Emergency medicine

Objective: To estimate the appropriateness of emergency department (ED) presentations by people aged ≥ 65 years living in residential care facilities.Design, setting and participants: Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel.Main outcome measures: Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge.Results: 541 residents aged ≥ 65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed “inappropriate” for 71/541 cases (13.1%; 95% CI, 10.5%–16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer.Conclusions: The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.

Judith C Finn PhD, RN, FRCNA · Leon Flicker MB BS, PhD, FRACP · Eileen Mackenzie RN, GDCritCare · Ian G Jacobs BAppSci, PhD, RN · Daniel M Fatovich MB BS, FACEM · Shelley Drummond RN · Michelle Harris RN · D'Arcy C D J Holman MB BS, MPH, PhD · Peter Sprivulis MB BS, FACEM, PhD

Objective: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings.Design: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned.Setting: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005.Participants: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle.Interventions: Hot water immersion (45°C) of the affected part versus ice pack application.Main outcome measures: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up.Results: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean ± SD]: 54 ± 22 mm versus 42 ± 22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%–39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%–69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups.Conclusions: Immersion in water at 45°C for 20 minutes is an effective and practical treatment for pain from bluebottle stings.

Conrad Loten MB ChB · Barrie Stokes BSc, MMath · David Worsley BMed · Jamie E Seymour BSc, PhD · Simon Jiang · Geoffrey K Isbister BSc, MB BS, FACEM, MD

Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission.Design: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records.Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003.Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period.Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital.Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r = 0.98; 95% CI, 0.79–1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1–1.6), 1.3 (95% CI, 1.2–1.5) and 1.2 (95% CI, 1.1–1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1–1.1; P < 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1–1.3; P = 0.01).Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Peter C Sprivulis MB BS, PhD, FACEM · Julie-Ann Da Silva BPsych · Ian G Jacobs RN, PhD · George A Jelinek MD, FACEM · Amanda R L Frazer MB BS, LLB

Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period).Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation.Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Looking Good. The Australian guide to skin care, cosmetic medicine and cosmetic surgery. Dr Laurence Anderson. Sydney: MJA Books, 2006 (v + 112 pp) ISBN 0-85557-044-X . “— an excellent publication that gives an accurate overview of what is available for the cosmetic medicine consumer. It is interesting, informative, well set out and easy Cosmetic medicine and cosmetic surgery have come of age. We can remove wrinkles and blemishes, straighten teeth and noses, and sculpt our bodies into works of art. We have the power to make ourselves beautiful and are not afraid to use it. These days, cosmetic procedures are varied, mainstream and affordable, and the line between beauty treatments and cosmetic medical options is blurred. In Looking Good, Dr Laurence Anderson, a member of the Cosmetic Physicians Society of Australasia, clearly explains how to look after our skin and demystifies the many cosmetic and plastic surgical procedures available. Looking Good answers the Australian public’s questions. A registered cosmetic physician and long-term GP, Dr Anderson covers skin anatomy, sun protection, diet, cosmetics and other general information in the first half of the book, then tackles available cosmetic procedures in the second half. These are broadly divided into minor or office procedures valued at around $1000 or less, and the major procedures costing up to $15,000 or more and often requiring a general anaesthetic. Various practitioners have contributed high quality “before and after” photographs, and the text is liberally illustrated with line drawings and other photographs. There are sections on overseas travel to get cosmetic medicine and how to prepare yourself and your family when you are considering surgery. Looking Good is not a shopfront for cosmetic practitioners and is quite candid about the downfalls, both physical and emotional, of this growing cultural phenomenon. While people have the right to maximise their attractiveness, the book points out that there is also the danger that for some cosmetic medicine may become an unhealthy obsession or be mistaken as the answer to life’s problems. Order this book

