Emergency medicine

Twenty-five patients living in a tick-endemic region of Sydney, New South Wales developed red meat allergy after experiencing large local reactions to tick bites. This represents a potentially novel cross-reaction between an arthropod and a food protein. Clinical recordsBetween 2003 and 2007, 25 patients (seven men, 18 women; mean age [range], 29.9 [21–63] years) presented to our allergy practice in Sydney, New South Wales with a history of an allergic reaction to red meat. All 25 patients reported a clinical reaction (one or more of: urticaria, angioedema, respiratory distress, syncope) after ingesting red meat. Ten of the 25 patients (40%) reported a delayed onset of symptoms, as defined by manifestations occurring more than 4 hours after ingestion. Seventeen of the 25 patients (68%) had severe reactions, characterised by cardiorespiratory involvement (one or more of: tongue swelling, throat constriction, shortness of breath, wheeze). Beef was the most commonly implicated red meat, followed by lamb, pork and game; 11 individuals reported reactions to more than one type of red meat. All patients lived in the northern beaches region of Sydney, which is endemically infested with several tick species. Twenty-four of the 25 patients gave a history of large local reactions to tick bites, defined as the rapid or delayed onset of a painful, pruritic lesion greater than 50 mm in diameter that persisted for at least 1 week.1 They all stated that the organism responsible for their local reaction was a hard-bodied tick, based on the presence of an armoured shell (scutulum). They also provided an estimate of the tick’s size, which ranged from 3 to 10 mm, and recalled the shape as resembling that of a human fingernail. No patient reported a history of large local or generalised reactions to other bites or stings, such as those from honeybees, wasps or mosquitoes. The remaining patient did not report any reactions, despite having incurred multiple tick bites. In all but one case, tick exposure preceded the development of the meat allergy by 1 to 6 months. One patient’s onset of meat allergy preceded the tick bite by 6 months. Patients’ IgE-mediated responses to red meat were confirmed by skin-prick test and/or fluoroenzyme immunoassay (ImmunoCAP, Phadia, Uppsala, Sweden). All patients had a positive result for at least one type of red meat; 22/25 (88%) had a positive reaction to more than one type (Box 1). There was no correlation between the wheal size on skin-prick testing or the amount of specific IgE detected by fluoroenzyme immunoassay and either the severity of the response to red meat ingestion or the size of the local reaction to the tick bite. The records of 29 patients (10 men, 19 women; mean age [range], 34.1 [17–71] years) with confirmed IgE-mediated responses to foods other than red meat, attending the same practice and residing in the same region, were examined as a retrospective control. The control group comprised patients with reactions to a spectrum of foods, most commonly seafood, peanut, tree nut and soybean. All 29 patients had reported a history of tick bites without subsequent reaction. These findings suggest that, in our patient population, the overwhelming majority of cases of the relatively rare condition of red meat allergy were preceded by sensitisation to tick bites. DiscussionBased on our experience of 25 patients, we suggest a novel association between tick bite reactions and red meat allergy. We speculate that individuals are sensitised to tick salivary proteins that are cross-reactive with proteins found in various red meats. Cross-reactivity between milk and beef,2 and between animal epithelia and meat,3,4 has been previously described, suggesting mechanisms of secondary sensitisation to meat. The association with reactions to tick salivary proteins may represent another such example. Anaphylactic and large local reactions to tick bites are IgE-mediated responses to tick salivary proteins.1 We infer that the species of hard-bodied tick most likely to be responsible for these local reactions is Ixodes holocyclus, commonly known as the paralysis tick (Box 2). I. holocyclus is not only the major species of tick found in the northern beaches region of Sydney that affects humans, but is also the species responsible for hypersensitivity reactions in humans.5 However, a skin-prick solution comprising paralysis tick antigens has not been standardised, and an in-house preparation carries a risk not only of anaphylaxis, but also of introduction of tick-borne disease; hence, there is currently no reliable, safe method of detecting IgE antibodies against I. holocyclus. It is intriguing that none of our patients who developed red meat allergy had an anaphylactic reaction to tick bite. It is possible that different allergens are involved in IgE-mediated local reactions and anaphylaxis, and that the allergens involved in local reactions are also found in red meat proteins, or, alternatively, that the inoculated allergens are processed differently in different individuals. There may be poorer inactivation of allergens by mast cells at the local site in some individuals, resulting in a more prolonged immunological stimulus.6 Bovine serum albumin has been identified as a major allergen responsible for a number of cases of meat allergy.7 More recently, IgE antibody to galactose-α-1,3-galactose has been identified as a cause of anaphylaxis and delayed immune reactions to red meat.8 This molecule is also present in recombinant mouse-derived monoclonal antibodies, such as cetuximab, and a number of invertebrates, such as amoebae and worms.9 It remains to be determined whether such homologous allergens exist in tick saliva. An alternative explanation is simply that the transfer of animal allergens by the tick occurs in genetically predisposed individuals. Bandicoots, possums and dogs, rather than cattle, are recipients of bites from the I. holocyclus species of tick, and it is therefore possible that there are allergens with a high level of homology found within bandicoot, possum and various ingestible red meat proteins. Also, the possibility of cutaneous exposure as a route of sensitisation to food allergens has been postulated as a mechanism for the development of peanut allergy.10 To determine the true prevalence of this cross-reactivity, a prospective study could examine consecutive patients who are bitten by ticks (with and without adverse reactions) for the subsequent development of red meat allergy. A standardised in-vitro assay for specific IgE against tick salivary allergens would need to be developed and incorporated into each participant’s evaluation. Further studies are required to characterise these allergens with immunoblotting and inhibition studies. 1 Skin-prick test and fluoroenzyme immunoassay results for patients with clinical reactions to red meat Patient Skin-prick test Fluoroenzyme immunoassay Beef Pork Lamb Game* Beef Pork Mutton 1 + − + nd + + − 2 + nd nd nd nd nd nd 3 nd nd nd nd + + + 4 + − + nd + + + 5 + nd nd nd nd nd nd 6 + + nd + nd nd nd 7 nd + nd nd nd nd nd 8 nd nd + nd + nd + 9 + + + + nd nd nd 10 + + + nd nd nd nd 11 + + + nd nd nd nd 12 + + + nd nd nd nd 13 + + + nd nd nd nd 14 nd nd nd nd + + + 15 + + + + + + + 16 + − + nd nd nd nd 17 + + nd + nd nd nd 18 nd nd nd nd + + nd 19 + + + nd − − − 20 + − + nd − − − 21 + + + nd nd nd nd 22 + nd + nd nd nd nd 23 + + + nd − nd − 24 + − + nd nd nd nd 25 nd + nd + + + + * Game refers to meat from wild animals, including kangaroo, venison and rabbit. + = positive result. − = negative result. nd = not done. 2 Developmental stages of Ixodes holocyclus Left to right: larva; nymph during engorgement; and adult female during engorgment. Image courtesy of Dr Bernard Hudson

Sheryl A Van Nunen MB BS, FRACP · Kate S O’Connor MB BS · Lesley R Clarke BSc, GradCertDiet · Richard X Boyle MB BS, FRACGP · Suran L Fernando PhD, FRACP, FRCPA

