Vincent's Hospital Emergency Department with limb-threatening ischaemia of both legs secondary to chronic ergotamine overuse. INTERVENTION AND OUTCOME: A prostaglandin infusion was started and a dramatic and rapid improvement of her peripheral circulation occurred within six hours. CONCLUSION: Ergotamine toxicity is an uncommon but well documented cause of peripheral vascular insufficiency that should be recognised and treated aggressively because its sequelae can be disastrous. Intravenously administered prostaglandin proved to be successful in this case and is a logical choice as first-line therapy for ergotamine toxicity.

Lightning strikes.

Lightning strike is a natural phenomenon with potentially devastating effects. The physics of lightning strike and the physiology of lightning injury are discussed. Three cases are reported and the clinical features are described. Aspects of the management of such patients are discussed with particular emphasis on assessment and resuscitation in the Emergency Department.

Overdose with chloral hydrate: a pharmacological and therapeutic review.

The purpose of this review is to highlight the toxicity of chloral hydrate and to review the management of overdoses with chloral hydrate. Three patients are presented in whom life-threatening cardiac arrhythmias dominated the clinical presentation. These arrhythmias were resistant to standard antiarrhythmic therapy. Also, we have reviewed selected features in eight patients who took overdoses of chloral hydrate who were admitted to an intensive care unit between 1981 and 1988. The pharmacology and toxicology of chloral hydrate are discussed with particular reference to the cardiac arrhythmias that are seen with overdosage. A proposed management scheme is detailed, including intravenously-administered propranolol as the preferred first-line antiarrhythmic agent. A case may be made for the discontinuation of the usage of chloral hydrate.

Sea snake envenomation at Bondi.

A rare occurrence of serious envenomation by a sea snake in the waters of a popular Sydney beach is reported. A 19-year-old man was bitten while swimming, then quickly developed major proximal neuromuscular complications. Prompt, effective first aid (firm limb bandaging and splinting), transport to hospital, and administration of antivenom led to the rapid, full recovery of the patient who was discharged from hospital on the following day.