Caesarean section. A manual for doctors. Caroline M De Costa and Paul Howat. Sydney: MJA Books, 2006 (v + 104 pp). ISBN 085557 045 8. Caesarean section is a must for any doctor considering obstetrics. It is well written, easy to read, exceptionally informative, and practical. It was written by two rural obstetricians with a wealth of experience, in collaboration with two anaesthetists. I know from personal experience that both authors spoke with many colleagues to find out how they cope with some of the difficult caesarean complications. My only criticism of the book is that there is some repetition of the topics, particularly anaesthetics, but that happens because each chapter could be considered to be a small monologue that stands alone. The organisation of the book is very good. It begins with the decision-making process that is necessary before performing caesarean section, goes through informed consent, and gives the pros and cons of carrying out the procedure and its anaesthetic. For readers who have not performed a caesarean section, or may have only performed a few, there is a good description of how to proceed. There is also a description of the basic surgical instruments required. After dealing with the basic procedure, the book describes some complications of caesarean section (eg, difficulties delivering the head). There is a chapter devoted to intra- and post-operative bleeding and practical hints for coping with the various causes of bleeding. Further chapters deal with caesarean section for placenta praevia and the indications for a classical caesarean section and how to perform it. The management of caesarean section in women who are HIV positive, and sterilisation at the time of caesarean section are discussed. The last two chapters deal with anaesthesia for caesarean section and are very good reading for procedural general practitioners who may need to administer anaesthetics, particularly in rural areas. One deals with regional anaesthesia (epidural, spinal, and combined anaesthesia); the other deals with general anaesthesia, outlining the potential problems of giving a general anaesthetic to a pregnant woman and how to cope when unable to intubate a pregnant woman. There is also a good appendix detailing references for further reading. In summary, this is an excellent practical book which should be read by all doctors who are about to embark on performing caesarean section and anaesthesia. It is also of value for experienced practitioners as it describes how other people have coped with some of the difficulties of caesarean section. Ian PettigrewAssociate Professor, Department of Rural Obstetrics and Gynaecology, Monash University, Mildura, VIC Order this book

Ian Pettigrew

Stephen F Wilson,* Peter McGeorge† * Program Director, Population Health, Sacred Heart Rehabilitation Centre, † Director of Mental Health Service, St Vincent's Hospital, Darlinghurst, NSW 2010. stwilsonATstvincents.com.au To the Editor: Corbett’s recent proposal to create a “Ministry for the Public’s Health” has merit. However, this Ministry may not achieve its intended purpose in relation to disadvantaged people, chronic and complex health care, or the mental health problems confronting acute services in today’s urban communities. The current situation may be the result of long neglect of population health. However, a new Ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system. The efficiencies of an integrated service for acute health care of older people are well known.2 This integration requires a reinvestment in community care and changes in roles and relationships of health workers. There is currently a gap between services maintained by state funding for acute care in and around hospitals, and services which are federally funded for the community sector via general practice, preventive and maintenance services. The gap created between these two workforces results in suboptimal “management” of chronic and complex disease and mental health, and care of disadvantaged groups. The lack of a strong focus on management drives patients to rely on the acute health care system, particularly emergency departments. This situation is aggravated by the poor coordination with general practice, non-government organisations and community services. The current challenge is to develop a health environment which simultaneously addresses the present and future needs for prevention, management and response. Another approach is to construct a health “sandwich”, with a foundation layer of population health, a “filling” of illness management services, and a top layer of acute response and hospital services. A model guided by the mission of St Vincent’s Hospital, and implemented in 2005, has created a partnership for emergency department, community health, aged care, rehabilitation and palliative care within an administrative division called Population Health. A Psychiatric Emergency Care Centre within the emergency department has established a shared approach to acute patient care along with the mental health services. In the future, a patient entering the emergency department for an acute response to physical, mental or combined illness should also be “consuming” a health program of management and disease prevention, which is lacking in current health service provision. This healthy sandwich may prove easier to digest than the dry biscuits of policy.

Stephen F Wilson · Peter McGeorge

CorrectionRe: “Is the Australian hospital system adequately prepared for terrorism?”, by Jeffrey V Rosenfeld, Mark Fitzgerald, Thomas Kossmann, et al, in the 5/19 December issue of the Journal (Med J Aust 2005; 183: 567-570). One of the coauthors’ names was incorrectly listed in the print issue as “Andrew Joseph”. His correct name is “Anthony Joseph”. The html and pdf versions were correct when published.