Clinical record A 68-year-old man presented to our general district hospital in December 2006 with the chief complaint of sore throat, which had started abruptly 2 hours earlier. The pain was described as intense with a stabbing character. He reported minimal improvement after being given 10 mg of morphine subcutaneously. The patient did not report experiencing any cardiac or pulmonary discomfort, and he had no pertinent past medical history. His family history included one sister who had died of a ruptured aortic aneurysm. The patient was a non-smoker and denied any recent medication use. Physical examination showed that the patient’s vital signs were stable, with a normal level of consciousness, a regular pulse of 61 beats/min, and a blood pressure equal at both arms of around 115/70 mmHg. He was slightly tachypnoeic and diaphoretic. An ear, nose and throat examination did not provide any diagnostic clues as to the cause of the pharyngeal pain. Findings of a cardiovascular examination were normal apart from an audible right carotid artery bruit. No other physical abnormalities were detected. Results of laboratory tests were unremarkable, except for a markedly elevated d-dimer level (8.41 mg/L; upper limit of normal, 0.50 mg/L). Routine chest radiography was suggestive of mediastinal widening (Figure A). On the basis of these findings, a thoracic computed tomography scan was performed, which showed a 5.4 cm dissecting ascending aortic aneurysm (Figure B). The dissection involved the aortic root, ascending part of the aorta and aortic arch, and propagated into the right brachiocephalic trunk and left common carotid artery (Figure C). Transthoracic echocardiography additionally showed the presence of a bicuspid aortic valve with moderate grade 2/4 aortic insufficiency. Thoracic aortic dissection was diagnosed, classified as a Stanford type A dissection, given the involvement of the ascending aorta. A congenital bicuspid aortic valve and an ascending aortic aneurysm were predisposing factors for aortic dissection. The patient successfully underwent emergency surgery with graft replacement of the aortic valve and the dissected aortic segment. A: Chest x-ray showing mediastinal widening. The upper normal mediastinal width is defined as a mediastinum to chest-width ratio of over 0.25, measured at the level of the aortic arch (illustrated by the length of the solid line); this is noticeably exceeded in our patient (dashed line). B: Computed tomography scan showing an aneurysmatic dilatation of the ascending aorta with a classical dissection flap (black arrowhead) separating a true and false lumen. C: Propagation of the dissection process into the supra-aortic vessels (white arrows). The clinical presentation in our case was rather trivial, but the combined results from two basic investigations — an elevated d-dimer level and an abnormal chest x-ray — heightened our clinical suspicion for aortic dissection and led us to perform aortic imaging. Thoracic aortic dissection generally results from a laceration of the intimal lining of the aorta. This allows blood leakage into the aortic wall resulting in a propagating separation of the aortic media, thereby creating a false blood-filled lumen.1 Hence, the major criterion for definitive diagnosis of aortic dissection includes visualisation of a so-called intimomedial flap that divides the aorta into a true and a false lumen. Several aortic imaging techniques can be used for this purpose, of which contrast-enhanced computed tomography (CT) and transoesophageal echocardiography (TOE) are the most feasible to perform in an emergency department setting.1,2 Moreover, these investigations help to localise the dissection, thereby allowing appropriate classification. Currently, the Stanford classification of aortic dissection is the most widely adopted system.1,2 This system has the virtue of merely dividing aortic dissection into two subtypes, depending on whether the ascending aorta is involved (type A) or not (type B).1,2 While the definitive diagnosis of aortic dissection is usually straightforward, making the initial clinical diagnosis can be extremely challenging. Aortic dissection is associated with a dramatic rate of misdiagnosis and delayed recognition.3 This is no doubt partially explained by the highly variable clinical presentation of the condition. Our case is a striking illustration of why acute aortic dissection is colourfully called a “clinical chameleon”.1 Although most patients with aortic dissection present with severe chest or back pain (Box 1), the pain can be variably localised to the neck, jaw or throat.4 Throat pain occurs most often in cases of a dissection of the aortic arch, particularly when the supra-aortic vessels are involved. Our patient complained only of a sore throat, and denied having thoracic pain. Only two similar cases have been previously reported.5,6 Moreover, findings on physical examination can be very subtle.1 Classical signs consistent with the diagnosis of thoracic aortic dissection, such as an aortic insufficiency murmur or decreased femoral arterial pulsation, were not present in our patient. According to the International Registry of Acute Aortic Dissection,7 these so-called typical findings are infrequently detected during physical examination (Box 1). In our case, the only notable features of the physical examination were diaphoresis and a right carotid artery murmur. The latter was presumably the result of propagation of the dissection into the right brachiocephalic trunk. Because symptoms and signs of aortic dissection can be diverse and sometimes treacherously trivial, the initial diagnostic suspicion might rely on abnormalities observed during the basal diagnostic work-up. This routinely consists of laboratory testing with d-dimer analysis and chest radiography. d-dimer analysis has only recently come to the fore, with several studies focusing on the stringent association between the d-dimer level and aortic dissection.3,8,9 The pathophysiological mechanism for this relationship is well explained by the release of tissue factor from the dissected aortic wall. This sets off a cascade of events — activation of the extrinsic coagulation system, generation of fibrin, and secondary fibrinolysis with d-dimer formation.8 The d-dimer assay is reported to have an excellent sensitivity and negative predictive value for aortic dissection (Box 1). The quoted sensitivity is equal for both types of dissection, although absolute d-dimer values tend to be higher in type A aortic dissections as they are usually more extended.10 Given its high sensitivity and negative predictive value, d-dimer testing is an attractive tool for the diagnostic work-up of aortic dissection, particularly in the setting of a low pretest probability for aortic dissection. In such cases, a normal d-dimer result can reliably exclude the presence of aortic dissection, hence obviating the need for further investigations.9,10 Besides elevation of the d-dimer level, the clinical suspicion for aortic dissection should also be heightened if the chest radiograph is abnormal (Box 1). Mediastinal widening (relative mediastinum to chest-width ratio > 0.25;11 Figure A) is the most common radiographic finding in aortic dissection.7 Of note, absolute estimations of the mediastinal width are practically inaccurate, as these measurements are influenced by the distance between the roentgenographic source and the thorax.12 It is worth mentioning that one in three patients with aortic dissection has a normal chest x-ray.11 Thus, relying on chest radiography alone as the initial diagnostic modality is inefficient as it clearly carries a high risk of misdiagnosis. When readily available, contrast-enhanced CT and TOE are the preferred imaging modalities in an acute care setting. Both investigations have a comparable diagnostic accuracy and allow a definitive diagnosis of aortic dissection to be established.1,2 However, the diagnosis must first be suspected before it can be confirmed — this case serves as a reminder of this life-threatening condition’s wide variability in clinical presentation, and the need to maintain continuing vigilance. 1 Clinical and basic diagnostic features of thoracic aortic dissection, and percentages of patients presenting with these features who are subsequently diagnosed with Stanford type A or B aortic dissection1,2 Stanford classification Features Type A* Type B† Clinical symptoms and signs7 Presence of any pain 94% > 95% Retrosternal pain 71% 44% Interscapular pain 33% 41% Back pain 47% 64% Abdominal pain 22% 43% Blood pressure Hypotension or shock/tamponade < 25% < 5% Hypertension 35% 70% Aortic insufficiency murmur < 45% < 15% Decreased or absent peripheral pulsations < 20% < 10% Laboratory analysis8,9 d-dimer sensitivity (cutoff, 0.50 mg/L) > 95% > 95% d-dimer negative predictive value (cutoff, 0.10 mg/L) 100% Not reported Chest radiography7 Mediastinal widening 63% 56% Abnormal or blurred aortic contour 47% 53% Other radiographic features‡ < 25% < 25% * Dissection with involvement of the ascending aorta. † Dissection of the descending aorta without involvement of the ascending aorta. ‡ Such as displaced aorta, aortic calcification, tracheal displacement, pleural effusion. Lessons from practice Thoracic aortic dissection is characterised by a highly variable clinical picture, which has led to the condition being called a “clinical chameleon”. d-dimer testing can be of value in excluding aortic dissection. A normal chest x-ray does not rule out the possibility of aortic dissection. Advanced aortic imaging should be performed early in patients who have symptoms suggestive of aortic dissection in order to prevent misdiagnosis.

