Emergency medicine

About a thousand Australian children are seriously injured in motor vehicle accidents each year, despite 92% using seatbelts or child restraints. Premature graduation of children to adult seatbelts, misuse of seatbelts and use of lap-only belts increase the risk of injury or death. In Australia, use of a child restraint or booster seat is not mandatory for children aged > 1 year, while other countries mandate their use for children up to 5–12 years old. Australian parents are confused about the safest restraint and seating position, particularly for children aged > 2 years. Australian child restraint legislation needs to be reviewed to increase the rate of optimal restraint use.

Katie N Reeve MB BS(Hons), MRCPCH, MRCP · Yvonne A Zurynski BAppSc, MAppSc, PhD · Elizabeth J Elliott MD, FRACP, FRCPCH · Lynne Bilston BE(Mech)(Hons), MSE, PhD

“First responders” are people trained in advanced first aid who can respond at the same time as, and often more quickly than, ambulance services to suspected medical emergencies. Hatzolah is a volunteer First Responder group, based on halakhic (Jewish legal) principles, in a localised area of metropolitan Melbourne with the highest density of Holocaust survivors outside Israel. Low numbers of “call-outs” to Victoria’s Metropolitan Ambulance Service (MAS) from this community suggested that many were reluctant to make contact with a “uniformed” external agency. Hatzolah is an autonomous organisation operating under adapted MAS clinical practice guidelines and clinical governance processes. Hatzolah responders undergo an 18-month MAS training course comprising first aid, cardiopulmonary resuscitation, the use of semiautomated defibrillators, and oxygen therapy. We describe the first 11 years (1995–2005) of the Hatzolah service. The number of patients attended to annually has risen steadily, peaking at 867 in 2005. The most frequent reasons for call-outs were falls (19.4%), chest pain (9.7%), or respiratory distress (7.6%). Hatzolah’s median response times were 2 or 3 min for all cases. They attended 35 patients with cardiac arrest (median response time, 2 min), and arrived before the MAS to 29 call-outs (83%). Nineteen patients (54%) with cardiac arrest were resuscitated and transported from the scene alive. Among those transported, significantly more had a shockable cardiac rhythm (50% v 13%, P = 0.03). Five (14%) survived to hospital discharge. Hatzolah has evolved into an organisation providing a complementary service to the MAS. It serves as a model for the establishment of other metropolitan community First Responder groups.

Tony Chan MB BS · George Braitberg MB BS, FACEM · Danny Elbaum BBus(Accounting) · David McD Taylor MD, MPH, FACEM

Objectives: To measure physical assets in Australasian hospitals required for the management of mass casualties as a result of terrorism or natural disasters.Design and setting: A cross-sectional survey of Australian and New Zealand hospitals.Participants: All emergency department directors of Australasian College for Emergency Medicine (ACEM)-accredited hospitals, as well as private and non-ACEM accredited emergency departments staffed by ACEM Fellows in metropolitan Sydney.Main outcome measures: Numbers of operating theatres, intensive care unit (ICU) beds and x-ray machines; state of preparedness using benchmarks defined by the Centers for Disease Control and Prevention in the United States.Results: We found that 61%–82% of critically injured patients would not have immediate access to operative care, 34%–70% would have delayed access to an ICU bed, and 42% of the less critically injured would have delayed access to x-ray facilities.Conclusions: Our study demonstrates that physical assets in Australasian public hospitals do not meet US hospital preparedness benchmarks for mass casualty incidents. We recommend national agreement on disaster preparedness benchmarks and periodic publication of hospital performance indicators to enhance disaster preparedness.

Matthias Traub MD, FRACS · David A Bradt MD, FACEM, FAFPHM · Anthony P Joseph MB BS, FACEM

Crystalline methamphetamine usage can wreak havoc in emergency departments “Ice”, or crystalline methamphetamine, is a relatively new drug in Australia. It may be injected intravenously or swallowed, but is increasingly consumed by smoking. With about 1.8 million Australians (9%) reporting ever using methamphetamine and about half a million Australians aged 14 years and older (3.2%) reporting current use of the drug,1 Australia is among the top dozen countries in the world in terms of prevalence of methamphetamine use.2 However, its use varies considerably across the country, being higher in some states — such as Queensland (especially the Gold Coast region), South Australia and Western Australia3 — than others. Reported methamphetamine use increased in surveys of the general population in Australia in the 1990s, but has since declined slightly.4 However, in recent years, indicators of harm (such as psychosis, emergency department presentations, and methamphetamine-related crime) have increased considerably. There was a 59% increase in amphetamine-related psychosis nationally between 1999–00 and 2003–04.5 In New South Wales, methamphetamine-related arrests rose from 18 per 100 000 population in 1995 to 46 per 100 000 population in 2005 (an increase of 253%).4 Why is the consumption of methamphetamine apparently relatively stable, while harms seem to be increasing markedly? Possible explanations for this anomaly include the problems of conducting and interpreting surveys of illicit drug consumption, the increasing purity of street methamphetamine, and the increasing availability and use of more readily absorbed forms of methamphetamine, including ice, which have a far greater psychoactive effect on the brain. Methamphetamine has diverse health and social impacts. These include effects on hospitals, crime, personal relationships, employment and private debt. The nature and extent of these adverse effects have not yet been fully determined. The report by Gray et al6 in this issue (→ Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation) represents one of the first attempts in Australia to estimate the impact of amphetamine use on a hospital. The authors found that amphetamine-related presentations account for over 1% of all admissions. They involve high-acuity patients who often present with aggressive behaviour, require prolonged emergency department admission and consume considerable resources. They concluded that increasing amphetamine use has had a substantial impact on the hospital emergency department studied. Amphetamine-related presentations are a great burden on the health care system. It can take days before amphetamine-related psychosis can be distinguished from other serious mental health conditions, such as schizophrenia. Knowledge of the full nature and extent of medium- to long-term physical and mental health impairment from street amphetamine use is still evolving. Although we should be wary of predictions that illicit drug problems are destined to deteriorate inexorably and indefinitely, it is likely that amphetamine-related problems will continue to worsen in Australia for some time. In part, the increase in amphetamine production and use may reflect a shift from plant-based drugs (such as heroin or cocaine) to chemical-based drugs, which allow producers to evade law enforcement detection using aerial and satellite surveillance and to avoid the vagaries of the weather. The value of the global market in all illicit drugs for the year 2003 was estimated at US$322 billion at the retail level,7 with the lucrative profits of drug trafficking estimated to account for 26%–58% of turnover.8 Existing alcohol and drug treatment services attract and retain few methamphetamine users, but services that specialise in patients with stimulant problems seem more successful in attracting a higher proportion. The processes of amphetamine withdrawal and detoxification are still poorly understood. Psychosocial interventions (such as cognitive behavioural therapy, contingency management and motivational interviewing) may be sufficient for the many patients with milder problems. But these interventions are unlikely to be sufficient for those who consume substantial quantities of methamphetamine and have severe problems. While many pharmacotherapeutic agents have been tried without success, amphetamine substitution treatment9 appears to be an effective and safe treatment for carefully selected, treatment-refractory patients with severe problems. Drug law enforcement is often touted as a panacea for the problem of illicit drug use, but, as a recent review noted, There is strikingly little evidence that tougher law enforcement can materially reduce drug use. By contrast, drug treatment services remain in short supply, even though research indicates that treatment expenditures easily pay for themselves in terms of reduced crime and improved productivity.10 Accordingly, authorities would be wise to invest more in health and social interventions. New drugs appear frequently in the constantly changing illicit drug industry and are often hailed as “the most dangerous drug yet”. In the politicised and highly charged environment surrounding illicit drugs, it is difficult, but all the more important, to maintain a balanced and evidence-based approach to policy and practice. For many decades, tackling the illicit drug problem around the world has been considered primarily a matter for the criminal justice system. Funding has flowed accordingly, with health and social interventions usually treated as the poor cousins of law enforcement. Yet, in most countries, illicit drug use and consequent problems have continued to increase. The evidence for effectiveness and cost-effectiveness of health interventions for illicit drug use is far more impressive than the evidence for drug law enforcement. It is time that Australia regarded illicit drugs in general, and methamphetamine in particular, as primarily a matter for health and social interventions, although drug law enforcement should continue to play an important role.

