Emergency medicine

Objectives: To evaluate whether introduction of an emergency department (ED) telemedicine system changed patient management and outcome indicators and to investigate clinicians’ perceptions of the impact of the system on care provided and on their work.Design: Before-and-after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real-time audiovisual communication between clinicians at distant sites. Semi-structured interviews were conducted with medical and nursing staff at the end of the study.Participants and setting: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n = 169) and 18 months after (n = 181) the intervention at the district hospital. Thirty-one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study.Main outcome measures: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay).Results: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy.Conclusions: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large-scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians’ work are required.

Johanna I Westbrook BAppSc, MHA, PhD · Enrico W Coiera MB BS, PhD · Michelle Brear BAppScEnvHlth · Stuart Stapleton MB BS, FACEM · Marilyn I Rob MA, CStat, PhD · Monique Murphy BNurs, MHM · Patrick Cregan MB BS, FRACS

Marshall and Ruedy’s On call: principles and protocols. Mike Cadogan, Anthony F T Brown, Antonio Celenza. Sydney: Saunders Elsevier, 2007 (xvi + 576 pp). ISBN 978 0 7295 3803 9. Being on call can be a daunting experience. You are called to a patient you don’t know who has become unwell. They might have developed a severe headache, be short of breath or have chest pain. What are you going to do? When should you call for more experienced help? On call principles and protocols attempts to systematically answer such questions. Based on the book of the same name by Canadian authors Shane Marshall and John Ruedy, it differs in its arrangement, separating interpretation of common investigations and procedures, with a brief formulary to separate sections. For the common problems encountered, the authors detail what questions to ask over the phone and what initial instructions to give. Conditions under which the patient should be given immediate priority are listed. Assessment and management of life-threatening problems are dealt with first, followed by a more complete discussion, including when to call for more experienced help. Interestingly, the authors are all emergency physicians who have probably not been on call for ward patients for many years, but all have experience in medical education and the principles of assessing the emergency patient are not dissimilar. Some hospitals have their own handbooks dealing with hospital emergencies but the approach taken in this text is more systematic and comprehensive. One omission is a discussion of common surgical problems, such as management of diabetes peri-operatively and postoperative analgesia. Guidelines given for managing patients on aniticoagulation therapy, a common on-call problem, are restricted to over-anticoagulation and do not provide detail on heparin and warfarin prescribing. These omissions aside, the style and content of On call principles and protocols is well laid out and the book fills a niche for doctors practising hospital medicine. With a recommended retail price of $60 the book represents value for money.

Robert P Dowsett

To the Editor: The article by Haug and colleagues on household food stockpiling is a useful contribution to a neglected aspect of disaster planning.1 However, rather than providing a guide to what foods should be stockpiled, it may be more valuable to encourage families to increase the amount and rotation of the non-perishables they currently purchase. The authors seek to promote a balanced nutritional diet, but encouraging a family to continue their usual purchasing patterns when stockpiling for a pandemic or other disaster is a simpler, more sustainable, and possibly more effective way to promote household food stockpiling. We must assume that the family currently survives, for better or worse, on their current food purchase pattern. While the article states that supermarket stocks will become depleted within 2–4 weeks, it is likely that stocks would become significantly depleted at an individual store level within 2–3 days of the last truck delivery, particularly if panic stockpiling occurs. How long interruptions to the food supply chain last will depend on the nature of the disaster, but the Australian Government Department of Health and Ageing recommends that people have “enough fluids and food on hand to last you and your family a week.”2 It does not provide guidance on how much water is required per day. This is an important issue, as mains water could be unavailable within hours to days of electricity supply outages, because electricity is required to pump water into elevated water reservoirs to maintain water pressure. People may be unaware of their daily fluid requirements and may run out of water and other potable fluids before they run out of food. The US Health and Human Services recommends a 2-week food and water stockpile (“one gallon of water per person per day”), which is roughly equivalent to four litres per person per day.3 A random household survey in the Hunter Region of New South Wales after a storm-related disaster in June 2007 revealed that over 80% of households had enough non-perishable food for 3 days, but less than 40% had enough stored drinking water for 3 days (Hunter New England Health, unpublished data). Community continuity planning should be based on an understanding of baseline household food and water reserves, and household capacity and willingness to stockpile across all social strata. Governments should actively promote household stockpiling and identify strategies to bridge the shortfall in households unable to stockpile.

Craig B Dalton · Michelle A Cretikos · David N Durrheim

In reply: Dalton et al have raised several important points for discussion. They suggest that an adequate food “lifeboat” can be procured by simply encouraging a family to continue their usual purchasing patterns. Unfortunately, accumulating non-perishable items in this way would be a fast route to certain nutritional deficiency. It is the perishable items — fruit and vegetables, bread, meat and dairy products — that supply the bulk of micronutrients in modern food supplies. Within a few short months, an individual relying on usual pantry supplies could be suffering from acute deficiencies of vitamin C, and folate and other B vitamins. Babies conceived during this period would be at risk of neurological defects. We agree that an important issue is the possibility of failure of the mains water. Indeed, many of the foods in our list require water for cooking (rice, pasta etc). Rainwater tanks and the ability to sterilise water by gas heating or chemical means may be lifesavers. We agree that governments should be actively promoting appropriate stockpiling in homes, places of employment and in areas of essential infrastructure.

Jennie C Brand-Miller · Jennifer McArthur · Anna Haug

Objectives: To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations.Design and setting: Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day.Main outcome measures: Proportion of time spent on tasks and number of procedures performed or observed by interns.Results: Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy.Conclusions: The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.

Jia Ni Zhu · Tracey J Weiland BBSc(Hons), PhD · David M Taylor MD, MPH, FACEM · Andrew W Dent MPH, FRCS, FACEM

Objective: To investigate current use of Australian snake antivenoms and the frequency and severity of immediate-type hypersensitivity reactions.Design: Nested prospective cohort study as part of the Australian Snakebite Project.Patients and setting: Patients receiving snake antivenom in Australian hospitals between 1 January 2002 and 30 November 2007.Main outcome measures: The use of CSL Limited antivenom; frequency and severity of hypersensitivity reactions to antivenom; premedication and treatment of these reactions.Results: Snake antivenom was administered to 195 patients, mostly for venom-induced consumption coagulopathy (145 patients, 74%), followed by non-specific systemic effects (12%), neurotoxicity (5%) and myotoxicity (4%). Antivenom was given to nine patients (5%) without evidence of envenoming or who were bitten by a species of snake for which antivenom is not required. The commonest antivenoms used were brown snake (46%), tiger snake (30%) and polyvalent (11%). The median dose was four vials (interquartile range, 2–5 vials), and 24 patients received two different types of antivenom. Immediate-type hypersensitivity reactions occurred in 48 patients (25%); 21 satisfied our definition of anaphylaxis, with 11 moderate and 10 severe cases, including nine in which patients were hypotensive. The remaining 27 reactions were mild (skin only). Adrenaline was used in 26 cases with good effect. The frequency of reactions to tiger snake (41%) and polyvalent (41%) antivenoms was higher than that to brown snake antivenom (10%). Hypersensitivity reactions occurred in 11 of 40 patients receiving any form of premedication (28%) and in 2 of 11 given adrenaline for premedication (18%) versus 20 of 86 not receiving premedication (23%).Conclusions: Antivenom was used appropriately, and most commonly for coagulopathy. Hypersensitivity reactions were common, but most were not severe. The discretionary use of premedication was not associated with any reduction in reactions.