Sébastien Anguille MD · Aurélie M Derweduwen MD · Jeroen Lenz MD · Luc Vanuytsel MD, PhD · Frank J Cools MD

We need more inpatient beds and better management of existing beds The inability to admit emergency patients to a ward bed in a timely fashion (access block) is a blight on our hospitals and our community. Access block is the most serious issue confronting emergency departments (EDs), as the safety and quality of emergency care are compromised, as is access to emergency care.1 There is a 20%–30% excess mortality rate every year attributable to access block and ED overcrowding.2 This equates to at least 80 deaths per million population, a figure that is similar to the road toll.2 Australia has been at the forefront of research into this problem, and there is clear evidence that the main cause of access block and ED overcrowding is that there have been major increases in emergency admissions, but almost no increase in the capacity of the system to meet this demand.2-4 The number of available public hospital beds in Australia was reduced from 2.65 beds per 1000 population in the 1998–99 financial year to 2.4 in the 2001–02 financial year; since 2005 it has remained steady at 2.6 beds per 1000 population.2 These bed numbers are below the average for Organisation for Economic Co-operation and Development (OECD) countries of 3.9 acute-care beds per 1000 population.5 In the same period, the number of ED attendances annually has increased from 4.1 million to 6.7 million,6 and case complexity has also increased.2,3 Furthermore, annual increases in demand for emergency care are expected as a result of population growth and an increase in the burden of disease. This increased demand must be planned for to avoid further unnecessary deaths and suffering. To tackle this issue, the Australasian College for Emergency Medicine (ACEM) hosted the Access Block Solutions Summit in September 2008. The summit was opened by Nicola Roxon, the federal Minister for Health and Ageing, who, acknowledging the problem of access block, noted: “ . . . the capacity of our hospitals has not kept up with this demand. This is reflected in overflowing emergency departments . . .”.7 As a result of the summit, two articles highlighting both the problem of access block and potential solutions appear in this issue of the Journal. Richardson and Mountain provide a robust outline of the problem.8 It is worth highlighting that it has been repeatedly proven that general practice patients do not cause access block, ED overcrowding or delays in unloading ambulance patients8 (ambulance ramping; resulting in delayed ambulance response times). The persistence of this myth is detrimental to finding real solutions. More sobering are the results of the September 2008 point prevalence survey of national access block, conducted for the ACEM by the Road Trauma and Emergency Medicine Unit of the Australian National University.9 Caring for patients who are waiting for inpatient beds now represents around 40% of the workload in major hospital EDs, and up to 70% in some.9 Some patients spend days in EDs waiting for an inpatient bed, in particular, those with mental illnesses who are being admitted involuntarily. The survey confirmed that access block is getting worse, and this development is an indictment of our health system. The problem is nationwide, and no government has been effective in providing sustainable solutions. Cameron and colleagues provide a detailed overview of potential solutions.10 Although these are a pragmatic guide to fixing the problem, it will only be when all stakeholders agree that the problem is systemic and hospital-wide that solutions will be able to be implemented. This requires political will from the Australian Government. It was this political will that achieved significant changes to EDs in the United Kingdom. The health system as a whole must own and address this problem, by implementing improvements ranging from effective chronic disease management within the community, to basic inhospital processes such as efficient bed turnaround time. Patient flow must be maintained 24 hours a day, 7 days a week to achieve a hospital bed occupancy of 85% — a level that should be viewed as the most effective way to manage patient flow.11 This nominated spare bed capacity is essential for the effective management of emergency admissions, and to have surge capacity. This approach will enhance patient safety in the ED and throughout the hospital stay. It is essential that the nation’s performance on access block is included in the Council of Australian Governments’ ambitious health reform agenda for implementation from 2009, and is part of the agenda of the National Health and Hospitals Reform Commission. Key performance indicators with agreed nationwide criteria must be developed, implemented and collected at all levels to monitor this problem. At the same time, more research is needed to inform changes to improve the health system. The bottom line is that it’s all about available beds. Access block is best addressed by increasing the capacity of the system, most directly by increasing the number of beds available at all levels of care within hospitals. This means having more inpatient beds and optimising patient flow processes to increase bed availability. Only a small part of the solution to access block resides within EDs.8 While the science of access block is compelling, it is important to remember always that it is associated with a large amount of preventable human suffering. A fundamental precept of Hippocrates is primum non nocere. Access block is harming our patients and harming our health system. It is time to fix the problem. Australians expect and deserve better.

Daniel M Fatovich MB BS, FACEM · Geoff Hughes FRCP, FCEM, FACEM · Sally M McCarthy MB BS, FACEM, MBA

Hospitals cannot manage their emergency patients when there is significant access block. There are solutions that should be implemented but require national leadership to be effective. These solutions include an immediate increase in the number of acute hospital beds, improved coordination and increased community capacity to manage medical patients with complex conditions outside acute public hospitals, improved hospital processes, and better standardisation of treatment within emergency departments. There is little evidence that telephone triage, ambulatory care clinics or disaster management techniques, including ambulance diversion, reduce access block.

Peter A Cameron MB BS, MD, FACEM · Anthony P Joseph MB BS, FACEM · Sally M McCarthy MB BS, MBA, FACEM

Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE · David Mountain FACEM

Therapeutic guidelines. Toxicology and wilderness. Emergency Medicine Expert Group. Melbourne: Therapeutic Guidelines, 2008 (xxii + 311 pp). ISBN 978 0 9804764 0 8. Poisoning is a common presentation to Australian emergency departments and a common cause of death in those under 40, yet there is a real paucity of Australasian toxicology texts. Toxicology and wilderness, a new release in the Therapeutic Guidelines series, is a subset of topics prepared by the Emergency Medicine expert writing group for the electronic eTG complete. Toxicology and wilderness sensibly starts with in-depth information on the many aspects of resuscitation. There is a good overview on the approach to the poisoned patient, with a great nomogram to help assess the risk of torsades from a prolonged QT. The majority of the book is based on the toxicology of individual agents. It approaches each agent in a structured manner, detailing the indicators for toxicity, clinical presentation, key investigations and treatment. It has much helpful and sensible advice. The authors seem to advocate routine activated charcoal for most poisonings that present within 1 hour, which I would disagree with. The discussion on antidotes is understandably brief, although I was curious to read in detail about dicobalt edetate for the treatment of cyanide poisoning, and not the currently recommended and far safer hydroxocobalamin. I felt that there were sections where better emphasis on the potential for severity of the poisoning or management issues could have occurred. The book ends with a well written section on envenoming, then the unusual bedfellow of wilderness medicine. I think the strength of this book lies in the ready access of the electronic format for hospital practitioners. I found the information a good starting point but, due to the restrictions of the structure of this series, a little light in some areas. As to whether it sits on your bookshelf — you need to browse through to see if it fits a need.

Mark Little

A 28-year-old man with no past ophthalmic history presented with sudden loss of left central vision after dancing vigorously at a night club. On examination, visual acuity in the left eye was 6/60. Fundoscopy revealed a well circumscribed, dense preretinal haemorrhage obscuring his left fovea (Figure A). Optical coherence tomography confirmed the haemorrhage to be located just under the internal limiting membrane (Figure B). Conservative management was applied, and the patient’s vision returned to 6/6 after 3 months. First described by Duane in 1972,1 Valsalva retinopathy is now a well recognised cause of retinal haemorrhage that typically occurs in association with strenuous activity and the Valsalva reflex.

Henri Sueke

To the Editor: Petrie and colleagues alert us to some negative effects of “appearance medicine” television programs.1 I agree that participants in television programs on cosmetic surgery should not be induced to have surgery by the offer of a significant reduction or waiving of the fee for the operation on the condition that they expose themselves before, during and after the procedures. Removing the cost component is a significant enticement to undergo cosmetic surgery. However, many procedures need to be repeated and implanted products replaced. If potential patients cannot afford future expenditure, they may be unsuitable for cosmetic surgery. The intense competition between providers of cosmetic surgery procedures leads them to seek media exposure — surgeons and non-surgeons jostle for supremacy and market share. Australian and New Zealand cosmetic surgery websites show a wide array of highly posed, seductive images that promise more than is likely to be possible. In New South Wales, a medical practice amendment on advertising regulation was introduced on 1 July 2008, to provide stricter regulation of “before and after” photographs targeted at patients considering cosmetic surgery.2 However, patients have the right to be informed. A survey, cited by Petrie et al, of first-time patients seeking plastic surgery revealed what I consider a positive side to appearance medicine television programs: patients who regularly viewed such programs believed themselves to be more knowledgeable about plastic surgery, and its issues and risks, than “low-intensity” viewers of such programs.3 The growth of cosmetic surgery has been phenomenal and will continue during the next decade. At present, it is unclear whether patients are enticed or merely educated by appearance medicine television programs. However, it is clear that they are more likely to be knowledgeable because of the information provided to them, and that the knowledge they gain may improve their ability to assess a surgeon’s capability and credibility.