Jeffrey V Rosenfeld FRACS, FRCS(Edin), FACS · Mark Fitzgerald FACEM · Thomas Kossmann MD, FRACS · Gim Tan FACEM · Michele Gardner RN, GD, FRCNA · Andrew Pearce FACEM · Anthony Joseph FACEM · Shmuel Shapira MD, MPH

A government report concluded that the cause of the recent cluster of illness affecting 57 people at Melbourne Airport was a “mystery”. On reviewing the evidence, I noted the appearance of a constellation of distinct psychogenic features (in the absence of an identifiable pathogenic agent or source), and non-specific symptoms not correlated with any particular illness, strongly suggesting a diagnosis of mass psychogenic illness. Given the time differential between the illness onset in the index case and the initiation of air sampling, and the added factor of the air-conditioning in the terminal being switched to exhaust mode, the possibility that a toxic agent was responsible for making some of the victims ill cannot be completely excluded. Future investigations of similar incidents should, in the absence of clinical or laboratory findings, consider the diagnosis of mass psychogenic illness. Failure to do so can engender avoidable confusion and unease among the Australian public. The issue of diagnosing collective psychogenic illness will continue to be a major public health challenge, exacerbated by widespread anxieties over the threat of chemical and biological weapons and fears of contamination.

Robert E Bartholomew PhD, MA

Australian hospitals need to be prepared to deal with mass casualties from terrorist strikes, including bomb blasts and chemical, biological and radiation injury. Injuries from bomb explosions are more severe than those commonly seen in Australian hospitals. In disasters involving mass casualties in urban areas, many of the injured make their own way to hospital, often arriving before the more seriously injured casualties. Major hospitals in Australia should plan for large numbers of undifferentiated and potentially contaminated casualties arriving with minimal warning. It is critical that experienced and trained senior medical officers perform the triage of casualties in emergency departments, with frequent reassessment to detect missed injuries (especially pulmonary blast injury). Hospitals require well developed standard operating procedures for mass casualty events, reinforced by regular drills. Preparing for a major event includes training staff in major incident management, setting up an operational/control unit, nominating key personnel, ensuring there is an efficient intra-hospital communication system, and enhancing links with other emergency services and hospitals.

Jeffrey V Rosenfeld FRACS, FRCS(Edin), FACS · Mark Fitzgerald FACEM · Thomas Kossmann MD, FRACS · Gim Tan FACEM · Michele Gardner RN, GD, FRCNA · Andrew Pearce FACEM · Anthony Joseph FACEM · Shmuel Shapira MD, MPH