Gordian W O Fulde FRACS, FRCS, FACEM · Alex Wodak FRACP, FAChAM, FAFPHM

Objective: To describe the prevalence, characteristics and outcomes of amphetamine-related presentations to a tertiary hospital emergency department (ED).Design, setting and participants: Prospective observational study of amphetamine-related presentations to the ED of the Royal Perth Hospital (RPH), an adult, inner-city, tertiary referral hospital, between 3 August and 2 November 2005. For all patients presenting to the ED, the treating doctors were automatically prompted by the computerised data entry system to consider amphetamine use.Main outcome measures: Proportion of ED presentations related to amphetamine use; demographic features and usage practices of amphetamine users; characteristics of presentations and admissions; associated psychiatric illnesses and use of other drugs.Results: Over the study period, there were 13 125 presentations, of which 156 (1.2%) were judged to be causally related to amphetamine use. Of those 156 patients, over half were habitual drug users (89 [57.1%] used amphetamines at least weekly), and the majority were men (111 [71.2%]). The mean age was 28 years (range, 16–55 years). Presentations were of high acuity: 104 patients [66.7%] were rated 1, 2 or 3 on the Australasian Triage Scale; 50 (32.1%) arrived by ambulance; and 25 (16.0%) arrived with police. The mean time spent in the ED was 6 h (range, 0.5–24 h). Fifty patients (32.1%) required sedation, and the likelihood of requiring sedation increased almost threefold if the heart rate was over 100 beats/min on presentation. Sixty-two patients (39.7%) were admitted and 58 (37.2%) required psychiatric evaluation. Repeat attendance was common, with 71 patients (45.5%) having previous amphetamine-related presentations to the RPH ED.Conclusions: Amphetamine-related presentations comprise 1.2% of all ED attendances and have a major impact on hospital EDs. Patients are often agitated and aggressive, require extensive resources, and frequently re-attend. The burden of amphetamine-related illnesses on EDs is likely to increase in the future.

Suzanne D Gray MB BS · Daniel M Fatovich MB BS, FACEM · David L McCoubrie MB BS, FACEM · Frank F Daly MB BS, FACEM

Controlling oxygen delivery to limit oxygen saturation should reduce the incidence of hyperoxic hypercapnia The report by Joosten et al in this issue of the Journal (page 235)1 is a timely reminder of the importance of avoiding the induction of hyperoxic hypercapnia in patients with acute-on-chronic respiratory failure. The complication of acute hypercapnic respiratory failure precipitated by giving oxygen has long been recognised; most resident medical and nursing staff are aware of this problem. The natural intervention in patients presenting with acute-on-chronic respiratory failure is to relieve any hypoxia with supplemental oxygen, but this can be associated with carbon dioxide retention, narcosis, respiratory acidosis, and death. That the use of controlled oxygen flow rates could avoid this complication (and the need, in those days, for tracheostomy and invasive ventilation) was first recognised in the 1940s and 1950s.2 Although hyperoxic hypercapnia can now be managed with non-invasive ventilation, the article by Joosten et al reminds us that it still has adverse consequences for morbidity, length of stay and the use of hospital resources.1 Studies over the past 20–30 years have identified the characteristics of the patients most likely to have this problem, and have gone some way to identifying the mechanisms responsible. Chronic respiratory failure is the usual predisposing condition, and the most common cause of chronic respiratory failure is chronic obstructive pulmonary disease (COPD). Interestingly, hyperoxic hypercapnia is a phenomenon of acute exacerbations of COPD — giving oxygen to patients with stable hypercapnia rarely, if ever, causes clinically significant further hypercapnia.3 This may, of course, be related to the lower flow rates used for stable hypercapnia. Importantly, the degree of hypoxaemia at presentation is a better predictor of hyperoxic hypercapnia progressing to narcosis than is the initial degree of hypercapnia.4 Usual clinical teaching is that high concentrations of inspired oxygen remove the hypoxic drive to ventilation in susceptible hypoxaemic patients; the narcotic effect of the rising hypercapnia amplifies this effect, promoting further hypoventilation. However, a number of studies have cast doubt on this as the most important mechanism, at least up to the point of narcosis.5-7 The most comprehensive study of mechanisms, using the multiple inert gas elimination technique, suggests that relative hypoventilation is the defining event in those who retain carbon dioxide, but that worsening ventilation–perfusion mismatching and an accompanying increase in dead space ventilation contribute about 50% of the increase in carbon dioxide levels.8 This finding is clinically important because it identifies non-invasive ventilatory support as the appropriate intervention before narcosis progresses. The dictum “hypoxia kills quickly, hypercapnia slowly” engages the clinician when confronted with this situation. How can hyperoxic hypercapnia be avoided without exposing these patients to the more acute risk of inadequate oxygenation? Oxygen delivery controlled to an appropriate flow rate appears to be the answer, but there are no large-scale studies to indicate how the oxygen “dose” should be determined and monitored.9,10 In the absence of clinical trial evidence, it is reasonable to control oxygen flow rate to achieve an arterial oxygen saturation of 90%, but not above 93%–95%. This corresponds with an arterial oxygen tension of 60–70 mmHg at the start of the “flat part” of the oxyhaemoglobin dissociation curve, and ensures adequate arterial oxygen content and delivery in most circumstances. This is also consistent with the data of Joosten and colleagues, who found an arterial oxygen tension of less than 74.5 mmHg to be protective.1 The ready availability of continuously reading pulse oximeters makes the above recommendation a practical procedure, and its wide application in wards, emergency departments and, particularly, ambulances should substantially reduce the incidence of the hazardous and largely unnecessary complication of hyperoxic hypercapnia.