Darryl J Hodgkinson

Objective: To estimate costs of retrieval, transport and acute medical services associated with road crashes in northern Queensland from March 2004 to June 2007.Design, setting and participants: Case study of 696 people aged 16 years or older who had been involved in a road crash in the study area (all areas north and west of Bowen, excluding the urban areas of Townsville and Cairns) and had been admitted to hospital for a minimum of 24 hours after the crash. Data on mode of retrieval, acute care provided and total costs were obtained for each patient.Main outcome measures: Method of retrieval or transport; length of stay in intensive care unit (ICU) and/or hospital for each patient; costs of retrieval, transport and inhospital care.Results: Retrieval data were collected for 614 of the 696 study participants (88%). Most primary retrievals (446; 73%) occurred by road. More than half of interhospital transfers were undertaken by fixed or rotary wing services. Casualties in the study occupied a total of 6360 bed-days, of which 734 were ICU bed-days. The total retrieval, transport and acute hospital care costs of road crash victims in northern Queensland over the study period were calculated to be approximately $10.4 million.Conclusion: The costs associated with rural and remote road crashes in northern Queensland represent a considerable economic burden.

Teresa M O’Connor DPhSt, MPH · Heather A Hanks BMedSc(Hons) · Mark S Elcock MB ChB, FACEM, FCEM · Richard C Turner MB BS, BMedSc, FRACS · Craig Veitch DipAppSc(RT), BA(Hons), PhD

Objective: To characterise the nature and impact of World Youth Day (WYD) 2008 on emergency department (ED) presentations at key hospitals.Design, setting and participants: Retrospective analysis of WYD pilgrims presenting to the EDs of St Vincent’s Hospital and Sydney Hospital, 9–23 July 2008.Main outcome measures: Frequency of pilgrim ED presentations; presenting complaint, Australasian Triage Scale category, diagnosis, admission to hospital and demographic characteristics.Results: 191 pilgrims presented at the two EDs during the study period, comprising 7.8% of all visits to these EDs. Pilgrims had a median age of 22 years, and most were international visitors. The female-to-male ratio was 1.7 : 1. The most common diagnoses were lower limb strain or sprain, infections, and acute asthma. Pilgrims presented with less severe illnesses (with lower triage scores), and were less likely to be admitted to hospital than other patients.Conclusions: The pilgrim caseload was small, and these presentations were less acute and less likely to result in admission than non-pilgrim presentations. Thus, the overall impact on the hospitals was very small.

Myles W H Smith · Gordian W O Fulde MB BS, FRACS, FACEM · Patricia M Hendry

Mass gatherings, such as World Youth Day (WYD) 2008 in Sydney, provide an opportunity for public health workers to gain emergency management experience. Communicable disease (mainly influenza) among pilgrims was the major public health issue during WYD. Public health workers also identified environmental health issues, resulting in hazard reduction measures being made to reduce falls. Other public health issues highlighted include training, communication, surge capacity, and health education. Lessons learned from planning WYD mass accommodation could be applied to emergency accommodation in the case of evacuation.

Jan Fizzell MB BS, MPH, FAFPHM · Paul K Armstrong MB BS, FRACP, MAppEpi

Progressive reduction in trauma mortality and morbidity demands both peer-group and state registry evaluations, with ensuing recommendations implemented by a responsive state government trauma committee Between 1992 and 2005, the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) conducted several studies evaluating trauma care delivery and management in consecutive victims of road traffic accidents who had received medical treatment but subsequently died.1-4 These studies found that, between 1992 and 1997, combined preventable/potentially preventable (P + PP) death rates* among patients who died after road accidents were unaltered (* respectively, survival prospects with optimal treatment assessed as ≥ 75%, and as 25%–74%).1,5 Similarly, the frequency of errors and deficiencies contributing to death was unchanged. In 1997, recommendations were made to reduce identified problems6 and, in response, the Victorian Government established a Ministerial Task Force on Trauma and Emergency Services to implement a statewide integrated trauma system to expedite early definitive care.7 Previously, while there had been one adult major trauma service (MTS) in Victoria (The Alfred Hospital), most patients were taken to their nearest public hospital, where P + PP death rates were two to three times higher than at the MTS.3 The statewide integrated trauma system, developed in stages from 2000, has a four-tiered structure, with public hospitals assigned to different service levels according to the complexity of care they provide.7 Implementation of the statewide trauma system involved the development of two additional MTSs in Melbourne (a second adult hospital managing a sufficient caseload of seriously injured patients, and a paediatric hospital) and the designation of 11 metropolitan hospitals, 9 regional hospitals and numerous primary injury services in small rural communities. Under the integrated system, major trauma patients are identified at the scene of injury according to specified anatomical, physiological and mechanistic criteria and transported to an MTS, provided that the anticipated transport time from the scene of injury will not exceed 30 minutes.7 Longer times are accepted for patients who are managed and transported by Advanced Trauma Life Support helicopter crews. Otherwise, the patient is triaged to the nearest designated hospital and, after resuscitation, stabilisation and communication with the hospital, transferred to an MTS if appropriate. Early communication with the hospital from the scene of injury facilitates immediate patient reception by a trauma team. The team is comprised of at least one emergency medicine consultant and surgical and anaesthetic registrars, with a consultant general surgeon attending within 20–30 minutes for time-critical patients. Directors of trauma services are accountable for improved management in the hospital through coordination, audit and feedback. The Victorian State Trauma Registry, established in 2001, monitors and reports on progress to the State Trauma Committee, which is responsible to the Minister for Health.8 In a recent study, the CCRTF compared management and outcomes of 245 consecutive road traffic fatality cases before (1997–1998) and 193 consecutive cases after (2002–2004) the implementation of the integrated trauma system.4 The proportion of these trauma patients with TRISS (Trauma and Injury Severity Score)9 survival prospects of ≥ 75% who subsequently died fell from 31% before to 22% after the introduction of the new trauma system. The proportion of major road trauma victims admitted to MTSs increased from 34% to 62%. More patients were attended by Advanced Trauma Life Support road and helicopter paramedics, with increased time spent by paramedics at the scene of injury and increased transport times. The per-patient number of deficiencies and errors contributing to death was significantly reduced overall, particularly in the emergency department. P + PP death rates fell from 36% to 28% (preventable deaths from 5% to 3%, and potentially preventable deaths from 31% to 25%). While P + PP death rates remained markedly lower at MTSs than at other hospitals, P + PP death rates before hospital arrival and within each of the four hospital groups did not significantly change. The overall reduction in P + PP mortality can largely be attributed to increased admissions to MTSs. Recently, the Victorian State Trauma Registry estimated that there was a 37% reduction in the likelihood of death among hospitalised major trauma patients in 2002–2006 compared with 2001–2002.8 This finding, supported by research by Cameron and colleagues reported in this issue of the Journal (→ A statewide system of trauma care in Victoria: effect on patient survival),10 is further evidence of overall improvement following introduction of the new trauma system. In response to the lack of improvement within each hospital group, the CCRTF established an interactive strategy with the trauma services. Based on the most recent CCRTF findings, consensus recommendations to counter ongoing system and clinical deficiencies were developed jointly with each trauma service.11 Persisting deficiencies in the Victorian system include the lack of Trauma Director/Coordinator appointments at many hospitals; failure to ensure compliance with protocols and guidelines; delays in communication and referral; insufficient intensive-care beds; and problems with coordination, audit and feedback.11 In addition, funding for independent peer-group review of trauma mortality has ceased. Panel studies (involving multidisciplinary peer-group evaluation of patient management), trauma registry data and population-based research indicate that mortality and morbidity are reduced following the introduction of integrated trauma systems and that continuing improvements can be achieved.12-15 Statewide trauma systems operate in all jurisdictions in Australia except for Tasmania, the Northern Territory and Western Australia (where one is pending). Independent peer-group review is currently limited to New South Wales, where some fatalities, pre-hospital care and interhospital transfer cases are evaluated. NSW and Queensland have state trauma committees. Key system weaknesses recognised by the state trauma committees of the Royal Australasian College of Surgeons include MTS caseload dilution in NSW following the development of 12 MTSs; lack of consultant staff attendance for the early management of severe trauma and critical decision making in NSW and South Australia; insufficient surgical and intensive-care beds in the Australian Capital Territory; and deficiencies in theatre access and lack of intensive-care beds and funding in Queensland. Although the initiation of statewide trauma systems in Australia has been a major advance, it is still awaited in three jurisdictions. The number of MTSs designated should allow sufficient caseload of severe injury at each MTS.16 Future quality improvement requires identification of ongoing deficiencies so that targeted countermeasures can be introduced and their effectiveness assessed. Identifying such deficiencies depends on continuing analysis of trauma registry data, complemented by independent peer review of preventable mortality to clarify factors contributing to death. Effective oversight by a state trauma committee is mandatory to ensure an adequate response to the findings of the audit process and to implement corrective actions. Meetings between audit personnel and hospital staff would further facilitate quality improvement. The creation of a national trauma council would help to coordinate and develop standardised quality assurance and improvement in trauma care delivery across all Australian states and territories. Finally, quality improvement remains dependent on the commitment of consultant staff to direct all phases of trauma care.