Geoffrey K Isbister BSc, FACEM, MD · Simon G Brown MB BS, FACEM, PhD · Ellen MacDonald · Julian White MB BS, MD · Bart J Currie MB BS, FRACP

Eight children suffered drowning or near-drowning in Sydney pools over an 11-day period in January 2007. Four received basic life support (BLS) within 5 minutes of immersion and survived with good functional neurological outcomes. The other four were not discovered for ≥ 5 minutes and all died. This cluster serves as a reminder that timely effective bystander BLS is crucial to survival and good clinical outcomes in near-drowning episodes. Clinical recordDuring an 11-day period in January 2007, eight children presented to several emergency departments in the Sydney metropolitan region after a drowning or near-drowning event. While these incidents are known to be more common in summer, it is relatively uncommon to have such a cluster of cases occurring within a short period of time. We retrospectively obtained information on these patients from clinical documentation of the hospitals involved, including ambulance run-sheets, hospital medical records, and coroner’s reports. Details of the patients are shown in Box 1. Seven of the children were from western Sydney, while the other child presented to a hospital in North Sydney. Six were girls and two were boys, with ages ranging from 1.5 to 6 years. In all cases, the children had not been adequately supervised. In seven cases, the approximate period of time for which the child had been unaccounted could be determined from the records. This time ranged from about 1 minute to 20 minutes. Seven of the events occurred in backyard residential swimming pools and the other in a public pool. Three episodes occurred while children were visiting relatives; these children all drowned. Four children had a period unaccounted for of < 5 minutes. Timely effective basic life support (BLS) (defined as adequate ventilation and/or chest compression administered within 5 minutes of non-breathing1) was performed on each of these children by either their parent or a bystander. One patient regained consciousness and BLS was ceased. All four children survived without any neurological deficits. Of the other four children, three had a period unaccounted for of ≥ 5 minutes and one for an unknown time, estimated by the paramedics at the scene to be about 10–20 minutes. BLS was attempted on only one of these four patients. Two of these children died in the emergency department, and the other two had intensive care support withdrawn due to brain death. DiscussionOver the past 10 years, there has been a significant reduction in the number of drowning and near-drowning events in children.2 Several factors have contributed to this decrease, including community education programs alerting parents to the importance of supervising their children; legislation to place fences around backyard swimming pools, and efforts to teach effective BLS in the community.3-5 However, evidence is lacking of good compliance with these preventive measures, particularly backyard pool fencing,6 highlighting the need to continually stress water safety messages to parents. In addition, a recent paradigm shift in resuscitation guidelines, coupled with differences in interpretation of the new guidelines by various resuscitation authorities, has led to confusion among lay rescuers and clouded the key messages that should be delivered to the public.7,8 It is recommended that the guidelines published by the Australian Resuscitation Council should be followed (Box 2).7 Of the eight patients reported here, four received timely effective bystander BLS and had a good clinical outcome. For the other four children, BLS was attempted late or not at all. It is possible that the prognosis of these four children would not have been good even with BLS, given their probable long duration of immersion. Even for children with a period unaccounted for of < 5 minutes, the likelihood of neurological damage increases if effective BLS is not provided immediately. Hence, timely effective BLS is not just crucial for survival but also important for a better clinical outcome. There are avenues for lay people to be trained in BLS, but doing so often requires considerable motivation, as there is a monetary and time burden involved, and retraining is required as guidelines change and skill levels deteriorate. Although community attitudes toward BLS are positive, theoretical knowledge of BLS is poor.9 At our emergency department, when parents are asked about their willingness and ability to perform BLS should their child need it, few respond positively. We believe that a more uniform community effort is required to ensure this vital link in the chain of survival, when the primary prevention measures of supervision and fencing fail. This effort could include universal provision of BLS training in workplaces and in high schools. 1 Details of eight children involved in drowning or near-drowning events in Sydney, January 2007 Patient no. Age (months) Incident location Time unaccounted for (min)* Time to BLS after retrieval Who gave BLS Outcome† 1 49 Relative’s home 20 na na Died in PICU 2 23 Own home < 5 Immediate Medical doctor‡ Survived 3 47 Own home 2–3 Immediate Mother Survived 4 26 Relative’s home 20 Immediate Father Died in PICU 5 17 Relative’s home 5–10 na na Died in ED 6 42 Own home 1–1.5 Immediate Father Survived 7 29 Public pool < 5 Immediate Bystander Survived 8 72 Own home 10–20 na na Died in ED BLS = basic life support. ED = emergency department. na = not applicable because BLS not given. PICU = paediatric intensive care unit. * Best estimate of the period of time the child was unaccounted for (ie, possible duration of immersion). † All children who survived had no neurological deficit. ‡ Present at the time of the event. 2 Basic life support flow chart*7 CPR = cardiopulmonary resuscitation. * Reproduced with permission of the Australian Resuscitation Council.

Jeanette Marchant MB ChB, DCH, MRCPCH · Nicholas G Cheng MB BS, DCH, FRACP · Lawrence T Lam MAppPsy, MPH, PhD · Fiona E Fahy RN, RM, MN(Perioperative) · S V Soundappan MB BS, MS(General Surgery), MCh(Paediatric Surgery) · Danny T Cass MB BS, PhD, FRACS · Gary J Browne MD, FRACP, FACEM