Iven H Young BSc, PhD, FRACP

To the Editor: St John’s wort (SJW) (Hypericum perforatum) is a natural medicine commonly used for treating depression. We recently encountered a case of an overdose of SJW leading to serious manifestations in the patient. A 16-year-old girl presented to the emergency department with seizures and confusion. She was intubated and admitted to the intensive care unit. The only relevant history was of febrile convulsions at the age of 4 years. There had been no head trauma. Results of a computed tomography brain scan and cerebrospinal fluid examination were unremarkable. Electrolyte levels were normal, and standard drug toxicological screens were negative. An electroencephalogram (EEG) confirmed diffuse spike wave activity consistent with generalised epileptic activity. On further questioning, it was found that she had taken large quantities of SJW — up to fifteen 300 μg tablets a day in the 2 weeks leading up to admission and an additional 50 tablets just before presentation — for a recent “depressive episode”. Depression had not been formally diagnosed, and the tablets had been obtained “over the counter” from a local pharmacy. A provisional diagnosis of seizures due to an overdose of SJW was made. High performance liquid chromatography was not performed to quantify hypericum extract in serum and urine, as these tests are not available in our hospital. A repeat EEG at discharge on Day 6 was normal, and there were no further seizures in the following 6 months. Psychiatric assessment during the patient’s hospital stay revealed a likely suicide attempt following recent social stresses. There is some evidence for the efficacy of SJW in treating depression.1 In the United States and Australia it is available without prescription, but in Germany, where it is prescribed more frequently than fluoxetine for depression, it is available by prescription only. The reported incidence of adverse drug reactions to SJW is 0–5.7%.2 Although these are usually minor and transient, more serious adverse reactions (such as serotonin syndrome) have been reported.3 SJW was implicated as a likely, but unproven, cause of seizure-related events in a recent review,4 but our case appears to be the most severe reported so far. Adverse reactions are thought to be more common if SJW is taken in conjunction with selective serotonin reuptake inhibitors, but have also been described when SJW is taken alone.5

Dharshi C Karalapillai · Rinaldo Bellomo

Objective: To describe the effect of antibiotics on outcomes of treatment for Buruli or Bairnsdale ulcer (BU) in patients on the Bellarine Peninsula in south-eastern Australia.Design: Observational, non-randomised study with data collected prospectively or through medical record review.Patients and setting: All 40 patients with BU managed by staff of Barwon Health’s Geelong Hospital (a public, secondary-level hospital) between 1 January 1998 and 31 December 2004.Main outcome measures: Epidemiology, clinical presentation, diagnosis, treatment and clinical outcomes.Results: There were 59 treatment episodes; 29 involved surgery alone, 26 surgery plus antibiotics, and four antibiotics alone. Of 55 episodes where surgery was performed, minor surgery was required in 22, and major surgery in 33. Failure rates were 28% for surgery alone, and 19% for surgery plus antibiotics. Adjunctive antibiotic therapy was associated with increased treatment success for lesions with positive histological margins (P < 0.01), and lesions requiring major surgery for treatment of a first episode (P < 0.01). The combination of rifampicin and ciprofloxacin resulted in treatment success in eight of eight episodes, and no patients ceased therapy because of side effects with this regimen.Conclusions: Adjunctive antibiotic therapy may increase the effectiveness of BU surgical treatment, and this should be further assessed by larger randomised controlled trials. The combination of rifampicin and ciprofloxacin appears the most promising.

Daniel P O’Brien MB BS, FRACP · Andrew J Hughes MB BS, FRACP · Allen C Cheng MB BS, FRACP, PhD · Margaret J Henry BSc, PhD · Peter Callan MB BS, FRACS · Anthony McDonald MB BS, FRACS · Ian Holten MD, FRACS, FRCS · Mike Birrell MB BS · John M Sowerby MB BS · Paul D R Johnson MB BS, FRACP, PhD · Eugene Athan MB BS, FRACP

Objective: To describe the epidemiology of falls from ladders in a state-wide population.Design and setting: Retrospective review of data from the the Victorian State Trauma Registry and the Victorian Emergency Minimum Dataset on patients presenting to public hospital emergency departments (EDs) with injuries due to a fall while climbing a ladder, from 1 July 2001 to 30 June 2005.Main outcome measures: Overall trends in the incidence of ladder-related ED presentations, and in cases of major trauma, trends according to age, and trends according to activity at the time of the fall.Results: 4553 patients presented to EDs after falls from ladders in Victoria during the study period; 160 patients had injuries classified as major trauma. There has been a significant rise in the number of presentations to EDs following falls from ladders in Victoria, with a marked increase in the number of cases involving patients aged over 50 years and those climbing ladders outside of paid working conditions. Deaths occurred predominantly in the elderly after falls from heights above 1 metre.Conclusions: Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend.

Biswadev Mitra MB BS · Peter A Cameron MB BS, MD, FACEM · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD

Objective: To describe the epidemiology of mammal (human and non-human) bite injuries in Victoria.Participants, design and setting: Retrospective case series of injuries recorded in the Victorian Emergency Minimum Dataset (VEMD) (1998–2004) and deaths recorded in the National Coroners Information System (1 July 2000 – 1 June 2006).Main outcome measures: Frequency, nature and outcome of injury as a function of mammal, victim demographics and season.Results: Of 12 982 bite injuries identified in the VEMD, dogs, humans, and cats were implicated in 79.6%, 8.7%, and 7.2% of cases, respectively. Dog bite injuries were commonly sustained to the hands/wrists (31.3%) and face/head (25.4%); cat bites to the hands/wrists (67.6%) and arms (16.0%); and human bites to the hands/wrists (37.1%), arms (20.5%) and face/head (20.4%). Males comprised 73.7% and 56.3% of human and dog bite victims, respectively, while females comprised 64.1% of cat bite victims. A third of dog bite victims (33.4%) were children aged 14 years or less. Most human bite victims (79.8%) were adults aged 20–49 years, inclusive. More injuries were sustained on weekends and during the summer, 55.4% of injuries occurred in the home, and 11.6% of patients required hospital admission. Dog bites resulted in three deaths.Conclusions: Mammal bite injuries are common and often require inpatient care. Patterns of bite injuries relate to the type of mammal involved. These epidemiological data will inform prevention initiatives to decrease the incidence of mammal bites.

Catherine E MacBean BA(Hons) · David McD Taylor MD, MPH, FACEM · Karen Ashby BA, GradDipHealthSci, MPH