Francis T McDermott MD, FRACS, FRCS(Eng) · Stephen M Cordner FRCPath, FRCPA, DipCrim

Objectives: To examine the characteristics of adult patient attendances to emergency departments (EDs) in Perth hospitals by patients’ frequency of attendance.Design, setting and participants: A linked-data population study of adults (aged ≥ 15 years) attending all nine Perth hospital EDs between 1 July 2000 and 31 December 2006.Main outcome measures: Proportion of frequent attenders (FAs; those attending five or more times annually); and demographic characteristics, mode of arrival at the ED, disposition (admission, transfer, discharge or death), urgency and clinical conditions by frequency of attendance.Results: There was a mean of 1.5 attendances per individual per year, resulting in 1 583 924 attendances by 663 309 individuals over the 6.5 years of the study. Most patients (97.6%) attended Perth EDs fewer than five times a year. The more frequently patients attended, the more likely they were to be male, middle-aged and late-middle-aged, have self-referred, have mental and behavioural disorders and alcohol intoxication, to not wait to be assessed, and to arrive by ambulance. The groups of patients attending between 5–9 and 10–19 times per year (97.4% of FAs) had more urgent conditions, more circulatory system disease and higher admission rates than all other patients.Conclusion: Most FAs at Perth EDs present fewer than 20 times a year and have more serious and urgent illness than other patients, more often requiring inpatient services. A very small minority of patients (around 100 patients/year) attends 20 or more times a year, many with mental and behavioural disorders and alcohol intoxication not requiring hospital admission.

George A Jelinek MD, FACEM, DipDHM · Moyez Jiwa MD, MRCGP, FRACGP · Nicholas P Gibson PhD, RN, FRCNA · Ann-Maree Lynch BSc (Hons), PhD

The mark, especially the “high mark” and “spectacular grab”, distinguishes Australian Rules football from more earthbound varieties.1 Photographs taken at a recent South Australian National Football League match revealed a high mark where hyperextension of the proximal interphalangeal joint of the right index finger occurred. Interview with the player and examination of the affected digit 4 days after the match revealed no injury to the finger, although some bruising of the right thenar web space and mild tenderness of the first metacarpophalangeal joint were evident. A previous report concluded that virtually all pure hyperextension injuries of the proximal interphalangeal joint result in rupture of the distal end of the volar plate,2 but fracture dislocation appears to depend on joint angle at the time of injury.3 A review of published literature and photographic libraries failed to reveal a similar incident. Further research is required to characterise the biomechanical forces necessary to cause digital injury in sports requiring barehanded capture of a travelling ball.

Robert J Douglas

Objective: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy.Design: Prospective cohort study using historical controls.Setting: Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention).Participants: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital.Intervention: PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team.Main outcome measures: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA.Results: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months.Conclusions: Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.

Debbie A Quain BA(Nursing) · Mark W Parsons PhD, FRACP · Allan R Loudfoot MBA · Neil J Spratt PhD, FRACP · Malcolm K Evans RN, BA(HealthManagement) · Michelle L Russell RN, CM · Angela T Royan BNursing · Andrea G Moore BNursing · Ferdinand Miteff MB ChB · Carolyn J Hullick FACEM · John Attia MD, PhD, FRCPC, FRACP · Patrick McElduff BMath, PhD · Christopher R Levi BMedSci, FRACP