The government has undertaken roles in disaster planning and coordination to complement hospital and workforce readiness Rosenfeld and colleagues1 make many excellent points about individual hospital preparedness for terrorism. However, the article fails to fully contextualise the overarching emergency management arrangements and the considerable work that all levels of government have undertaken to support individual hospitals, area health services, jurisdictions and the nation as a whole.2,3 Many of the activities they suggest are already in place in different states. These include chemical, biological and radiological (CBR) training and health student training; media management; and tracking and identification of patients. The following points expand on some of the areas touched on by Rosenfeld et al. Disaster planningHospitals have disaster plans in place that complement broader jurisdictional and national disaster plans. Some of these broader plans include the Commonwealth Government Disaster Response Plan,2 guidelines for the treatment and management of smallpox and anthrax,4 the Mass Casualty Transport Review, the Mental Health Disaster Response Plan,5 the National Response Plan for Mass Casualty Incidents Involving Australians Overseas,6 and the National Burns Plan (AusBurnPLAN).7 AusBurn-PLAN, in particular, can activate national assistance to an affected jurisdiction by moving medical teams in and redistributing patients to other hospitals to ensure that the most appropriate care is delivered. The National Medicines Stockpile8 was established in 2002 to provide specialised pharmaceuticals and equipment in response to terrorist acts or other health emergencies. In addition, states and territories can call on their own embedded stocks. The National Medicines Stockpile includes stocks of antidotes, antibiotics, personal protective equipment, ventilators and negative pressure units. Contingency plans have been developed to deploy these assets to an affected jurisdiction if a chemical, biological or radiation incident occurs. Another important asset in disaster planning is the planned National Trauma Centre at Royal Darwin Hospital (RDH), initiated in response to the first of the Bali bombings, in 2002.9 RDH responded effectively and appropriately to both the 2002 and 2005 Bali terrorist attacks, but the establishment of the National Trauma Centre at RDH with two specialised chairs (a Chair of Emergency Preparedness and Response at the Northern Territory Clinical School and a Chair of Trauma and Critical Care at the Menzies School of Health Research) will further enhance the overall response capability of Australia. Hospital readinessRosenfeld and colleagues believe that, currently, most Australian hospitals would not be able to “cope” with more than 10–24 seriously injured patients. It is not clear how this number was determined. A review of over 100 terrorist bombings with improvised explosive devices since 199610 showed that most of the live casualties had relatively minor injuries, with less than 15% having injury severity scores over 15. Tragically, in major terrorist events, many people die at the time of the incident, as was the case after the September 11 attacks in the United States — but 48 hours after the tragedy only 18 patients remained in hospital. Another review of 13 major terrorist attacks11 found that only 9%–22% of survivors were critically injured (injury severity score > 15). Most of the casualties received relatively minor injuries. We agree that the “walking wounded” can be inappropriately “up-triaged” and/or self-present to key trauma centres, leading to a potential loss of focus on severely injured patients who need resuscitation and life-saving surgery. Hospitals must have contingency plans to corral less-injured patients in advance of the arrival of ambulances bringing the more severely injured. In New South Wales, for example, disaster plans factor these issues in by ensuring that the more severely injured patients are directed to trauma centres by helicopter and ambulance and the less injured are corralled or transferred by bus to smaller hospitals. Testing health system response capabilityNo plan is effective unless tested periodically by practice drills. There have been extensive exercises at a jurisdictional and national level for a number of disaster scenarios that test hospital systems. Exercise “Supreme Truth”, held at the Royal Adelaide Hospital in 2003, practised and evaluated the response of a major public hospital to a mass casualty incident involving a CBR agent.12 Among its outcomes were improvements to the SA Major Incident Plan, the facilities for managing CBR events, and the interface with emergency services. National Counter Terrorism Committee exercises have been led by the Australian Government. Of particular importance is Exercise “Explorer”, held in 2004, in which a terrorist bombing scenario in Sydney’s central business district was formally tested at a purpose-built site at Holsworthy.13 Over 250 patients were formally triaged and treated by ambulance personnel and health teams at the site. The disposition of patients to appropriate trauma centres was successful. As part of the same exercise, the AusBurnPLAN arrangements were tested.7 Severe burn patients were identified for transfer to other states, and medical-team support was provided in a coordinated fashion to NSW. Hospitals were also tested recently in “Mercury ’05”, a national multi-jurisdictional counter terrorism exercise with a focus on mass casualties. Mercury ’05 demonstrated how emergency management arrangements can be activated in a disaster during the surge phase (the first 12 hours after a disaster) to enhance overall capacity when operating within a nationally coordinated framework. More exercises are planned for 2006 that will yield valuable lessons for hospitals. In addition, “table-top” exercises, such as the Emergo Train system,14 appropriately test hospitals’ ability to manage a sudden surge in casualties and ensure that the most critically injured patients receive timely resuscitation and life-saving surgery. CoordinationResponse to a disaster requires coordination between a range of professionals and across jurisdictions. The Australian Health Disaster Management Policy Committee (AHDMPC) has the ability to support health-system “surge” response, both locally and nationally. This cross-jurisdictional group was established by the Australian Health Ministers’ Advisory Council in February 2003. It is charged with identifying Australia’s level of preparedness to respond to the consequences of a terrorist attack or a naturally occurring disaster and to coordinate a national response in the event of mass casualties or outbreak of disease. The AHDMPC has now coordinated planning and response in relation to avian influenza, the Indian Ocean tsunami and the recent Bali bombings, and has conducted debriefing following the Madrid and London bombings. It has also undertaken a number of audits of Australia’s emergency response capability and will use the results of those audits and ongoing monitoring to identify and address gaps. WorkforceSenior clinicians in hospitals must accept emergency management principles as part of their core business. Emergency response training at the local hospital level can be factored into the functioning of all hospital training programs, and should be regarded as no different from training in resuscitation or other clinical management issues. All hospitals should undertake disaster preparedness drills at least twice a year. It is incumbent on all clinicians to add emergency preparedness to their range of clinical skills and to be aware of the disaster plans within their institution. The AHDMPC has also made workforce disaster preparedness a priority and will shortly review the Department of Health and Ageing and Emergency Management Australia’s National Disaster Medicine course and undertake a national stocktake of health emergency management courses. There is also evidence of growing interest in biosecurity and disaster-response training and education from other quarters. For example, a recent review of the Public Health Education and Research Program has recommended that capacity and expertise in this area be developed and made more widely available through a variety of universities.15 ConclusionDisaster management calls on the skills of many professionals and many areas of government. Steps taken over recent years, including the establishment of the AHDMPC, have enhanced cooperation and coordination between sectors. There is a need for continuous improvement and for testing improvement initiatives through ongoing exercise programs.