We report two cases of spotted black snake (Pseudechis guttatus) envenoming. One patient experienced localised burning pain around the bite and developed nausea, vomiting, diarrhoea, upper abdominal cramping and diaphoresis. He was treated with intravenous fluids and antiemetics, but no antivenom, and was discharged 23 hours after the bite. The second patient developed a severe headache, blurred vision and mild nausea, associated with severe pain and swelling of the bitten limb that took 4 days to resolve. No antivenom was given and the patient had no sequelae. Neither patient developed significant coagulopathy, myolysis or neuromuscular paralysis. Bites by this species appear to cause effects similar to those of the more common red-bellied black snake (P. porphyriacus). Clinical recordPatient 1A 47-year-old male farmer in the Upper Hunter region of New South Wales was bitten by a spotted black snake and developed non-specific systemic effects with localised pain and swelling. The snake came from under a bale of hay and bit him on the dorsal aspect of the right foot. He applied a 7.5 cm elastic bandage up to the knee within 5 minutes, and arrived at the local hospital asymptomatic. The patient had no significant past medical history and took no regular medications. The dead snake was identified as Pseudechis guttatus by G K I, using a key for identification.1 The patient was transferred to a larger hospital 2 hours and 20 minutes post-bite, and the first aid was reinforced. He had no abnormalities on examination. Thirty minutes after arrival, he developed burning pain around the bite, associated with nausea, vomiting, diarrhoea, upper abdominal cramping, and diaphoresis. This was treated with 10 mg intravenous metoclopramide and intravenous fluids. A snake venom detection kit swab from the bite site was positive in the black snake well. He had persistent vomiting, which was treated with 8 mg ondansetron. He was transferred to a tertiary hospital intensive care unit 7 hours post-bite. The symptoms gradually resolved, except for ongoing pain at the bite site. The following morning, 15 hours post-bite, he was asymptomatic except for persistent pain in the foot. The pressure bandage was removed, with no immediate change in his condition. There was mild bruising around the bite site and evidence of a second bite. He also had right, tender inguinal lymphadenopathy. About 20 minutes after removal of the bandage, the pain in the right leg increased significantly and he was treated with oral opiate analgesia. Results of coagulation studies remained normal and his creatine kinase had a minor elevation to 348 IU/L (reference range, 50–200 IU/L) 17 hours post-bite. The patient remained well and was discharged 23 hours after the bite. Patient 2A 33-year-old amateur herpetologist was bitten on the left hand by a captive spotted black snake while cleaning the cage. Identification of the snake as P. guttatus was confirmed by J W. The patient immediately applied a local pressure bandage with no splint. Over an hour, he developed a severe frontal headache, blurred vision, mild nausea and dizziness, and presented to hospital about 2 hours post-bite. He appeared to have mild slurring of speech, but no ptosis or other signs of neurotoxic envenoming. The bitten hand was very painful, with swelling and slight bruising (Box 1A). He was treated with intravenous fluids and analgesia, but no antivenom. Results of laboratory tests on admission were normal, except for the activated partial thromboplastin time, which was marginally elevated (41 seconds; reference range, 25–40 seconds). The following day, 13 hours post-bite, he had a persistent headache, mild nausea and severe pain in the bitten hand. Although the systemic symptoms resolved over 12 hours, the bitten hand remained painful and swollen, requiring parenteral opiate analgesia. Forty-eight hours post-bite, the pain and swelling extended to the left elbow (Box 1B,C), with axillary adenopathy. He was treated with intravenous flucloxacillin and seen by the surgical team. Compartment pressures were within the normal range and no surgical intervention occurred. Four days post-bite, the pain and swelling were subsiding significantly (Box 1D). He was discharged on oral flucloxacillin and recovered over several days. DiscussionBlack snakes are found throughout Australia, with mulga snakes (Pseudechis australis) occurring across most of the mainland except the east coast.2,3 In the east, the most common is the red-bellied black snake (P. porphyriacus), and most of the human population in this area will have encountered this snake at some stage. The spotted black snake or blue-bellied black snake (P. guttatus; Box 2) is less common, and primarily inhabits south-east Queensland and inland northern NSW.2,3 These cases suggest that spotted black snake bites are similar in effects to red-bellied black snake bites,2-4 including generalised systemic features and local effects, such as marked swelling and pain at the bite site. They were not similar to the more severe effects of mulga snakes3,5 and Collett’s snake (P. colletti),6 characterised by myotoxicity, anticoagulant coagulopathy and secondary renal impairment. The limited number of cases does not exclude the possibility that spotted black snake bite does occasionally cause significant myolysis like that from red-bellied black snake bite. Serial creatine kinase measurements should be done in all cases of spotted black snake bite with systemic envenoming. There is only one previous report of a bite by a juvenile spotted black snake.7 In that case, localised necrosis at the bite site was treated with surgical debridement. However, the report only included photographs and little further information. Animal studies have demonstrated that spotted black snake venom is both neurotoxic and myotoxic,8,9 and both effects are neutralised by black and tiger snake antivenoms. However, neither of our patients had any evidence of significant neurotoxicity or myotoxicity that may be expected from in-vitro studies. Neither patient was given antivenom, because there was no evidence of major systemic envenoming. As with red-bellied black snake envenoming, antivenom is only used when non-specific systemic effects do not respond to symptomatic treatment. It could be argued that, for Patient 1, who had ongoing vomiting, antivenom might have significantly reduced symptoms and resolved the vomiting, as it can do with red-bellied black snake bites. However, the vomiting responded to ondansetron, and use of antivenom always carries a risk of an allergic reaction. Although antibiotics were used in the second patient, the extensive local pain and swelling are more likely to be due to local venom effects and tissue reaction, also seen with red-bellied black snakes.4 1 Local and regional effects of the bite in Patient 2 A: The hand 3 hours post-bite. B: The forearm 48 hours post-bite. C: The hand 48 hours post-bite. D: The hand 4 days post-bite. Original photo copyright Dr Julian White. 2 Spotted brown colour phase of spotted or blue-bellied black snake, Pseudechis guttatus Original photo copyright Dr Julian White.

Melanie Jansen · Monique McLeod · Julian White MB BS, MD · Geoffrey K Isbister BSc, FACEM, MD

To the Editor: An experiment was recently conducted during a morning doctor’s seminar at the Busselton Hospital to assess four treatments for jellyfish stings using specimens of Carybdea species collected from the nearby waters of Geographe Bay. Two doctors and three medical students consented to participate. The tentacles of the jellyfish were dragged over the moistened forearm, producing two well separated stings on each forearm. After 5 minutes, there were visible red wheals developing at the sting sites. Four different treatment modalities were then tried, one at each sting location: ice, vinegar, aluminium sulfate, and hot water at about 45°C. The participants were asked to assess the degree of pain relief given by the treatment, and the time taken to achieve that pain relief (Box). Hot water was the only successful treatment, relieving 88% of the pain; all participants obtained significant relief in 4–10 minutes. Other treatments were incomplete and temporary. Hot water was later used to treat the other stings. It was also noted that the palpable wheals disappeared when hot water was used. This suggests that, in addition to relieving the pain, the heat treatment was stopping the inflammatory reaction. Heat has been advocated as a treatment for fish spine envenomations from various species, and early application of heat has been found to prevent long-term sequelae.1,2 I have previously reported my experiences with stings from the large tropical jellyfish Tamoya gargantua.3 Application of heat led to the relief of pain over 10–15 minutes. Loten et al recently reported the use of hot water in treating bluebottle Physalia physalia stings, and suggested the mechanism was through heat inactivation of the jellyfish toxin.4 There is an urgent need for knowledge of this simple remedy to be spread, and there is the potential that it could even be lifesaving when used with more serious jellyfish stings in the north of Australia. Degree of pain relief for the five participants (1–5) after various treatments for jellyfish sting Pain relief during treatment Continuing relief after treatment Treatment 1 2 3 4 5 Mean 1 2 3 4 5 Mean Ice 40% 0 75% 10% 0 25% 0 0 0 10% 0 2% Vinegar 30% 0 20% 0 0 10% 0 0 20% 0 0 4% Aluminium sulfate 75% 20% 30% 35% 50% 42% 0 20% 0 35% 50% 21% Hot water 90% 95% 90% 80% 85% 88% 90% 95% 90% 80% 85% 88% 0 means no relief of pain; 100% means complete relief of pain. The pain relief was temporary (pain returned when treatment stopped) for all except hot water and (to a lesser extent) aluminium sulfate.