The future viability of general surgery may depend on combining subspecialty elective surgery with full-scope acute practice in both public and private settings Subspecialisation in surgery is an irresistible and irreversible force. It improves standards of patient care1 but tends to be accompanied by an erosion of competence in the broad scope of the major specialty. For example, many major hospitals in Australia have had difficulty retaining subspecialty breast surgeons on the on-call roster because these surgeons feel that their competence to manage the full range of general surgical emergencies has been diminished by their day-to-day practice involving primarily the breast and axilla and rarely the abdomen. Nevertheless, the community needs surgeons willing and able to provide acute surgical care in the major specialties, including general surgery. Is it possible to have a model of care that satisfies both of these apparently divergent scopes of practice? A century ago, there was a single broad field of surgery. During the 20th century, specialties within surgery developed, many of these arising from general surgery, which continues to be the largest specialty. The Royal Australasian College of Surgeons (RACS) currently recognises nine specialty disciplines, by training and examination: general surgery; orthopaedic surgery; otolaryngology, head and neck surgery; plastic and reconstructive surgery; cardiothoracic surgery; neurosurgery; paediatric surgery; urology; and vascular surgery.2 Recognition as a surgical specialty has required definition of a discrete area of knowledge and skills, and a group of practitioners dedicated to the practice, teaching and advancement of the specialty. Subspecialisation within each specialty continues this development, driven by surgeons’ motivation to increase their knowledge and improve patient care. However, it may also have professional and personal benefits for the surgeon, including a more regulated lifestyle and enhanced prestige and remuneration. Examples of subspecialisation within the specialty of general surgery are breast, endocrine, upper gastrointestinal, hepato-pancreatico-biliary, and colorectal surgery. Of particular concern is that general surgery — comprising the largest specialty group of surgeons and those most likely to be required to treat emergencies — is now attracting proportionally fewer applicants for training. In 2007, general surgery offered 51% of available training posts but attracted only 30% of applications.2 Until recently, a third of trainees transferred to another specialty during their training. Although it is hoped that the new Surgical Education and Training (SET) program3 will bring improvements for all surgical specialties, attraction to and retention in general surgery training is likely to be a continuing challenge. Despite the best efforts of the RACS and public hospitals, the number of training positions in general surgery of sufficient quality to meet accreditation standards has increased only gradually from 266 in 2004 to 304 in 2008.2 These factors at the supply end, combined with the fact that 40% of active general surgeons are aged over 60,2 are creating serious workforce pressures. Very few surgeons remain on the on-call roster after age 60. The situation seen in Australia is similar in other developed countries and is particularly concerning in the United States, where Fischer has warned of the impending disappearance of the general surgeon.4 General surgical specialists have been trained to a competent level in the full range of the specialty, including trauma and the acute abdomen. However, as subspecialisation develops, surgeons may become de-skilled in the requirements of emergency surgery. Thirty years ago, general surgeons practised the full range of the specialty, taking pride in the breadth and depth of their knowledge and skills. This has changed significantly. In a 2003 survey,5 the practice patterns of members of General Surgeons Australia were: general surgery with subspecialty, 45% general surgery with more than 90% subspecialty, 23% “general” general surgery, 18% subspecialty only, 14% Nevertheless, 83% felt an obligation to stay on emergency rosters out of duty to the community, trainees and professional colleagues. But for how long will this goodwill continue? Emergency work is demanding, and reliance on a diminishing pool of “general” general surgeons will not be sustainable. Indeed, the future viability of the specialty of general surgery may depend on the development of a model of practice that combines subspecialty elective surgery and full-scope acute practice in both public and private settings. What is required to encourage surgeons to continue to work on emergency rosters? First, we need a review of these rosters. The tradition of ongoing responsibility for the care of patients taken in during an on-call period being maintained by visiting surgeons — who make up most of the workforce and who are in private practice outside the public hospital for most of their working week — should be reconsidered. The Australian Medical Association has promulgated safe-hours principles,6 and these depend, in part, on the acceptance of safe-handover principles.7 The RACS supports both these professional workplace ideals.8 Rosters have been successfully trialled where a consultant-led surgical team is on call exclusively for emergencies, with no scheduled elective duties, for a defined time period such as 24 hours, or longer. At the end of this time, the team completely hands over care of patients with unresolved problems to the next team.9 Second, we need a review of the efficient use of operating theatres for emergency and elective surgery. Lack of access to beds and operating theatres for elective surgery is a continuing source of frustration for patients, surgeons and trainees, and may be solved by separating the services.10 This can be achieved by establishing a separate hospital for elective surgery, at least for surgery of minor or moderate complexity, or by effective quarantining of services within a major hospital complex. Third, surgeons need to maintain competence in emergency surgery relevant to their major surgical specialty. It is possible to identify the requirements of emergency surgery as a defined scope of practice within each of the nine major specialties. This set of knowledge and skills could be formalised in a curriculum for continuing professional development and delivered in an adult learning format, including online modules and hands-on technical skills laboratories. Surgeons would then have the confidence to continue to serve on on-call emergency rosters, thereby acting as mentors and role models for trainee surgeons, while also continuing to practise a subspecialty interest in elective surgical practice. Finally, hospitals should value their surgeons and provide appropriate incentives and conditions of service, including adequate remuneration and tangible support for continuing professional development. This will require cultural and organisational reform, but hospitals could then reasonably expect surgeons to provide emergency services as a condition of their employment. My emphasis here has been on general surgery, where the problems are so obvious. However, service issues also apply to other surgical specialties with developed and developing subspecialisation (notably orthopaedics and otolaryngology) and are also relevant to other medical specialties. Problems particularly occur in the public sector; while provision of acute care in the private sector is also problematic, motivations and incentives in private sector settings appear to be more effective in maintaining services. In rural and remote areas, the provision of elective and emergency services is also threatened by workforce pressures beyond the issue of subspecialisation. The RACS has recently responded to concerns about the increasing difficulties in providing adequate emergency and trauma care by publishing a position statement outlining guidelines for the sustainability of emergency surgery services.10 To continue to provide emergency surgical care to the Australian community, it is apparent that models of coexistence must be found, and that solutions will include effective rostering and practice models, the certainty of availability of facilities for care, and the appropriate valuation of surgeons, as well as ongoing support for the maintenance of professional competence.

Ian R Gough MD, FRACS

The effects of “appearance medicine” programs need closer scrutiny Recent data released by the British Association of Aesthetic Plastic Surgeons show that more people are having cosmetic and weight reduction surgery than ever before: the number of surgical procedures performed by members of the Association in 2007 was 12% greater than in the previous year.1 The increased demand for cosmetic surgery was not limited to women — 18% more procedures were performed on men compared with the previous year. The greatest increases were in anti-ageing procedures, such as facelifts and eyelid surgery, which both increased by over 36%. Data recently reported by the American Society of Plastic Surgeons show that almost 12 million cosmetic surgery procedures were performed in the United States during 2007, representing a 59% increase from the number performed in 2000.2 Current Australian figures are difficult to establish but seem to be rising.3 An important driving factor behind the increase in cosmetic and weight reduction surgery may well be the large number of “reality” television programs that focus on weight loss and appearance change. Recent data from patients seeking first-time cosmetic surgery reveal that many were regular viewers of “appearance medicine” programs, and that four out of five reported that plastic surgery reality television influenced their decision to undergo cosmetic surgery.4 Dentists also report that “extreme makeover” programs have recently increased the demand for cosmetic dental procedures.5 Two categories of programs are particularly relevant. In the first category are programs with a focus on weight reduction through drastic diet and lifestyle changes. Recent examples in Australia include The biggest loser Australia and Overhaul; in the United Kingdom, they include Supersize vs superskinny and Superslim me. Contestants in such programs compete to make the fastest or most dramatic changes in weight. In 2007, The biggest loser Australia averaged over a million viewers per episode, and the finale drew nearly two million viewers.6 The winner of this series lost 70 kg, which represented 47% of his starting weight. In the second category of programs, participants undergo extensive surgical and cosmetic procedures to improve their lives. In the UK, this category includes Supersize surgery and Make me perfect. In the US, popular examples are The swan and I want a famous face, where participants compete to make the most drastic changes in appearance through strict diet and exercise regimens, and cosmetic surgery procedures.7 The winner of the 2004 series of The swan underwent 13 cosmetic face, dental and body procedures, including brow, eye and mid-face lifts, liposuction, fat transfer to the lips, and abdominoplasty. The portrayal of cosmetic and weight loss procedures on television typically distorts the speed and difficulty of these changes. Most programs focus on the few individuals who have the most dramatic changes in appearance, thus exaggerating the likelihood of positive outcomes. Condensation of time, to fit a television program format, also makes the rate of weight loss and other appearance changes seem extremely rapid. Complications, infections and failed procedures are barely mentioned, giving the impression that negative outcomes are rare. Moreover, the environments in which appearance medicine programs are filmed are often highly artificial, as they provide time and resources (such as equipment, personal trainers and chefs) that are not readily available to the public at large. The recent increase in numbers and popularity of appearance medicine programs has heightened the potential for harm to both participants and viewers. Given the dissatisfaction that participants typically express about themselves and their lives at the programs’ commencement, the extreme psychological pressure that is created during filming, and the difficulty of maintaining rapid weight loss, it would be surprising if all participants and their families walked away unscathed. However, we have been unable to find any follow-up studies of program participants. Another concern is that viewers may be negatively affected by appearance medicine programs. A recent study demonstrated that women who felt societal pressure to be thin had significantly lower self-esteem scores after viewing an episode of The swan, compared with a home improvement program.8 Viewers may find it easier to identify with participants of reality shows than with actors in scripted television programs. This process may contribute to inflating viewers’ expectations of the transformations they themselves could achieve through surgical procedures, and the ease and speed with which these changes occur.9 The issue of the negative effects of appearance medicine television highlights the differences between public concern for the welfare of participants in medical research and television program participants. While researchers need to convince ethics committees that their participants will not be harmed, or induced by money to participate in risky experimental procedures, similar well developed constraints do not exist for television programs. Ethical safeguards for those who choose to participate in such programs are needed, as is research into the effects of these programs on both viewers and participants. Both would help improve participant selection procedures and ensure that vulnerable individuals are not placed in potentially damaging situations.