To the Editor: The assertion of Davis and Batmanian and their colleagues that thrombolytic treatment for ischaemic stroke is reasonably safe and highly effective1,2 is not supported by the primary randomised trials of its use.3 Is tissue plasminogen activator (tPA) safe? It remains undisputed that none of the trials for thrombolysis in stroke have shown any mortality benefit.4 All of the trials have shown increases in symptomatic intracranial haemorrhage; in the NINDS trial, the increase was from 0.6% in the placebo arms to 6.4% in the treatment arms — a 1000% relative increase — and 45% of those with symptomatic bleeds died.5 Presumably, any mortality benefit from opening blocked arteries is lost because of the increased mortality from intracranial bleeding. Therefore, the drug is not safe. Is tPA effective? Thrombolysis for acute myocardial infarction was assessed in tens of thousands of patients in many independent studies, with virtually all showing clear mortality benefit. By comparison, the stroke thrombolysis literature is full of negative studies, with only one positive result. The NINDS trial4 stands alone as the only randomised controlled trial (RCT) providing positive evidence for thrombolysis for stroke. Ignoring criticisms of its interpretations and methodology, of which there are many, it had fewer than 600 patients and its results have not been reproduced independently. Breaches of protocol continue to be published. Batmanian and colleagues gave patients tPA after 180 minutes despite all the evidence saying this has no benefit, justifying it by saying the decision had been made at 170 minutes.2 Davis and colleagues1 based their claims of safety and efficacy on registries, subgroup analyses, meta-analyses, and expert panels all based on the same single RCT — the NINDS trial.4 This is low-grade evidence for a potentially lethal therapy. It is time a major RCT was done to repeat the NINDS trial and finally determine whether its result was a statistical anomaly or a real effect. There is no shortage of stroke patients — Batmanian et al found that 14% of patients were eligible for this therapy.2 The paucity of evidence for thrombolysis for stroke does not justify rushing patients to stroke centres, bypassing perfectly good hospitals in the hope of finding some of the 3% of patients eligible for treatment, of whom one in eight (0.38% of all stroke patients) would theoretically have a better neurological symptom score if given thrombolysis.6,7 I feel that it is a waste of time and effort, and a danger to patients, to focus all resources on supplying a potentially lethal therapy that is often incorrectly used and provides a marginal benefit.

Gino J Toncich

To the Editor: I found it ironic to read the recent editorial by Davis and colleagues endorsing the use of tissue plasminogen activator (tPA) therapy for stroke patients.1 The irony relates to the fact that a week later I attended the annual scientific meeting of the Australasian College for Emergency Medicine, where data were presented (Hoffman J. New information on the use of tPA in acute ischaemic stroke. 24th Annual Scientific Meeting of the Australasian College for Emergency Medicine; 2007 Nov 25–30; Gold Coast, Qld) that cast strong doubt on the conclusions derived from the NINDS trial.2 There are further objections to the claim that the value of tPA has been adequately proven,3 none of which are remotely addressed by the editorial. As an emergency physician, this dichotomy of opinion is frustrating. There is obviously conflicting evidence, which usually means that data are insufficient. Hence, until more research is completed, especially clinical trials that replicate the original NINDS study, the claim of Davis et al that tPA is “highly effective, reasonably safe and grossly underused”1 is inappropriate.

Daniel M Fatovich

In reply: We welcome the opportunity to respond to issues raised by Hurley and Toncich. Australian, United States and European stroke guidelines based on level 1, grade A evidence recommend intravenous recombinant tissue plasminogen activator (IV-rtPA) for patients with acute ischaemic stroke (AIS) who meet specific inclusion criteria and present within 3 hours of AIS onset.1,2 Recombinant tPA is approved for this indication by the Therapeutic Goods Administration. We obtained informed consent before thrombolysis, but recognise that this is challenging because of the urgent need to initiate treatment, rather than doubts regarding benefit. A Cochrane systematic review of eight randomised controlled trials (RCTs), which together comprised 2955 patients, concluded that IV-rtPA within 3 hours of AIS onset was more effective in reducing death or dependency (odds ratio [OR], 0.66; 95% CI, 0.53–0.83), with no statistically significant adverse effect on death (OR, 1.13; 95% CI, 0.86–1.48).3 The Third International Stroke Trial (IST-3), which Hurley cites to support his view that sub-3-hour stroke thrombolysis remains controversial, was in fact designed to address different issues: efficacy of rtPA given 3–6 hours after symptom onset and to those aged over 80 years, as well as imaging predictors of response. We believe Hurley’s figure from his own letter is an incorrect attempt at meta-analysis. He combines data from RCTs and selected observational studies (excluding the Safe Implementation of Thrombolysis in Stroke Monitoring Study [SITS-MOST] of 6483 patients4), a method subject to selection bias. Although the original Cleveland study (as cited by Hurley) showed high rates of intracranial haemorrhage, 50% of patients in the study were not treated according to the protocol. The incidence of intracranial haemorrhage was subsequently reduced to the expected level following implementation of a quality improvement program to ensure strict adherence to protocols.5 Hurley suggests that projections of IV-rtPA benefits are misleading because of baseline imbalances in the NINDS trial. These concerns were addressed by reanalysis of the data by an independent committee commissioned by NINDS,6 which not only reconfirmed the original results but suggested an even greater benefit for AIS patients receiving IV-rtPA. We believe Hurley’s statement that mortality rates are increased when stroke thrombolysis occurs in non-teaching hospitals is unsubstantiated. In the study cited, mortality rates were similar to those observed in RCTs of IV-rtPa, with no difference between teaching and non-teaching hospitals.7 Indeed, large registries in Europe (where 50% of centres had little or no prior experience)4 and in Canada8 report efficacy rates following thrombolysis similar to those from RCTs with lower rates of intracranial haemorrhage and mortality. In our view, IV-rtPA within 3 hours of AIS does not require more RCT evidence. Due to therapeutic inertia, only a small proportion of eligible stroke patients receive this therapy. Comprehensive acute stroke protocols in the emergency department in partnership with stroke clinicians could improve delivery of this highly effective treatment.

Julia J Batmanian · Meeyin Lam · Caitlin Matthews · Andrew Finckh · Martin Duffy · Robert Wright · Bruce J Brew · Romesh Markus

In reply: Stroke experts around the world consider that the evidence for thrombolysis with tissue plasminogen activator (tPA) within 3 hours is overwhelming. Licensing authorities such as the Therapeutic Goods Administration in Australia and the Food and Drug Administration in the United States have approved use of tPA after rigorous, independent analysis of all the available data. However, it seems that a minority of sceptical emergency physicians remains, who will probably never be convinced. Further trials in the sub-3-hour time window are unlikely to receive ethical approval. The focus of stroke research has now moved on. Current targets include expansion of the time window and alternative approaches to recanalisation such as intra-arterial thrombolysis and clot retrieval. Hurley states that there was a baseline imbalance in the pivotal NINDS trial in favour of tPA. We think this old chestnut was laid to rest by an independent reanalysis of the NINDS data.1 The quoted Cochrane review included all thrombolytic agents (such as the now-abandoned streptokinase),2 whereas meta-analyses restricted to tPA alone are unequivocally positive.3 The figure presented by Hurley is misleading, combining both randomised controlled trials and selected population registries — yet excluding SITS-MOST, an observational study of 6483 patients.4 Both Toncich and Fatovich criticise the trial evidence. This contrasts not only with the virtually universal expert opinion of stroke clinicians, but also with the opinion of many emergency physicians.5,6 Indeed, the INSTINCT (Increasing Stroke Treatment through Interactive behavioral Change Tactics) trial aims to identify local barriers to the use of tPA in emergency departments, with the goal to increase appropriate use of tPA in acute ischaemic stroke.5 Finally, stroke physicians do not need to be neurologists. We consider that most general physicians, and indeed emergency physicians, should acquire the core skills to deliver intravenous tPA in acute ischaemic stroke. Would anyone familiar with modern stroke medicine deny tPA to an otherwise well 65-year-old with hemiparesis who presents 90 minutes after symptom onset? It is critical that all eligible patients in Australia are offered this licensed therapy.1-6

