Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique.

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

General practice: a secondment from emergency medicine--so what!

The Joint Committee for Higher Medical Training has issued a core curriculum for training in accident and emergency medicine. This article highlights some of the knowledge, skills, and attitudes one may usefully gain from a period of 6-12 months in general practice and how this can be integrated and adapted to a career in emergency medicine.

Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern?

OBJECTIVES: To investigate how well junior doctors in accident and emergency (A&E) were able to diagnose significant x ray abnormalities after trauma and to compare their results with those of more senior doctors. METHODS: 49 junior doctors (senior house officers) in A&E were tested with an x ray quiz in a standard way. Their results were compared with 34 consultants and senior registrars in A&E and radiology, who were tested in the same way. The quiz included 30 x rays (including 10 normal films) that had been taken after trauma. The abnormal films all had clinically significant, if sometimes uncommon, diagnoses. The results were compared and analysed statistically. RESULTS: The mean score for the abnormal x rays for all the junior doctors was only 32% correct. The 10 junior doctors were more experience scored significantly better (P < 0.001) but their mean score was only 48%. The mean score of the senior doctors was 80%, which was significantly higher than the juniors (P < 0.0001). CONCLUSIONS: The majority of junior doctors misdiagnosed significant trauma abnormalities on x ray. Senior doctors scored well, but were not infallible. This suggests that junior doctors are not safe to work on their own in A&E departments. There are implications for training, supervision, and staffing in A&E departments, as well as a need for fail-safe mechanisms to ensure adequate patient care and to improve risk management.

Cervical spine imaging in trauma patients: a simple scheme of rationalising arm traction using zonal divisions of the vertebral bodies.

OBJECTIVE: To evaluate the effectiveness of arm traction for cervical spine imaging in trauma patients and devise a scheme to predict the probability of visualising the C7/T1 level in trauma patients. METHODS: 98 trauma patients were studied. Each vertebral body was divided into three equal horizontal zones, the disc space between vertebral bodies being equivalent to one zone. The fifth cervical vertebra was used as the starting level (zone 1). Zones obtained pre and post arm traction on the lateral cervical spine radiographs were recorded. Results were analysed to show the probability of imaging the lower cervical spine, including the cervico-thoracic junction. RESULTS: If the initial film showed less than zone 10 (mid-C7 vertebra), the probability of showing zone 13 (upper body of T1) with arm traction was only 7.7%, that is, one success in every 13 pulls; or conversely, 12 failures in every 13 pulls. CONCLUSIONS: Unless an initial cervical spine radiograph includes the upper one third of the body of the C7 vertebra, the probability of attaining the C7/T1 level with arm traction is < 15%. It is suggested that all initial radiographs of the lateral cervical spine in major trauma patients be done with arm traction, and where the upper one third of the body of C7 vertebra is not seen, then computerised tomography, swimmer's, or oblique views be considered.

Unusual presentation of tuberculosis to the accident and emergency department.

A patient with localized, reactive tendinitis secondary to tuberculosis presented to the accident and emergency (A&E) department. Tendinitis is a relatively common complaint, and it is important to consider uncommon systemic causes, including tuberculosis.

Resuscitation training for cardiac patients and their relatives--its effect on anxiety.

It is feared by many doctors that teaching basic life support (BLS) to high risk cardiac patients or a member of the family increases their anxiety. We trained a group of patients with recurrent ventricular tachycardia in BLS together with a friend or family member. Measurement of anxiety before and three months after training demonstrated a reduction in anxiety in both groups. This suggests that basic life support training can be targeted to high risk groups without fear of increasing anxiety.

Are accident flying squads also worthwhile for medical emergencies?

A retrospective analysis of 208 flying squad attendances was performed to assess the effect of pre-hospital care by the team on outcome in emergency medical conditions, and in the trauma victim. Sixty-two (26%) of these cases were medical, but only 24 (11.5%) required immediate cardiopulmonary resuscitation. Only one out of the four successful resuscitations finally left hospital alive. In trauma, there was no significant enhancement of survival due to the presence of the team by comparing the expected against observed mortality and the injury severity score for age-matched groups. The value of flying squads as a training aid, perception of the local community and relationships with other emergency services are discussed. Alternative solutions to improving pre-hospital care include advanced trained ambulance and bystander resuscitation schemes. Although difficult to quantify the authors feel that flying squads are of benefit.

Effectiveness of the call-out system for a London Coronary Ambulance service.

St Bartholomew's Hospital, in the City of London, has for many years run a Coronary Ambulance service, called by the public via the 999 system. During a 9-month period only 55% of 214 cardiac emergencies arriving at St Bartholomew's Hospital came with Coronary Ambulance support, although the service was available if called. In cases where the Coronary Ambulance was summoned, the call-out was inappropriate in 57% of cases. In addition, 153 cardiac emergencies arrived at the Accident and Emergency Department during hours when the Coronary Ambulance was not available. Reasons for breakdowns in the call-out system are discussed and remedies involving the public and London Ambulance Control are suggested.