Keith J Petrie PhD · Kate E Faasse BSc · Sarah A I Fuhrmann BSc

To the Editor: In bicycle accidents, direct impact with the bicycle handlebar can cause serious abdominal injuries. These injuries occur not only in high-speed collisions, where the rider is thrown from the bicycle, but also in low-speed crashes, where the bicycle handlebar strikes the rider in the abdomen or pelvic region.1 We retrospectively reviewed all children who presented to Princess Margaret Hospital for Children with abdominal bicycle handlebar injuries from January 2002 to July 2007. The patients were identified from the emergency department trauma database; 60 boys and 10 girls were identified, aged 5–15 years. Significant injuries (defined as injuries to the liver, spleen, kidney, pancreas, small bowel, stomach or urinary bladder) were noted in 25 of the 70 patients (36%), and 15 of the 70 patients (21%) required surgery. Twenty-one patients (30%) had handlebar imprints on the abdomen (Box, A), and 17 of them (81%) had significant injuries. Traumatic abdominal wall hernia (TAWH) was present in three patients (Box, B). The odds of a significant injury were 21.8 times higher (95% CI, 5.8–82.1) for patients with handlebar imprints than for those with no handlebar imprints. Computed tomography (CT) was the main method of diagnosis of significant injury, and there was a statistically significant association between handlebar imprints and a positive CT scan result, defined as evidence of a solid or hollow viscus injury (2-sided Fisher’s exact test, P = 0.01). Of those patients who underwent CT scanning, 89% of those with handlebar imprints (16/18) had a positive CT scan, compared with 36% of those with no handlebar imprints (4/11). The odds of a positive CT scan were 14 times higher (95% CI, 2.1–95.1) for patients with handlebar imprints than for those with no handlebar imprints. Similar rates of significant injury resulting from impact with handlebars have been reported previously.2 TAWH was first described in 1906,3 and 31 cases of handlebar-related TAWH in children have been reported to date, excluding our cases.4,5 TAWH is produced by sudden application of blunt force to the abdomen that does not penetrate the skin, but is strong enough to disrupt muscle and fascia. Surgical repair is usually required to prevent complications.5 Children with handlebar imprints should be observed closely, and assessed by CT scan and treated surgically as indicated. They should be encouraged to use protective gear, such as handlebar padding, helmets and protective clothing, when riding bicycles. Injuries caused by bicycle handlebars in children A: Handlebar imprint on abdomen. B: Traumatic abdominal wall hernia, caused by handlebar injury, with omentum protruding through the defect.

Parshotam K Gera · Andrew P Barker · Ian Gollow · Jillian Orford · Sue Wicks · Liz Whan

To the Editor: We read the article by Bunting and colleagues1 with interest, as it attempted to address the important question of whether agitation and aggression are more commonly seen with methamphetamine toxicity. However, we have several concerns about the results presented in this study and the conclusions drawn by the authors. First, while they have shown that methamphetamine users were more likely to be agitated and aggressive than patients in other “toxicology-related presentations”, this is not surprising. The most common “toxicology-related presentations” to emergency departments are deliberate self-poisonings with drugs like paracetamol, non-steroidal anti-inflammatory drugs, and benzodiazepines,2 and these agents do not cause significant agitation. The control group in the study by Bunting and colleagues should have been patients presenting with toxicity associated with other recreational drugs. Second, the real issue is whether agitation and aggression are more common with methamphetamine than with other sympathomimetic agents, such as cocaine, amphetamine and methylenedioxy-methamphetamine, as well as ketamine. The authors should therefore have compared patients in methamphetamine-related presentations with those presenting with toxicological symptoms related to this group of drugs, which have also been shown to be associated with significant aggression.3,4 Third, the authors have not stated how they determined whether the presentation was related to methamphetamine or other drugs. It must be assumed that this was on the basis of patients’ self-report. Patients could potentially have been miscategorised without appropriate confirmatory toxicological screening. Fourth, the authors made no comment on the effect of ethanol co-ingestion and the risk that this can precipitate violence and aggression, which could be a considerable confounding factor. Previous authors have reported that violence and aggression are more commonly associated with ethanol ingestion than with use of other recreational drugs.4 Finally, we are concerned that the conclusion of their abstract is not backed up by the results of their study, as there are no data presented to support their statement that “methamphetamine appeared to be used consistently, rather than as an episodic ‘party drug’”. We therefore urge that clinicians interpret the results of this study with caution.

Paul I Dargan · David M Wood

Musculoskeletal conditions are a major contributor to the burden of disease globally and their impact is predicted to increase. Consistent with findings in other countries, the current standard of musculoskeletal education in Australian medical schools is inadequate to meet today’s musculoskeletal care requirements. A national multidisciplinary approach unifying the key musculoskeletal clinical and basic science disciplines has been adopted to provide clear, evidence-based education guidelines that are specifically aimed at priority musculoskeletal conditions; a direct link is therefore established between community health care needs and education at a national level. This “top-down” approach provides the potential for a far more effective and efficient delivery of musculoskeletal education by allowing the identification of the key basic knowledge and skills required to achieve core competencies and by providing appropriate direction for students. The Australian Core Competencies in Musculoskeletal Basic and Clinical Science are being developed for medical schools to incorporate into their curricula, with the ultimate aim of improving the standard of health care for Australians with musculoskeletal conditions.

Mellick J Chehade PhD, MB BS, FRACS(Ortho) · Aleksander Bachorski BE(Hons), GradDip(MW

New medical graduates expect to work in an environment that allows scope for flexibility and change across a career in medicine. Recruitment to general practice is adversely affected by its perceived limited scope of practice. Training in procedural and hospital skills is not difficult to access for general practice trainees, but complex and inconsistent credentialling criteria and protectionist attitudes among some specialist colleges mean that many skilled general practitioners are unable to utilise the full range of their skills in clinical practice. The discipline of emergency medicine is also experiencing difficulty in recruiting trainees. The employment of skilled GPs in emergency departments (including metropolitan departments) could improve vocational satisfaction for GPs and emergency physicians, and possibly also improve patient outcomes and flow through the emergency department.