Stephen M Davis · Peter J Hand · Geoffrey A Donnan

To the Editor: A 20-year-old sub-elite Australian Rules football player presented with pain and tenderness in the lower third of the sternum. He had been involved in a moderate body collision with an opposing player about 3 weeks before presentation, and had continued to train and play despite sternal discomfort. He described no other symptoms. On examination, there was no obvious sternal deformity. There was mild to moderate tenderness over the lower third of the sternum, and minimal sternal discomfort on lateral chest compression. Chest auscultation was clear. Plain chest and sternal x-rays were normal. A technetium-99m HDP bone scan showed increased tracer uptake in the lower sternum, consistent with an undisplaced oblique sternal fracture (Box). Management of the player’s injury and his fitness to train and play were discussed informally with medical and paramedical practitioners. Their opinions ranged from an immediate return to competition to 12 weeks of complete rest. After discussions within the player’s club, he was placed on a training regimen that avoided all upper body clashes and stresses, and he was rested from match play. He was regularly reassessed for symptoms and made an uneventful return to full competition 6 weeks after his initial injury. He remained asymptomatic and competitive for the remainder of the season and at 1-year review. The usual cause of sternal fracture is blunt anterior chest trauma, with about 90% of sternal fractures caused by trauma resulting from the forces associated with motor vehicle accidents.1 Sternal fracture is rarely encountered in Australian Rules football and such a case has not previously been described in the literature. The Australian Football League Injury Report database revealed only four cases of sternal fracture over the period 1992–2006, accounting for a total of 18 missed games (range, 1–11 games) (John Orchard, Conjoint Senior Lecturer, Sports Medicine Program, University of New South Wales, personal communication, May 2007). Patients suspected of suffering a sternal fracture should be investigated with appropriate chest x-rays. If these are inconclusive, it is now suggested the patient should be further investigated with sternal ultrasound, which has recently been demonstrated to be superior to bone scan in identifying sternal fractures,2 and without the associated radiation exposure. Patients with an acute suspected sternal fracture should also undergo electrocardiography. If the electrocardiogram is normal and there is no evidence of intrathoracic injury on radiological investigation, the patient can safely be discharged.3 Chest pain is the predominant persisting symptom after sternal fracture.4 Conservative management with rest, analgesia and/or anti-inflammatories, and, if required, appropriate padding and taping5 should result in full recovery and an uneventful return to competition. Bone delay views from dynamic localised technetium-99m HDP bone scan There is a band of low to moderate tracer uptake running in a slightly oblique line across the lower sternum (arrow), suggesting a sternal fracture.

Robert J Douglas

Transsexual and other disorders of gender identity: a practical guide to management. James Barrett, editor. Oxford: Radcliffe Publishing, 2007 (298 pp). ISBN 978 185775 719 4. This is an outstanding book, fulfilling a marked need. Barrett, principal author and editor, is a consultant psychiatrist and lead clinician at the Charing Cross Hospital Gender Identity Clinic in London. He draws on 20 years’ clinical experience; his writing and presentation are clear and most helpful. The book concentrates on the major aspects of the health care of transgender men and women, including the role of the psychiatrist and the contributions made by other medical specialists, speech therapists, and surgeons. That the general practitioner’s role in patient care was not given emphasis surprised me. GPs are often in the best position to provide continuity of patient care and coordination of the various specialist consultations. For the male-to-female transsexual, a masculine voice may be the major obstacle to the person being accepted in the desired sex role. Two chapters describe what can be achieved by speech training and laryngeal surgery. Feminisation of the male body or masculinisation of the female body is one of the most urgent requests that transgender patients have at their first consultation. Once their diagnosis of transsexualisation has been established, they will require lifelong hormone therapy. The chapter on this subject is essential reading. It is a masterly dissertation on all of the principles of hormonal treatment and the various regimes and modes of administration. Side effects of such therapy and their management are also discussed. Discussions of surgical treatments deal with breast augmentation or reduction, removal of penis and testicles, vaginoplasty, vulvoplasty, and phalloplasty. All are excellent chapters, but that on phalloplasty deserves special mention because it deals with a difficult and complex subject in an enlightening manner. In all of these chapters, postoperative care and complications are adequately discussed, along with limitations of the various surgical procedures. The legal issues of gender change are included in a chapter that addresses marriage, the family, employment, pensions and privacy. Even transsexuals in the military services, various religious traditions and their teachings about gender change, and fertility issues affecting transsexuals are considered in the concluding chapters of the book. The editor and authors have definitely produced a practical text on gender identity disorders for everyday clinical use. I strongly recommend it to all health care professionals involved in the care and management of patients with issues of gender identity. Educators in medicine and the health sciences should consider recommending this book for their undergraduate students. It can truly be said that this book is a clinical gem.