John G Taylor

Radiographs of a woman presenting with abdominal pain revealed a large foreign body within the pelvis. A diagnosis of perforation of the colon was made, and at laparotomy an 8.5 cm long glass fragment was removed from the bowel. A laceration to the lower back, sustained in a fall onto a glass coffee table, had been explored and sutured 20 months earlier. Imaging findings showed the subsequent course of the overlooked glass fragment within the pelvis. Clinical record A Abdominal radiograph A: A large triangular foreign body is visible in the pelvis. Note the deformity of the right transverse processes of L4 and L5 (arrows). B Surgical photograph B: The sigmoid colon is opened to show a large triangular glass fragment in the lumen of the bowel. C Computed tomography scan C: A loop of terminal ileum is in continuity with the anterior surface of the right psoas muscle (arrow), directly in line with the bony tract created by the glass fragment. A 60-year-old woman presented to the emergency department complaining of abdominal pain, nausea and bloating, that had developed over the previous 3 days. On examination, there was generalised guarding and tenderness. A chest radiograph showed a pneumoperitoneum, and an abdominal radiograph showed a large, triangular, radiopaque foreign body within the pelvis (Figure, A). A diagnosis of bowel perforation by a foreign body was made, although the patient denied any history of foreign body insertion or ingestion. Further questioning revealed that 20 months earlier she had fallen onto a glass coffee table, sustaining a large laceration to the lower back, just above the natal cleft. She had presented to the emergency department of a large metropolitan hospital where the wound was explored and sutured, but no radiographs were taken. At laparotomy, the patient had faeculent peritonitis, with a small perforation of the antimesenteric wall of the sigmoid colon. An 8.5 cm long triangular fragment of glass was found within the mid sigmoid colon (Figure, B). A Hartmann’s procedure was performed. DiscussionInitially, this was a baffling case. The source of the glass foreign body was obviously the earlier coffee table accident — but how did the glass fragment get into the bowel and why did it take 20 months to present clinically with intestinal perforation? The radiographs and subsequent computed tomography (CT) scans provided the answers. The abdominal radiograph was reviewed the day after clinical presentation and surgery. It was noticed that there was partial bony fusion of the right transverse processes of the fourth and fifth lumbar vertebral bodies. A CT scan confirmed that new bone formation at this level had produced a solid block of bone with a central defect in the shape of a rectangle. It is thought that the glass fragment snapped off deep to the skin and fractured the right transverse processes of L4 and L5, with the subsequent fracture healing process giving rise to a perfect bony cast of the fragment. It is well documented that a fracture initiates a sequence of inflammation, repair and remodelling, and that the remodelling process continues for years.1 Another CT scan showed the bony tract caused by the glass fragment projecting anteriorly into the right psoas muscle. Directly anterior to this, the terminal ileum could be seen lying on the anterior surface of the right psoas muscle (Figure, C). It is thought that the sharp end of the glass fragment gradually worked its way out the front of the psoas muscle and into the terminal ileum. The radiographs and CT scans provide a vivid account of the course of the glass fragment after it penetrated the skin. All but the most superficial and easily explored penetrating injuries caused by glass should be assessed radiographically at the time of injury.2

Sally A Johnston MB BS · David A Lisle MB BS, FRANZCR · Roderick C Borrowdale MB BS, FRACS

A 26-year-old woman accidentally swallowed a 15 cm long spoon during a “laughing attack”. The spoon was removed from the stomach with a single lumen gastroscope (with great difficulty).

Bernard R Beldholm MB BS · Alice U Lee MB BS, FRACP, PhD

Existing trauma registries in Australia and New Zealand play an important role in monitoring the management of injured patients. Over the past decade, such monitoring has been translated into changes in clinical processes and practices. Monitoring and changes have been ad hoc, as there are currently no Australasian benchmarks for “optimal” injury management. A binational trauma registry is urgently needed to benchmark injury management to improve outcomes for injured patients.

Tamzyn M Davey BSocSci(Hons) · Cliff W Pollard MB BS, FRACS · Leanne M Aitken RN, PhD · Mark Fitzgerald MB BS, FACEM, MRACMA · Nicholas Bellamy MB ChB, MD, FRCP · Daniel Cass BSc(Med), FRCS, FRACS · Peter D Danne MD, FRACS, FACS · William M Griggs DipAvMed, FANZCA, FJFICM · Peter A Cameron MB BS, MD, FACEM · Robert N Atkinson DCH, FRACS, FAOrth · James Hamill MB ChB, FRACS · Sudhakar Rao MB BS, FRACS · Drew B Richardson MB BS, FACEM · Christine O'Connor BPsyc(Hons), PhD