Simon M Willcock PhD, FRACGP, DipRACOG

Updated guidelines recommend improving access to specialised stroke units and thrombolytic therapy, and the rapid assessment of patients with transient ischaemic attacks for stroke risk Stroke, with its high incidence and serious consequences, is one of the foremost health challenges for Australia and globally. Although stroke rates appear to be decreasing,1 population ageing will intensify the impact of this disease and the need for effective prevention and management strategies.2 Stroke is a complex disease with a range of causes, manifestations, outcomes and treatment approaches, but is too common and costly to be left as the province of a single clinical discipline, neurology. As the therapeutic time window in which to rescue or “protect” the brain from ischaemic damage is extremely short, there is a need for good systems of communication and responsive, expert team care, both in the community and in hospitals, to ensure safe and effective delivery of interventions early after onset and in subsequent phases of acute stroke. Indeed, the single most important therapeutic advance in stroke medicine is arguably the recognition that well coordinated, multidisciplinary care in the form of stroke care units (SCUs) can significantly improve the chances of recovery from stroke. So how can we improve patient access to expert SCU care and therapies that provide the best opportunity for a favourable outcome? A popular approach to improving the quality of health care delivery is the development of clinical guidelines. A good example is the Clinical guidelines for acute stroke management,3 produced by the National Stroke Foundation in 2007. These guidelines update a document published in 2003 and are available from the Foundation’s website (http://www.strokefoundation.com.au). They aim to provide clinicians and patients with all the key information needed to make the best decisions about the benefits and risks of treatment, through the use of systematically developed statements, recommendations and algorithms based on supporting grades of evidence. In addition, the document may provide a degree of medicolegal protection for the treating clinician, and political leverage for developing services both locally and generally. So what can we learn from these stroke guidelines, developed with specific relevance to the local context? The guidelines followed the rigorous standards of development and production set down by the National Health and Medical Research Council (NHMRC) and cover a wide range of clinically relevant topics in a simple, accessible format. The multidisciplinary expert working group that developed the guidelines is to be commended for seeking a wide range of external advice and comment, for incorporating consumer values and preferences in a unique additional grading of the recommendations, and for making sensible judgements for nearly half of the 148 recommendations where high-level randomised evidence was lacking — not surprisingly, mainly in the areas of supportive care and early rehabilitation. A key recommendation emphasised in the updated guidelines is the need for rapid assessment and management by specialists of patients who present not only with established features of an acute stroke but also with a transient ischaemic attack (TIA). TIA has generally been considered more “benign” than stroke and akin to migraine, because of its brevity and reversibility. However, recent studies show that the risk of recurrent stroke early after a TIA is similar to the risk after mild ischaemic stroke: about 10% in the first week and 20% by 3 months.4,5 Thereafter, the annual risks of stroke and myocardial infarction are around 5% and 2%–3%, respectively.6 Given that 30%–40% of patients with ischaemic stroke have had a preceding TIA or minor stroke,7,8 and that evidence is accumulating of the benefits of early interventions such as antiplatelet therapy, blood pressure-lowering therapy and carotid endarterectomy, TIAs provide an important opportunity for stroke prevention.8,9 However, the diagnosis of true stroke-related “focal” TIA is often challenging as it generally relies on patients recalling symptoms from a time when they were possibly impaired. As outlined in the stroke guidelines, a simple measure — the ABCD2 tool (a 7-point score calculated from age, blood pressure, clinical features, duration of symptoms, and diabetes status [Box])10 — can help clinicians, including those in primary care, with patient triage. Those at “high” risk of subsequent stroke have the option of admission to hospital to expedite investigations and management, while those with “low” risk could be followed up quickly in specialist outpatient clinics, where available. Early assessment offers further benefits for patients, through establishing correct diagnoses for TIA-mimics, such as syncope, seizure, anxiety–hyperventilation and vestibular disturbance, allowing specific interventions and avoidance of unnecessary, costly and sometimes risky avenues of management. For all these reasons, and as suggested by Kehdi et al in this issue of the Journal,11 early in-hospital management of patients with TIA may improve outcomes. However, there are major implications for resources and service configuration if rapid expert neurological assessment is to be provided to patients who present to emergency departments with TIA as well as those with stroke. Importantly, the stroke guidelines also included cost-effectiveness analyses of the currently available, clinically proven interventions for prevention and treatment of stroke. Most noteworthy was the finding that substantial economic and health-related benefits could be derived from improved patient access to high-quality stroke services through a modest additional investment of resources. Given that a substantial proportion of the Australian population lives in rural or remote areas, where there are no SCUs or other specialty services, the guidelines recommend the creation of networks linking smaller regional and rural centres to larger centres with SCUs. Furthermore, as the availability of SCUs varies widely even in urban settings, the guidelines recommend that ambulances preferentially transfer patients with suspected stroke to hospitals with SCUs. This recommendation is controversial. Recent audits12 and experience indicate that not all SCUs are resourced appropriately to allow safe and effective use of the thrombolytic agent, recombinant tissue plasminogen activator (rtPA), in carefully selected patients who present within the first few hours after the onset of ischaemic stroke. Given that rtPA is proven to be cost-effective, a reorganisation of services to allow ambulances to route patients directly to “active rtPA SCUs” could allow many more people to benefit from this treatment. How can the recommendations in the stroke guidelines be implemented in the real, service-challenged world, where modifying the behaviour of clinicians and providers is difficult, and clinical settings are often not conducive to change? The transfer of evidence into clinical practice has, to date, been unpredictable and often slow and haphazard for many reasons, including poor knowledge, limited therapeutic expertise, lack of time and, in particular, economic restraints. The use of guidelines can better align clinical management with evidence-based practice, but this is difficult when expertise and services are non-existent or inappropriately resourced. There is limited empirical evidence to support any specific strategy for change over another, but current data suggest that change is possible through comprehensive approaches that target different levels and settings in the health care system.13 The stroke management guidelines are a positive step. Implementation strategies, including the development of policy at the highest, central level, are now needed. A key step would be for the federal government to mandate the recommendation of the National Service Improvement Framework that all people with acute stroke receive SCU or appropriate alternative care around the country.14 Implementation of such policies would provide the best opportunity to improve the outcomes for patients with stroke and the growing population at risk of this devastating illness. ABCD2 tool for assessment of patients with transient ischaemic attack10 A. Age ≥ 60 years = 1 point. B. Blood pressure ≥ 140/90 mmHg = 1 point. C. Clinical features: unilateral weakness = 2 points, speech impairment alone = 1 point. D. Duration > 60 minutes = 2 points, 10–59 minutes = 1 point. D. Diabetes = 1 point. Total. 0–3 = low risk of stroke, 4–7 = high risk of stroke.

Craig S Anderson FRACP, PhD

Objective: To compare outcomes at 28 days and 1 year between patients admitted to hospital and those discharged after presenting to the emergency department (ED) with transient ischaemic attack (TIA).Design and setting: All TIA presentations to EDs in a large metropolitan and rural region of Sydney and its surroundings, New South Wales, between 2001 and 2005 were extracted from state health department databases and followed up over 1 year. Admission and discharge data and subsequent TIA or stroke presentations were identified.Main outcome measures: TIA recurrence or stroke.Results: Of 2535 presentations to an ED with TIA during the 5-year period, 1816 patients were admitted to hospital (71.6%) and 719 were discharged from the ED (28.4%). At 28 days, the discharged group had significantly higher rates of recurrence than the admitted group for all events (TIA or stroke) (5.3% v 2.3%, P < 0.001), stroke (2.1% v 0.7%, P = 0.002), and recurrent TIA (3.2% v 1.6%, P = 0.01). During the 29–365-day follow-up period, there was no significant difference between the discharged and admitted groups for all events (4.2% v 5.1%; P = 0.37), stroke (1.3% v 2.5%; P = 0.06) or recurrent TIA (2.9% v 2.6%; P = 0.65).Conclusion: Patients with an ED diagnosis of TIA may benefit from admission to hospital through a reduced risk of early stroke.

Elias E Kehdi MB BS, MOptom · Dennis J Cordato FRACP, PhD · Peter R Thomas PhD · Roy G Beran FRACP, MD · Cecilia Cappelen-Smith FRACP, PhD · Neil C Griffith FRACP · Ibrahim Y Hanna FRACP · Alan J McDougall FRACP, PhD · John M Worthington FRACP, BSc · Suzanne J Hodgkinson FRACP, PhD

Objective: To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria.Design, setting and participants: Retrospective analysis of paediatric motorcycle injuries (1 July 2000 – 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children’s Hospital (RCH), Melbourne.Main outcome measures: Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers.Results: The VEMD recorded 3163 patients aged ≤ 16 years presenting to EDs with motorcycle injuries during the study period; population-based rates of these injuries increased by an average of 9.6% per year (95% CI, 6.2%–13.1%; P < 0.005). In the same period, there was a total of 167 motorcycle-related admissions to the RCH, increasing annually in line with statewide ED presentations. About a quarter of paediatric motorcycle accidents occurred in children aged under 10 years (VEMD, 22%; RCH, 27%) and most occurred off road (VEMD,89%; RCH, 71%). At the RCH, median length of stay was 3 days (interquartile range [IQR], 1–7 days) and the median Injury Severity Score was 9 (IQR, 4–10); 41% of patients required an operation, 13% were admitted to an intensive care unit, and two died.Conclusion: In Victoria, the incidence of motorcycle-related injuries is increasing in children and adolescents. Most of these injuries occur off road, outside of any legislative framework. There is an urgent need for coordinated legislative changes and educational efforts to decrease motorcycle injuries in children.

Catherine A Bevan MB BS, MRCPCH · Franz E Babl MD, MPH, FRACP · Penny Bolt MB BS, FRACP · Lisa N Sharwood RN, MPH

Re: “Bystander basic life support: an important link in the chain of survival for children suffering a drowning or near-drowning episode”, by Jeanette Marchant, Nicholas G Cheng, Lawrence T Lam, Fiona E Fahy, S V Sounndapound, Danny T Cass and Gary J Browne, in the 21 April 2008 issue of the Journal (Med J Aust 2008; 188: 484-485). The fifth author’s name was spelled incorrectly. The correct spelling of the author’s name is S V Soundappan. The web version of this article was corrected on 2 June 2008.

Jeanette Marchant · Nicholas G Cheng · Lawrence T Lam · Fiona E Fahy · S V Soundappan · Danny T Cass · Gary J Browne