William A W Walters

Initiatives to prevent access block should be aimed at long-term structural changes to bed availability to meet the needs of a complex and ageing population; current management practices are creating a growing mismatch between supply and demand The Australasian College for Emergency Medicine and the Australian Council on Healthcare Standards have defined access block for emergency patients as the percentage of all patients admitted, transferred or dying in the emergency department (ED) where their total ED time exceeds 8 hours.1 Simply put, access block is the absence of flow at a system level, not just the ED. In United States literature, access block is referred to as “overcrowding”. How does flow stop?In Australia, the total number of acute hospital beds has decreased over the past two decades, with a 14% decrease in the number of public hospital beds between 1992 and 2002.2,3 In the US, the number of medical and surgical beds declined by 18% from 1994 to 1999, while ED attendances increased by 15%.4 During this time, there have been concomitant decreases in inpatient length of stay and more day procedures and day admissions.5 However, in the United Kingdom, after a period of decline, the number of multiday admissions per 1000 residents increased in 2002 and 2003. This was thought to be the result of postponed demand related to illnesses for which there were waiting lists, and to the increasing burden of chronic disease. In 2003, 30% of the multiday admissions could be attributed to just 20 International classification of diseases, ninth revision (ICD-9) diagnoses, and a third of these were attributable to chronic heart disease.6 CapacityCapacity decisions in hospitals are generally made without the help of quantitative model-based analyses.7 Hospital managers have been stimulated to reduce the number of beds and increase the occupancy rates to improve operational efficiency. Modelling is usually based on average bed occupancy. However, this model is not capable of describing the complexity and dynamics of the patient flow. This is known as the flaw of averages. A formula has been described that can be applied to almost every queuing system.8 It shows the relation between the expected number of patients in the system, EB(t), the average length of stay (μ), and the unscheduled need, described by the Poisson process, λ: EB(t) = λμ For example, at an intensive care unit (ICU), five patients arrive per day on average. The average length of stay is 6 days. The parameters of this queuing system are: λ = 5 and μ = 6. Using the above formula, the expected number of patients at the ICU is 30. If management decides to size the unit on this average bed number, operational problems will occur on a regular basis. The probability (Pi) that more than 30 beds are occupied at any time is easily calculated according to the formula: Pi = e-λμ(λμ)i/i! where e = expotential and i = the number of beds occupied. In this example, Pi = 0.45 (ie, need will exceed capacity 45% of the time).9 It has been shown that a high degree of reserve capacity (up to 30%) is required to avoid high rates of surgery cancellations because of unavailable beds downstream.10 However, most health policy experts believe that a 15% capacity buffer is adequate, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more.11 Ageing populationIt is projected that between 1996 and 2016, the general population in Australia will increase by 21% or 3.1 million, the number of people over the age of 65 years will increase by 59% or 1.3 million, and those over the age of 80 years will increase by 76% or 368 000.12 The effect of the ageing population on access block is twofold. As noted earlier, there is already a relative decrease in access to residential care beds in the community, especially beds designated for high-dependency patients, in the face of a significant growth in the number of people seeking placement.13,14 It has been shown that incidence rates of institutional aged care double for each 5-year interval from the age of 60 years.15 The general effect of illness and ageing must also be considered. In one study, undertaken between 1990 and 2004, while there was a 54% increase in the total number of ED patients, there was a disproportionate increase of 198% in the number of patients aged over 70 years, including a 671% increase in the number of those aged over 90 years. The time taken to manage patients increased with age, with older patients (aged over 70 years) being 4.9 times more likely to require admission to hospital than younger patients (aged 30 years or less), and older patients’ average length of stay was 6.9 times longer. There were 3.3 times more younger patients than older patients, but older patients occupied 9.8 times more ED bed-days.16 Preventing avoidable hospitalisationsIn response to unprecedented and sustained increases in demand for health care services that were placing significant pressures on hospitals, the Victorian Government committed $582 million as an initial investment over 4 years from 2001–02 to 2004–05 to implement the Hospital Demand Management Strategy. Of this allocation, $150 million was invested to develop new approaches to caring for patients known to have a high risk of deterioration in their health, and thus preventing avoidable hospital use in the future. These new approaches to patient care were developed, implemented and evaluated through a program called the Hospital Admission Risk Program (HARP). Many patients with complex and chronic illnesses were treated as hospital outpatients or in the community. These programs have shown good initial outcomes with HARP patients experiencing 35% fewer ED attendances and 52% fewer ED admissions, and 41% fewer days in hospital.17 There are, however, some emerging data that question the sustainability of the early gains of these programs, in the face of age and worsening disease.18 The federal–state divideIn Australia, health care is funded by both federal and state governments. Public hospital funding is largely provided by the state, and primary and subacute care is funded by the federal government. Aged care provides a good example. The federal government has responsibility for residential aged care. In the absence of adequate residential capacity for the aged, patients are inappropriately accommodated in public hospitals. Solving this problem will require a combined approach to stop the “buck passing” between the federal and state governments.19 OutcomesAccess block is not an inconvenience. It is not a problem of EDs. Access block is an illness, and not a benign illness. It has a morbidity and mortality rate and a growing literature about it. A search in MEDLINE (1950 to Week 2 of October 2007) using the keywords access block, crowding and overcrowding identified 163 articles. This Journal alone has published 26 articles in recent years. We know that access block causes ambulance diversion,20 independently predicts increased inpatient length of stay21,22 and increases patient mortality.23,24 One study reported 43% more deaths in an overcrowded cohort compared with a non-overcrowded cohort of ED patients, with the effect more profound in the older population. Another showed a linear relationship (R2 = 0.95) between the degree of overcrowding and 7-day mortality.24 There is a high correlation between overcrowding and patients who leave an ED without treatment. Another report showed a 0.665 correlation between increasing overcrowding and the rate of patients who left before being treated.25 While most of these patients are not in the high-acuity triage categories, tragic consequences can nevertheless arise. In the case of one patient who died of infective endocarditis after being discharged from an ED, the coroner concluded that “it has to be recognised that as a matter of common sense, in an environment of severe overcrowding the potential for error on the part of medical practitioners, especially in a setting where a decision has to be made as to whether a patient should be discharged or not, will inevitably exist”.26 A previous editorial in this Journal proposes two solutions — reduce hospital demand and optimise bed capacity.27 I would propose that we acknowledge the limitations of the first strategy as our population ages and requires increasing community support. As shown earlier, bed capacity needs to be able to meet surge requirements and not the average need. While ED and inpatient reforms have and will deliver some gains, the problem we now face is bed stock. ED overcrowding is not caused by patients in low-acuity triage categories who present to the ED and are able to be quickly discharged. These patients are dealt with through a variety of “streaming” processes (eg “fast track” or “likely discharge” models of care). It is patients who need hospital admission who drive the system into ED cubicle block and overcrowding.

George Braitberg FACEM, FACMT, DipEpiBiostats

Objective: To determine characteristics and outcomes of patients who did not wait to see a doctor in emergency departments (EDs).Design and setting: Population-based outcome study using probabilistically linked ED and Western Australian death records, with ED records from all seven Perth public hospitals that have EDs from 1 July 2000 to 30 June 2003.Main outcome measures: Rates of “did not wait” (DNW) presentations, overall and for individual hospitals; characteristics of DNW patients; mortality rates among DNW patients at 2, 7 and 30 days.Results: DNW rates varied from 2.6% to 6.3% (average, 4.1%) and were generally lower in tertiary teaching hospitals. DNW patients had conditions of lower urgency, predominantly Australasian Triage Scale category 4 (67.1%) and 5 (23.4%). The DNW rates in these categories were 5.8% and 10.6%, respectively (P < 0.001). Patients referred by health care providers had lower DNW rates (0.5%; P < 0.001). DNW patients were more frequently male (4.4% v 3.8%; P < 0.001), and young to middle-aged adults (15–44 years; 5.8%; P < 0.001). Patients with a higher than average DNW rate were more likely to arrive by private transport (5.0%; P < 0.001) or with police (5.8%; P < 0.001), re-present for review (8.6%; P < 0.001) or have social or behavioural problems (7.7%; P < 0.001). Most patients (91.9%) did not wait on only one occasion. The 30-day mortality rate among DNW patients was significantly lower than for patients seen by a doctor and discharged (0.14 v 0.20%; P = 0.026), and for all patients seen in the ED (1.28%; P < 0.001).Conclusions: Patients who did not wait for medical assessment in Perth EDs had conditions of lower acuity and had lower mortality rates than those who waited for assessment.