. . . a ceaseless flow of students, nurses, doctors, orderlies: fetching and carrying, advising; servants to the patient and their attendant team. Half a dozen medical students have spent the night in the Emergency Department, as the first flight from Bali brings in a dozen or so patients at 2 am. Twenty-six hours earlier, bombs destroyed two nightclubs packed with tourists and local residents at Kuta Beach, Bali.1 Most of the first casualties to arrive are able to walk and, although their injuries are severe, they are soon ministered to in Area 3 (the “walking wounded”) and sent off to the ward. At 5 am, as the first shift of students retires to sleep, the next batch arrives: six 3rd years (of which I am one), Matthias from Switzerland and a couple of 4th years. Didier, Director of Emergency, fills us in on what is happening and tells us to distribute ourselves into the three emergency rooms and two wards: our job is to act as runners, gophers, and extra hands. There is an unseemly wrangling for the best position, but as it turns out we all play our part. In fact, as it turned out, there weren’t enough of us to go round! Word comes that the next flight is due at 6:30 am, so there is time for a bit of a snooze and some nervous chitchat: a seasoned nurse confesses to feeling terrified that she will not be able to cope, that she won’t know what to do. Didier is on the phone constantly; there is a busy flow of information from the airport, from Bali, from interstate hospitals (Box 1). He keeps everyone updated on events as they unfold. Finally, the plane has landed; there are 30 patients, all are severely burnt, one so severely that we can’t tell if it is a man or a woman; six are already earmarked for the Intensive Care Unit. There is a flurry of last-minute instructions and reminders: Didier does his Churchill speech: “. . . great medicine . . . important . . . teamwork . . . faith in you all . . .” It could sound trite, but he means it and he will be proved right. The first ambulance arrives. An ambulance crew wheels in a patient, wrapped in a space blanket, drips and oxygen in a nurse’s hands. An anaesthetist from the airport team reports to Didier: broken forearm, estimated 20%–30% burns to the back and legs, fluids OK, obs stable. An unhurried inspection, a brief conversation with the patient and despatch into the second emergency area: he is not one of the seriously injured patients. The automatic doors at the entrance close on the next stretcher; nobody knows how or if they can be held open — mysteriously, they break and stay open. Ambulances bring patients every 5 minutes, with the same routine: update from the airport doctor, inspection, and triage to the appropriate area (Box 2). The airport team and Didier work in concert to manage the flow: there is always an emergency team waiting to receive each patient, no one is parked in a corridor or left unattended. An ICU patient arrives and is swept upstairs. He’s lucky, a retrieval expert has flown with him from Bali, complete with four bags of emergency equipment. This will mean extra help in ICU for the rest of the day. Emergency Area 1 looks like the inside of an anthill. I have a camera . . . Kerrie, one of the emergency specialists, has asked for some pictures. It’s too early yet for the hospital photographer, so I stand on a table in the resuscitation room, photographing the busy scene below. It looks like madness, but there is a pattern, a disciplined chaos, that resolves into four trolleys — each surrounded by a team of doctors and nurses, standing, quietly busy, playing their parts in a static choreography (Box 3). In between there is a ceaseless flow of students, nurses, doctors, orderlies: fetching and carrying, advising; servants to the patient and their attendant team. A surgeon appears, the first of many, moving from patient to patient, assessing needs and planning the next step in treatment. On my patient, a surgeon is cutting down into the inguinal fold, looking for the femoral artery to plug in a line . . . burns patients leak their body fluids at an alarming rate and we can’t find a vein in his arms or legs to pour liquid into him. Our patient has two bags of fluids up at a time, one with a pressure cuff to squirt it in. I clingwrap a leg which has full thickness burns down one side, while others wrap his arms, back, and buttocks; then we logroll him and see the full extent of the burns on his back. Someone compares the qualities of the different brands of clingwrap — which is the best for burns, which clings and which doesn’t. Jacqui, our team leader, asks the patient if he can remember what happened: “I was sitting at the bar, there was an explosion and I caught fire . . . I rolled on the ground to put it out . . . ” We can tell which side was closest to the bomb — the burns are worse on that side. The nurse asks if he has been in contact with anyone; she brings a mobile phone, so he can phone his mum. The human cost of the bombing strikes home: the burns, shrapnel wounds, infected wounds, blood, urine, moans of pain as we prod and poke. All these make up the professional part of the unfolding drama. We examine and analyse, put up drips, take blood, carefully record the location and extent of burns, peel off bandages, clingwrap body parts. It isn’t hard, it’s not horrific. Not at the time. It’s what we do, the bread and butter of medicine. We fold our professional armour around us with our white gowns. But hearing a young man, twenty-something, good-looking, strong, ask to speak to his mum on the phone — that is the hard part, the side that isn’t protected by a white gown. He’s letting her know he’s alive, that he’s in safe hands (we’ve told him, “you’re in the Royal Darwin Hospital . . . we’ll take care of you”), that he’s going to be all right. But we know he isn’t going to be all right: OK, he will live but, in between our thoughts of what to do next, we know that his future is going to be full of pain and disfigurement and mental trauma, and many of his hopes and dreams were burnt up along with his back and legs. Over on the far trolley, one patient is really seriously ill . . . off to ICU, but not just yet. His arms are burnt all round and the tissue under the burnt skin is swelling, compressing the muscles, slowly killing them, releasing toxins that will inevitably poison him. A surgeon carefully cuts full length down his arm and into his hand, releasing the tight sheath around his muscles, giving them a chance to stay alive. It looks like an anatomy lesson. The surgeon methodically cauterises small arteries, gently holding the patient’s hand as though reading his palm, while the smell of burnt flesh is sucked from the room by the air conditioning. Didier complains about the lack of medical students . . . I think everyone is here; we are all part of the team. Hours pass, and the last patient heads off to the ward: time for a break. There are 10 family-sized pizzas in the tearoom, ordered from the local pizza shop by a wellwisher in Adelaide. I photograph the empty resuscitation room, then snap an emergency nurse beside a neatly made-up trolley, waiting for the next patient — it all looks so normal. Tired people sit and drink tea, eat curry, pizza, sandwiches from downstairs in catering. We go for a walk, up to the ward. Everywhere there are signs of planning and preparation: boxes of fluids, dressings, trolleys, instruments. In the cafeteria are trays of food, cold drinks, desserts . . . the whole hospital plays a part, the “sharp end” functions so well because of those backstage. We hear later of the office staff phoning the families of patients, working as hard as we did to inform, reassure, sympathise; they are at a different sort of sharp end. The next plane lands with 20 more patients and the performance begins again: slick, smooth, fast. After all, we are seasoned now. The first night has been a success, even the students look professional; we are not just runners now. There are tasks to do which are ours: organise bloods; remove dressings; record the history, examination and assessment; clingwrap there, lift here. There are moments of time to watch and appreciate the choreography, the choreographers and the dancers — the emergency teams move with familiar precision and practised teamwork. The ring-ins slowly integrate into their rhythms, so by the end of the day it all seems like some grand ritual. The emergency specialists are like satellites, constantly orbiting each team, assessing, coordinating, advising, helping. By the middle of the afternoon it is pretty much all over for the students. The next plane has just two patients and then there are no more. We walk up to the ward . . . “is there anything we can help with?” We take some blood, struggling to find any sort of vein, finally going for the foot because there is nowhere else. The patient says, “they all find it hard”. One of us has to take blood from a line and doesn’t know how to do it, so I guide her through it: set up a sterile field, glove up, clean the bung, take 10 mL and discard, take the sample, flush the line, flush it again, clean it, clean it . . . it’s precious. It’s time to go home; 12 hours of adrenaline needs dissipating, we need to talk to each other. Someone offers his place, another cooks dinner; we have a beer and begin the debrief, reliving the day. For the next 2 days we are tired. There is a sense of anticlimax. The normal world has gone on around us and it goes on still. Suddenly, the hospital looks no different, except for odd stacks of boxes here and there that have yet to be returned to stores. We have an official debrief and hear the big picture — the confidence that Darwin could handle it, the thoroughness in the planning. We hear the stories from other places, and we praise the work of Denpasar Hospital and the Balinese, and our colleagues there, and on the tarmac at the airports. We feel important and proud to have been part of the grand dance. But someone asks about our patients: where have they gone and how are they and will they be all right; and there is a moment’s quiet, and we each have our own thoughts. 1 “Didier is on the phone constantly” 2 “Ambulances bring patients every 5 minutes” 3 “Trolleys — each surrounded by a team of doctors and nurses”

David E Chapman BA, BM BS

To the Editor: With Australia’s rapidly ageing population and an explosion in the number of retirement villages and nursing homes, Finn and associates are to be congratulated for ventilating the subject of the interface between residential aged care facilities and emergency departments.1 My experience of emergency department (ED) and aged care facility relations spans over 50 years and I have been involved in both sides of the equation. Firstly as a surgeon, then as director of an ED, and finally, as a resident of a retirement village for over 20 years (including, for my wife, 5 years in the affiliated nursing home), and during that time my wife and I have had at least eight episodes as patients in an ED. Retirement villages and nursing homes are not equipped or organised to handle medical or surgical emergencies. Problems of “disposal” arise after ED assessment and treatment in a public hospital. The hospital may not have an empty bed. The patient’s condition may not be serious enough to require a hospital bed, but the patient may not be well enough to return to his or her retirement village. Privately insured patients may have the option of transferring to a private hospital but usually spend an unnecessarily long time in the ED awaiting such transfer. Matters that need attention are: a standing arrangement between public and neighbouring private hospitals to facilitate quick transfer of suitable patients. the removal of long delays in EDs that occur while waiting for the results of investigations and even longer periods awaiting “higher opinions” after receiving these results. a speedier and more detailed hospital summary addressed to the general practitioner (if known) as well as to the aged care facility concerned.