Jacqui Hall MB ChB, FACEM · George A Jelinek MD, FACEM, DipDHM

Objectives: To assess changes in emergency department (ED) activity and visits to EDs that could have been managed by general practitioners (GP-type visits) in the Christmas and New Year holiday period compared with the rest of the year.Design and setting: Retrospective descriptive and analytical comparison of New South Wales ED visits in the holiday period and the rest of the year; data were obtained from the NSW Emergency Department Data Collection database for the period 2001 to early 2006. More detailed information in 2005–2006 allowed GP-type visits to be assessed in this period only.Main outcome measures: The change in the number and percentage of weekly ED visits during the holiday period.Results: Between 2001 and 2006, average weekly counts of ED visits increased by 9% (95% CI, 7%–11%) during the holiday period. The holiday increase was largely accounted for by visits that were less urgent, and for patients who were not admitted, did not arrive by ambulance, had a shorter treatment time and arrived between 08:00 and midnight. In 2005–2006, average weekly counts of GP-type visits increased by 21% (95% CI, 15%–28%) compared with 8% (95% CI, 4%–12%) for ED visits overall. However, GP-type visits accounted for only 39% of the additional holiday visits. GP-type visits increased mainly for adults and more in urban than rural areas.Conclusions: The Christmas and New Year period is the busiest time of year for NSW EDs. However, only some of the additional holiday visits can be attributed to GP-type visits. Improving access to GPs, but also to broader hospital and community-based health care services over the holiday period, should be considered for managing the excess demand.

Wei Zheng MPH · David J Muscatello MPH · Adam C Chan MB BS(Hons), FACEM

Emergency departments are under pressure. Chronic staff shortages, access block and other problems are increasingly affecting the ability of medical and nursing staff to treat patients On 23 September 2007, The Age (Melbourne) reported a leaked letter to the Victorian Health Minister from Dr Andrew Buck, an emergency registrar, who described compromised patient care in the overcrowded and understaffed emergency department (ED) at Monash Medical Centre in Melbourne.1 News of a miscarriage in its ED waiting room on 25 September shifted the focus to Royal North Shore Hospital in Sydney, initiating scores of complaints in the media from patients and clinicians about treatment provided in New South Wales public hospitals.2 A fatal cardiac arrest occurred in the waiting room of the Canberra Hospital ED on 5 October. Meanwhile, an identical event occurred in the Royal Perth Hospital ED.3 These events patently demonstrate that pressures facing these departments are shared nationwide, and that chronic staff shortages and access block are increasingly affecting the ability of medical and nursing staff to treat critically ill patients in a timely manner.4 The effects of overcrowding and overwork on patient outcomes have been well described. A study in 2006 found that presentation to the ED during periods of high bed occupancy was associated with higher mortality at 10 days, translating to an estimated additional 13 deaths per year.5 Numerous studies have described the association between clinician’s fatigue and stress with adverse outcomes for patients. The wellbeing of doctors and their clinical practice are affected by making mistakes and the increasing public scrutiny of health care.6 The qualitative effects of working in chronically stressful ED environments on workforce morale and retention have been less well examined. Despite evidence that overcrowding and overwork harm both patients and clinical staff, few measures have been introduced to combat the pressures or to address the issues at a system level. Recent media criticism and public scrutiny has caused me, along with many of my colleagues, to reflect on my choice to practise and train in emergency medicine. I have worked in several EDs during the past 6 years: large and small, rural and metropolitan. I can honestly say that there is no other clinical job that provides the exhilaration and satisfaction of a good day spent working in the ED. Unfortunately, a bad day in the ED can leave you very flat indeed. There are so many reasons why emergency medicine appeals to me as a specialty. Above all, it is always interesting. We deal with all sorts of people and all sorts of problems, often finding ourselves in the thick of human tragedy or triumph. We are the medical jacks-of-all-trades, which means that we have something to offer when faced with any kind of clinical problem, often providing a bridge between other disciplines. We are “safe hands” in the hospital, possessing resuscitation skills to save the lives of critically ill patients, and medical and procedural skills to initiate early treatment. We work with our minds, our hands and our hearts to a degree not shared by any other single specialty. We have the ability to do enormous good for our patients and their families. Emergency departments have a special quality. The nature of the work makes multidisciplinary teamwork a necessity. Nurses, doctors, allied health professionals and clinical support staff work, and socialise, together more closely in an ED than in most other departments. Emergency medicine attracts competent, quick-thinking and personable clinicians, who not only care for their patients, but look after each other too. An ED nurse told me recently that the only thing that kept her coming to work each day in the face of public criticism was that she loves her colleagues and did not want to let them down. I share her sentiment and her pride. Despite the many positive features, emergency medicine is struggling to attract and retain clinical staff. Obvious disincentives include shift work, which continues into consultant life; limited access to private billing, resulting in low pay compared with other specialties; and the lengthy and difficult training program. Work intensity has increased, with more patients presenting for treatment, and admitted patients staying longer in the ED while waiting for an inpatient bed to become available. This includes many agitated psychiatric patients. Staff who feel that they are unable to provide timely and high-quality care to their patients become burnt out and take time out from the discipline, entrenching chronic workforce shortages and creating further stress for those left behind. Emergency medicine is very exposed at the “front-end” of the hospital system, and has therefore become overtly political, subjecting staff to regular media attack and reactive, knee-jerk policy implementation. As our doors are always open, EDs are increasingly caring for those who have nowhere else to turn — the homeless and indigent — who present with uncontrolled chronic, often preventable, conditions and have limited or no access to appropriate outpatient treatment or social supports. It is difficult for ED practitioners to feel valued in the current climate. Negative media reports have given patients and families implicit permission to criticise and even abuse clinical staff. There have been verbal and physical assaults against ED doctors and nurses after the recent publicity, and colleagues report that they increasingly feel emotionally and physically frightened at work. Reliance on locum and overseas-trained staff to fill medical and nursing vacancies has increased. Not only is there resentment of the pay differential, but reliance on casual staff potentially affects teamwork and delivery of patient care. Clinicians also feel undervalued by colleagues in other hospital-based disciplines who do not recognise or respect their unique skill set. It is commonplace for a junior doctor from an inpatient team to speak down to an emergency consultant or advanced trainee. While the “ED versus the world” mentality that ensues may enhance clinical teamwork, it can too easily slide into “ED versus ED” as stress levels increase, damaging workplace cohesion and the quality of patient care. Emergency medicine is at a crossroads. It is vital that steps be taken to improve workforce recruitment and retention, and to better manage escalating workloads. These measures must deal with education and training needs, industrial conditions, availability of hospital beds, and provision of appropriate primary, community and outpatient care. Staff-to-patient ratios recommended by the Australian Medical Workforce Advisory Committee in 2003 should be adopted.7 Emergency clinicians should be valued and supported in providing the best possible care for their patients.