Keith S Jones

Objective: To compare the survival rate from out-of-hospital cardiac arrest in rural and urban areas of Victoria, and to investigate the factors associated with these differences.Design: Retrospective case series using data from the Victorian Ambulance Cardiac Arrest Registry.Setting: All out-of-hospital cardiac arrests occurring in Victoria that were attended by Rural Ambulance Victoria or the Metropolitan Ambulance Service.Participants: 1790 people who suffered a bystander-witnessed cardiac arrest between January 2002 and December 2003.Results: Bystander cardiopulmonary resuscitation was more likely in rural (65.7%) than urban areas (48.4%) (P = 0.001). Urban patients with bystander-witnessed cardiac arrest were more likely to arrive at an emergency department with a cardiac output (odds ratio [OR], 2.92; 95% CI, 1.65–5.17; P < 0.001), and to be discharged from hospital alive than rural patients (urban, 125/1685 [7.4%]; rural, 2/105 [1.9%]; OR, 4.13; 95% CI, 1.09–34.91). Major factors associated with survival to hospital admission were distance of cardiac arrest from the closest ambulance branch (OR, 0.87; 95% CI, 0.82–0.92), endotracheal intubation (OR, 3.46; 95% CI, 2.49–4.80), and the presence of asystole (OR, 0.50; 95% CI, 0.38–0.67) or pulseless electrical activity (OR, 0.73; 95% CI, 0.56–0.95) on arrival of the first ambulance crew.Conclusions: Survival rates differ between urban and rural cardiac arrest patients. This is largely due to a difference in ambulance response time. As it is impractical to substantially decrease response times in rural areas, other strategies that may improve outcome after cardiac arrest require investigation.

Paul A Jennings BN, MClinEpi · Peter Cameron MB BS, MD · Tony Walker BParamedStud, GDipEd · Stephen Bernard MB BS, FACEM · Karen Smith BSc(Hons), PhD

Caring for those who cannot or will not care for themselves In discussions and studies about access to health care — from prevention to inpatient management — the lower end of the socioeconomic spectrum rarely rates a mention. This sizeable subgroup, especially in cities but also in rural settings, is over-represented among people attending emergency departments.1 Frequent attenders to emergency departments are a heterogeneous group — a mix of patients with chronic medical, mental health, alcohol and drug problems, as well as other psychosocial issues.2,3 Individual patients often have a combination of some or all of the above problems. Interestingly, the frequency of attendance may change with time, although patients with psychiatric and substance misuse issues tend to be persistent heavy users.4 Despite the fact that they may be as sick as other, non-frequent attenders, frequent attenders are often perceived as time-consuming “illegitimate” users of emergency department resources.1 From the patient’s viewpoint, despite having good access to primary health care, the emergency department is seen as the most appropriate place to seek help because of a perceived need for urgent care.5 Rather than as a substitute, emergency departments are often used in conjunction with primary care services, with the emergency department providing appropriate higher level care.6,7 Some of the debate about the resourcing of very expensive 24-hour services, such as stressed emergency departments, focuses on “diverting” patients away or “streaming” them somewhere else (eg, general practice) after appropriate triage. Multidisciplinary teams (including allied health workers) that target high-risk patient subgroups — the elderly, patients with respiratory illnesses, patients with mental health problems — have been introduced in many hospitals to address the swamping of emergency services. But does all this actually make a difference? In this issue of the Journal, Phillips et al (page 602)8 evaluated the effect of multidisciplinary team case management on frequent attenders’ utilisation of an inner city emergency department in Melbourne, compared with their utilisation before case management (ie, the study population acted as their own historical controls). Emergency department utilisation and scores for housing stability, alcohol and drug use, and primary and community care engagement were determined. Perhaps surprisingly and paradoxically, despite intensive case management, Phillips et al found an increase in emergency department utilisation and overnight stays. A potential interpretation of this increased utilisation is that it may well reflect an increase in engagement of these patients, with the desired increased attention and improvement in their health. Furthermore, the study found that linkage with primary care and community services improved. Interestingly, in 2002, Moss et al, at another Melbourne inner city emergency department, found that a similar strategy produced a significant fall in hospital admissions.9 In an ideal world, there would be no debate about allocation of care teams to sick patients or the effectiveness of preventing health deterioration. Nor would certain groups of patients only be really visible once they have deteriorated — and then only mainly visible to certain parts of the health care system (eg, emergency departments, and community and mental health services). In health care, as elsewhere, planners can largely underestimate the need for, and the effect of, a new service where none previously existed. This would be easy to imagine when dealing with a marginalised, and at times psychosocially challenged, group of people. Quoting Malone: . . . reducing unwarranted or unwanted emergency services utilisation is not merely a matter of redirecting individuals to other medical care providers but is lodged within the larger and far more complex issue of how and where we as a society and as individuals care (or fail to care) for those who cannot or will not care for themselves in socially sanctioned ways . . .1 Research, measuring appropriate outcomes including accurate assessments of cost, has to be increased to allow resources to be rationally allocated.

Gordian W O Fulde FRACS, FRCS, FACEM · Martin Duffy MB BS, FACEM

Objective: To evaluate the effects of multidisciplinary case management (CM) on emergency department (ED) utilisation and psychosocial variables for frequent attenders at the ED.Design: Retrospective cohort analysis, with the study population as historical controls and data analysed 12 months before and after CM intervention in the period 1 January 2000 – 31 December 2004. Subgroup analyses were performed according to primary problem categories: general medical, drug and alcohol, and psychosocial.Setting: Inner urban tertiary hospital ED.Participants: Frequent ED attenders who received CM.Main outcome measures: ED attendances: length of stay, triage category, ambulance transport, disposition, attendances at the only two EDs nearby. Psychosocial factors: housing status, drug and alcohol use, and primary and community care engagement.Results: 60 CM patients attended the ED on 1387 occasions. Total attendances increased after CM for the whole group (610 v 777, P = 0.055). Mean average length of stay (minutes) of the total study population and each subgroup was unaffected by CM (297 v 300, P = 0.8). Admissions for ED overnight observation increased as a result of CM (P = 0.025). CM increased scores for housing stability (P = 0.007), primary care linkage (P = 0.003), and community care engagement (P < 0.001) for the whole group and variously within subgroups. Drug and alcohol use was unaffected by CM.Conclusion: ED-initiated, multidisciplinary CM appears to increase ED utilisation and have a positive effect on some psychosocial factors for frequent attenders. A trend towards increased ED attendance and utilisation with CM may have implications for policies that seek to divert frequent attenders away from hospitals.

Georgina Ann Phillips MB BS, FACEM · David S Brophy BA, BSW · Tracey J Weiland BBSc(Hons), PhD · Antony J Chenhall MB BS, FACEM · Andrew W Dent FACEM, FRCS, MPH

Objective: To determine the usefulness of abdominal ultrasonography for diagnosing colorectal cancer in patients presenting with abdominal distension.Design, setting and participants: A prospective case series of consecutive adult patients with abdominal distension admitted to the National Taiwan University Hospital between January 2001 and July 2004. All participants were examined by abdominal ultrasonography. Those with suspected colorectal tumours on ultrasonography had follow-up colonoscopy, while all other patients had computed tomography scans.Main outcome measures: Accuracy of abdominal ultrasonography for diagnosing colorectal cancer in patients with abdominal distension; incidence of colorectal cancer.Results: Of 511 patients eligible for inclusion in our study, 97 (19.0%) were confirmed to have colorectal cancer. For diagnosis of colorectal cancer, ultrasonography had a sensitivity of 92.8% (95% CI, 85.2%–96.8%); a specificity of 98.8% (95% CI, 97.0%–99.6%); a positive predictive value of 94.7% (95% CI, 87.6%–98.0%); a negative predictive value of 98.3% (95% CI 96.4%–99.3%); and an accuracy of 97.7%.Conclusion: Ultrasonography is a sensitive tool for diagnosing colorectal cancer in patients presenting with abdominal distension.