Clare A Skinner MB BS, MPH, BA(Hons)

To the Editor: We report a case of successful resuscitation after cardiac arrest associated with obstruction of the airway by chewing gum. In December 2005, in Port Hedland, Western Australia, a 57-year-old electrician was found unconscious by workmates 5 minutes after he was seen working normally. He was not breathing and had no pulse. Bystander cardiopulmonary resuscitation (CPR) was commenced immediately and an ambulance arrived within 3 minutes. Cardiac monitoring showed the patient was in ventricular fibrillation. Direct-current defibrillation was performed three times, resulting in reversion to ventricular tachycardia, rapid atrial fibrillation and, within minutes, spontaneous reversion to sinus rhythm. The time from ambulance dispatch to arrival at Port Hedland Regional Hospital was less than 15 minutes. Rapid transport to hospital enabled prompt assessment of the patient, who was found to be maintaining sinus rhythm with left bundle branch block but no ST segment changes. Following the return of spontaneous circulation and consciousness, the patient’s Glasgow Coma Score and oxygen saturation unexpectedly deteriorated. On rapid sequence intubation, chewing gum was found lodged in the patient’s larynx; it was removed, and intubation completed. An urgent computed tomography scan found no intracranial cause for the deterioration in his condition. The patient was transferred to a tertiary centre by the Royal Flying Doctor Service. There was a rise in the patient’s troponin level after the cardiac event, but normal coronary arteries with globally depressed ventricular function were seen on angiography, and an ejection fraction of 30% on echocardiography, suggesting an underlying cardiomyopathy. An implantable cardiac defibrillator was inserted. The patient recovered, with a diagnosis of hypoxia associated with myopathic cardiac arrest complicated by laryngeal obstruction from chewing gum. He suffered a moderate hypoxic brain injury during the event and underwent a short period of inpatient rehabilitation, before returning to work within 6 months. He had no significant sequelae 18 months after the cardiac event. There have been previous reports of sudden death due to airway obstruction by chewing gum in children and one recent report of adult death, but no reports of successful resuscitation after cardiac arrest and hypoxia associated with chewing gum obstruction.1,2 There have also been reports of delayed problems with ventilation due to migration of previously aspirated chewing gum.3 While it is unlikely that the chewing gum airway obstruction was the primary event in this case, given the finding of cardiomyopathy, we believe that the laryngeal obstruction contributed to the patient’s secondary deterioration. This case demonstrates the importance of CPR training in the community, rapid paramedical and medical response, and the need to consider complicating causes in the event of cardiac arrest when return of spontaneous circulation does not result in clinical improvement as expected. It is made all the more remarkable by its occurrence in a remote regional centre of north-west WA.

Angus G Thompson · Shakeeb Razak · Rohan Jayasinghe

Charles Halliley Kellaway (1889–1952) was one of the first Australians to make a full-time career of medical research. He built his scientific reputation on studies of snake venoms and anaphylaxis. Under Kellaway’s directorship, the Walter and Eliza Hall Institute gained worldwide acclaim, and he played a critical role in its success between the world wars. His administrative and financial strategies in the era before the National Health and Medical Research Council (NHMRC) helped local medical research weather the Depression and gain a strong foothold by World War II.

Peter G Hobbins BA, BSc(Hons) · Kenneth D Winkel MB BS, PhD, FACTM

Objective: To compare demographic and clinical characteristics of methamphetamine users and patients with other toxicology-related problems requiring medical intervention in a hospital emergency department (ED).Design and setting: Prospective observational study of toxicology-related presentations to the ED of St Vincent’s Hospital (SVH), Sydney, an inner-city tertiary hospital, between 1 October and 31 December 2006.Main outcome measures: Differences between methamphetamine-related and other toxicology-related presentations to the ED in relation to behaviour, mode of arrival, accompaniment, need for scheduling, location of drug use, intravenous drug use history, psychiatric history and demographic characteristics.Results: During the study period there were 10 305 patient presentations to SVH ED; 449 (4%) were toxicology-related presentations, of which 100 (1% of total) were methamphetamine-related. Methamphetamine users were significantly more agitated, violent and aggressive than patients with other toxicology-related presentations and significantly less alert, communicative and cooperative (P < 0.001); 24% of methamphetamine users (24/100) arrived with police accompaniment versus 9% of other toxicology patients (33/349) (P < 0.001). Methamphetamine users were more likely to have a history of intravenous drug use and mental health problems (P < 0.001); 39% of methamphetamine presentations (39/100) required scheduling under the Mental Health Act 1990 (NSW) compared with 19% of other toxicology-related presentations (67/349) (P < 0.001); 43% of methamphetamine-related presentations (43/100) involved drug use on the street compared with 24% of other toxicology-related presentations (83/349) (P < 0.001). Two-thirds of all methamphetamine users were male, and the most common age group for both male and female users was 26–30 years. The mean age and sex distribution of patients with other toxicology-related presentations were not significantly different. Among methamphetamine users, 27% of women (9/33) were in the 21–25-year age group compared with 10% (7/67) of men (P < 0.001).Conclusion: There were significant differences between methamphetamine-related and other toxicology-related presentations to SVH ED. Methamphetamine users were more aggressive, violent and dangerous, and thus more likely to pose a risk to health personnel and others. Methamphetamine appeared to be used consistently, rather than as an episodic “party drug”.

Philippa J Bunting BBus, CA · Gordian W O Fulde MB BS, FRACS, FACEM · S Lesley Forster MB BS, FRACMA, FAFPHM

Objective: To assess efficacy and safety of a 24-hour comprehensive protocol-driven model for rapid assessment and thrombolysis of stroke patients in the emergency department.Design: Prospective open observational study.Participants and setting: All patients with acute stroke presenting within 3 hours to the St Vincent’s Hospital (Sydney) emergency department between 1 December 2004 and 30 July 2005.Main outcome measures: Proportion of patients treated, patient demographics, clinical outcome, adverse events and time to treatment parameters.Results: 134 patients (100 stroke; 34 transient ischaemic attack) were admitted to the stroke unit during the study period. Of the 100 stroke patients, 40 presented within 3 hours of symptom onset. Fifteen patients had no contraindications and received intravenous thrombolysis. At 3 months, 10 patients (67%) were independent (modified Rankin score [mRS], 0–2) and seven (47%) had an excellent functional outcome (mRS ≤ 1). Symptomatic intracranial haemorrhage was not observed. The median time from symptom onset to tissue plasminogen activator treatment was 155 minutes (range, 105–197 min). Median onset-to-door, door-to-computed tomography, and door-to-needle times were 48, 25, and 87 minutes, respectively.Conclusion: Rapid assessment of stroke in the emergency department according to a comprehensive protocol allows identification and treatment of acute ischaemic stroke patients eligible for thrombolysis.