Shyr-Chyr Chen MD, MBA · Zui-Shen Yen MD, MPH · Hsiu-Po Wang MD · Chien-Chang Lee MD, MPH · Chiung-Yuan Hsu MD · Wen-Jone Chen MD, PhD · Chien-Yao Hsu MD · Hong-Shiee Lai MD, PhD · Fang-Yue Lin MD, PhD · Wei-Jao Chen MD, PhD

To the Editor: Much has been written to describe the best clinical protocols to improve patient outcome following a medical emergency in hospital.1-4 However, one simple step in the process has not been clearly articulated: what is the hospital internal emergency number to ring to summon the medical emergency or “code blue” team? Each hospital in Australia sets its own emergency phone number. Examples include 333, 444, 555, 666, 777 and 2333 — there are probably others. For the highly mobile workforce in our hospitals, it is often difficult to recall which number to ring when challenged by the immediacy of a situation. All hospitals should upgrade their phone systems to have a single standard phone number for internal emergencies. This solution has been successfully applied in the broader community. In the Australian community an emergency call is 000, in the United States it is 911, and in the United Kingdom it is 999. It ought to be possible for all Australian hospitals to use a standard emergency telephone number to initiate an internal emergency response. I have only been able to find one health service internationally that has attempted this solution — the UK National Health Service advises trusts to use the number 2222.5 Technical advice on what number would be most suitable in Australia would be required. Telecommunications experts should advise on the technical aspects, cost and a reasonable time frame for all hospitals. State and federal health services would need to direct all hospitals to move to the new number, either as able or by a date to be determined. I hope to raise the debate on what appears, at a superficial level, to be a very simple initiative that could save lives, or at least remove one more cause of error and delay in the internal emergency response of each hospital.5 I have written to various authorities asking that this concept be explored. Those that have responded agree in principle, but have not taken responsibility for its progression. If this is a good idea, who should or could take control of it? It would be helpful to find an authority to back this proposal. This is a call for help.

Gerald F Williams

To the Editor: Reading the excellent Christmas edition of the Journal, I was struck by the symmetry of the computed tomography scans of rectus sheath haematomas in a husband and wife, reported by James and colleagues1 (Box). I was wondering if the couple had not been involved in a minor car accident or incident of heavy braking several days earlier, where the lap–sash or buckle of a seatbelt might explain the mirror injuries?

Mark R Nelson

In reply: The rare and spontaneous nature of rectus sheath haematoma leaves its origins open to such interesting questions. Neither of our patients was able to recall a history of motor vehicle trauma, but minor braking trauma certainly remains a possibility, as does respiratory infection leading to protracted cough. Computed tomography scans of matching rectus sheath haematomas in a 62-year-old woman (A) and her husband (B).

David James

A collaborative trial is needed At a time when there is a widely held perception that older people, and particularly nursing home residents, are occupying acute care hospital beds at the expense of others,1 the article by Finn et al2 in this issue of the Journal is very pertinent. It describes the presentation, over a 6-month period, of a cohort of 541 patients from aged care facilities (nursing homes and hostels) to the emergency department of a large tertiary hospital, and notes that the substantial majority (87%) of these presentations were considered to be appropriate. These patients were acutely unwell (most having been so for less than 2 days) and required the investigations and expertise available in the emergency department for diagnosis and management. Sixty per cent of these patients required hospital admission and most (90%) survived to be discharged back to their aged care facility. There are currently about 78 000 people in nursing homes across Australia and about 81 000 in hostel care.3 These numbers will continue to grow as the number of older people increases. Consequently, presentations to emergency departments and admissions to hospital are also likely to increase, placing further strain on already busy hospitals. Hospitals can be dangerous and unfriendly places for frail older people or people with dementia, who are most likely to be residents of aged care facilities. Polypharmacy, undernutrition, skin tears, pressure areas, fall-related injuries, nosocomial infections, and deconditioning are some of the hazards of hospitalisation.4 It is therefore now very appropriate to be looking at methods of reducing the need to hospitalise these patients by providing assessment and management of selected conditions within aged care facilities. Finn et al suggest some of the resources that would be required to prevent inappropriate hospital presentation (such as the ability to insert indwelling catheters and to replace percutaneous endoscopic gastrostomy tubes), but more than this will probably be necessary. Recently, a number of hospitals around Australia have identified the need to work more closely with aged care facilities and general practitioners to provide acute care to patients in nursing homes. For example, Gold Coast Hospital in Queensland has piloted a “Hospital in the Nursing Home” program that delivers acute care to nursing home residents using their own GP and nursing home staff, with medical and nursing input from Gold Coast Hospital staff.5 This service also provides education and information to nursing home staff in areas such as wound care, continence management and intravenous fluid administration, enabling staff to improve their skills in these areas. Clinical pathways are used for management of pneumonia, urinary sepsis, dehydration, palliative care and wounds. The service has treated 400 patients, resulting in hospital bed-day savings of more than 1500 days over 2 years and allowing residents to stay in familiar surroundings while receiving acute care (Ms Kerry Robinson, Project Officer, Aged Care Early Intervention and Management, Gold Coast Hospital, personal communication). This would appear to be a positive outcome for all parties, but a randomised controlled trial would be needed to confirm the effectiveness of the intervention. Finn and colleagues also raise a number of other issues that merit attention, and addressing these issues could potentially avoid some presentations and improve information sharing in others. Their study revealed that a GP had been consulted for only a quarter of patients presenting to the emergency department. Increased GP availability and involvement is clearly important, given that 126 out of the 136 presentations involving GP input were judged “appropriate”, whereas up to 45 of the 71 presentations considered “inappropriate” could have been avoided if GP review had occurred. With the increased use of Enhanced Primary Care Initiatives, in particular, comprehensive medical assessment for permanent residents of residential aged care facilities (Medicare Benefits Schedule item 712), and Aged Care GP Panels, it is hoped that there will be much greater direct involvement of GPs in the care of their patients in aged care facilities. Overseas experience indicates that increased availability of primary care (both medical and nursing) in nursing homes results in fewer hospital admissions.6 The lack of communication between aged care facilities and the emergency department in 61% of presentations is also of concern. Use of a common aged care facility transfer sheet may improve this, and as the use of technology increases (eg, electronic care plans for residents), the use of electronic referrals may assist the process of information transfer. Inadequate communication or documentation between aged care facilities and emergency departments has been shown to increase the likelihood of admission to hospital.7 The preparation and use of advance care directives was also suggested by Finn et al to guide response to acute events occurring in residential care. Advance care directives (also known as “health care directives” or “living wills”) allow residents to document their preferences for treatment and care. The directives may indicate a desire for hospital admission and full treatment or a preference for limited treatment in certain situations. Many aged care facilities already encourage their use and help residents and their families formulate such directives in the weeks following their admission. Advice in preparing these directives is available from a number of sources, such as NSW Health.8 Finn and colleagues have given us an understanding of current presentations of patients from residential care facilities to emergency departments that can assist us in developing different and better quality services for these people. Adequate training and resourcing of staff in aged care facilities, increasing involvement of GPs, and consultation with residents and their families are the first steps in developing these services.

Susan E Kurrle MB BS, DipGerMed, PhD