Julia J Batmanian BSc(Med), MB BS(Hons) · Meeyin Lam BAppSc(Physio), MIPH · Caitlin Matthews BSc(Hons), MB BS(Hons) · Andrew Finckh MB BS, FACEM · Martin Duffy MB BS, MMed(ClinEdi), FACEM · Robert Wright FRACP, FFARACS, FJFICM · Bruce J Brew MB BS, MD, FRACP · Romesh Markus PhD, FRACP, MB ChB

To the Editor: While Joosten et al highlight the uncommon but serious problem of potential carbon dioxide (CO2) narcosis after emergency management of respiratory illness,1 it is important that their findings are kept in perspective and do not lead to inadequate administration of oxygen to patients with acute dyspnoea. Their findings are based on a retrospective chart review. The main claim that the administration of oxygen causes increased length of hospital stay and possibly death for those presenting to emergency departments with exacerbation of chronic obstructive pulmonary disease (COPD) can be challenged by selection bias, sample size, assessment of severity of illness, and the definition of clinically significant hypercapnia. Ninety per cent of their study patients arrived by ambulance, presumably indicating the relatively sudden onset of acute distressing symptoms — a call for urgent help, not the “killing me slowly” drowsiness and confusion of CO2 retention. Of those who received more than 4 litres of oxygen (O2) per minute, 57% (16 of 28) were in triage category 1 and 2, but only 31% (4 of 13) of those who received O2 at a lower flow rate were in triage category 1 and 2. Sixty per cent (12 of 20) of those with a high partial pressure of arterial oxygen (Pao2), when measured after arrival and treatment were in triage category 1 or 2, but only 14% (3 of 21) of those with a lower Pao2 were in triage category 1 or 2 (P = 0.002; Fisher’s exact test). Clearly the first group was a sicker group on arrival, and the increased length of stay of these patients was more likely to be the result of this, rather than of O2 therapy supervised by emergency specialists in an emergency room of a teaching hospital. The contention that oxygen therapy in emergency departments is “often uncontrolled” is not supported by any data supplied. Critical care staff, including ambulance and emergency personnel, are acutely aware of the challenges posed by patients with chronic respiratory disease. However, they are also aware of the need to achieve adequate oxygenation in patients with acute dyspnoea. Patients are observed closely for signs of clinically significant hypercapnia and respiratory support is adjusted accordingly. Some patients may require a higher fraction of inspired oxygen (Fio2), particularly in the initial phases of care, to achieve this. As the patient’s condition improves, the Fio2 is often reduced. The methods in the study by Joosten et al fail to account for this. Respiratory rate, for example, was not reported. Treating the patient, not the chart, is of most importance. It would be a pity if the article by Joosten et al resulted in the withholding of oxygen from acutely dyspnoeic patients with a rapid respiratory rate and adequate respiratory drive because of some fear that they could be retaining CO2. We agree that a better and seamless patient-centred information system with cooperation between sectors of the health system, the patient, the patient’s general practitioner, and ambulance, emergency and in-hospital services, would assist in identifying those at risk of CO2 narcosis and improve patient care.

Andrew W Dent · George A Jelinek · Sandra L Neate · Tracey J Weiland · Ann-Maree Kelly

In reply: We performed a retrospective audit as part of a quality improvement program following a number of serious adverse events in various areas of our hospital. Our article showed that carbon dioxide retention in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is common (41 of 65 patients admitted with chronic obstructive pulmonary disease [COPD] over 4 months), and that guidelines on blood gas measurement and oxygen use were not being followed. Dent and colleagues state that more patients in our study who received more than 4 litres of oxygen per minute were in a triage category that indicated a more serious condition. However, the multivariate analysis showed that triage category did not predict length of stay. In contrast, partial pressure of arterial oxygen (Pao2) did, and patients with a Pao2 of less than 74.5 mmHg (range, 36.7–74.0 mmHg) had a shorter length of stay than those with a Pao2 of 74.5 mmHg or higher (range, 74.5–452.0 mmHg). Many patients had a Pao2 much higher than neccessary to achieve a haemoglobin saturation of about 90%. Dent and colleagues state that our data did not support the claim that oxygen therapy is often uncontrolled in the emergency setting. In fact, only 68% of the patients receiving more than 4 litres of oxygen per minute had arterial blood gas measurements performed. We agree with Dent et al that the management of AECOPD may not be as simple as following guidelines. However, we hope to raise awareness of the fact that hypercapnia in COPD is common, requires careful assessment, and that oxygen therapy should be titrated to physiological endpoints.

Simon A Joosten · David Smallwood · Mariko S Koh · Louis B Irving · Xiaoning Bu

To the Editor: Cosmetic surgery has grown in appeal over the past few years, and more and more procedures are being performed. However, the literature on attitudes towards cosmetic surgery is scant. Here, we report the results of a cross-sectional study that assessed Australian university students’ attitudes towards, and experiences of, cosmetic surgery. Preclinical students from the faculty of medicine at the University of Melbourne were chosen to participate, as they formed a fairly homogeneous group and were considered at a higher risk of experiencing appearance concerns than the general population.1,2 Students from clinical years were excluded, as their greater exposure to clinical medicine could have impacted on their attitudes towards cosmetic surgery. Participants completed a questionnaire that covered their experience of and familiarity with a range of cosmetic procedures, as well as attitudes towards cosmetic procedures. About 320 students were approached for this study, and 284 agreed to participate (45% male; age [mean ± SD], 20.8 ± 3.4 years; body mass index [mean ± SD], 21.9 ± 2.7 kg/m2). Respondents noted a high degree of familiarity with cosmetic enhancement procedures (Box); only 8% were not familiar with any procedures. Thirty-six per cent knew someone who had had cosmetic surgery and 11% knew at least one person in their family who had had cosmetic surgery. Only four respondents (1%) had themselves had cosmetic surgery. Many respondents were fearful of undergoing surgical procedures (53% “agreed” or “strongly agreed”). Over a third disapproved of people surgically altering their appearance for reasons of self-esteem (36%) or to feel better about themselves (35%), and 38% thought cosmetic surgery was a waste of money. Most respondents (63%) indicated they would be embarrassed to let others know if they had had such surgery, although 52% believed that appearance was an important facet of a person. The majority (70%) would not consider cosmetic surgery in later years, even if their partner wished them to (79%). These findings are in stark contrast to a United States study of female college students, which found that about 5% of participants had undergone cosmetic surgery, 67% knew someone who had received a cosmetic surgical intervention, and around 33% had a family member who had undergone cosmetic surgery.3 Overall, their attitudes to cosmetic procedures were much more favourable, which might reflect a greater acceptance, availability and prevalence of cosmetic surgery in the US. Our findings have relevance for the future Australian medical workforce, and suggest that broader issues relating to body image should be covered in the medical curriculum. Proportion of students familiar with cosmetic enhancement procedures Procedure Proportion of students Lipoplasty 83% Botox injections 82% Facelifts 78% Breast augmentation 78% Rhinoplasty 73% Breast reduction 71% Abdominoplasty 69% Cellulite treatment 48% Chemical peels 47% Blepharoplasty 41%

David J Castle · Riteesh Bookun