Mary Murnane · David M Cooper

Objective: To describe the epidemiology and clinical features of box jellyfish envenoming in the Top End of the Northern Territory and, in particular, confirmed stings from the major Australian box jellyfish, Chironex fleckeri. Design: Prospective collection of clinical data and skin scrapings or sticky-tape tests for nematocyst identification from patients presenting to Royal Darwin Hospital and remote coastal community health clinics in the Northern Territory, spanning 10 950 km of coastline; analysis of tidal, weather and seasonal data. Patients: All patients with jellyfish sting details recorded between 1 April 1991 and 30 May 2004. Main outcome measures: Demographic and clinical features, use of C. fleckeri antivenom, and associations between weather, seasonal and tidal factors and confirmed C. fleckeri stings. Results: Of 606 jellyfish stings documented, 225 were confirmed to have been caused by C. fleckeri. 37% of C. fleckeri stings were in children, 92% occurred during the “stinger season” (1 October to 1 June), 83% occurred in water 1 m or less deep, and 17% occured while victims were entering the water. Stings were least common on outgoing tides (P < 0.001) and commonest between 15:00 and 18:00 (P < 0.001) and on days with wind speed less than that month’s average (P < 0.001). Nearly all victims experienced immediate pain, but this could often be controlled with ice; only 30% required parenteral narcotics and 8% required hospital admission. Cardiorespiratory arrest occurred within several minutes of the sting in the one fatal case, involving a 3-year-old girl with only 1.2 m of visible tentacle contact. C. fleckeri antivenom was given to another 21 patients, none of whom had life-threatening features at the time they were given antivenom. Conclusions: Most C. fleckeri stings are not life-threatening; patients who die usually have cardiopulmonary arrest within minutes of the sting. The potential benefit of antivenom and magnesium under these circumstances remains to be shown, but a protocol with their rapid use is recommended if cardiopulmonary arrest has occurred. Unfortunately, this is unrealistic for many rural coastal locations, and the priority remains prevention of stings by keeping people, especially children, out of the sea during the stinger season.

Bart J Currie FRACP, DTM+H · Susan P Jacups BN, MPH

Objectives: To determine whether weather conditions affect emergency department (ED) attendance and admissions from the ED.Design and setting: A retrospective observational study in a large metropolitan ED.Main outcome measures: ED attendance (total and via ambulance) and admissions to hospital from ED, as a function of weather variables.Results: On warm, dry, sunny and good weather days there were significantly more ED attendances in total than there were on cool, rainy, dull and bad weather days, respectively (P ≤ 0.001). There were significant correlations between ED attendance and temperature (r = 0.36, P < 0.001), rainfall (r = − 0.20, P < 0.001) and hours of sunshine (r = 0.17, P = 0.001). Attendance via ambulance was not affected by weather variables. Admissions from the ED were positively correlated with temperature (r = 0.15, P < 0.01) and negatively correlated with rainfall (r = − 0.12, P = 0.02).Conclusions: As there is a clear relationship between weather conditions and ED attendance, incorporating meteorological forecasting into emergency medicine training may improve ED scheduling. To improve the morale of ED staff coping with an onslaught of patients on good weather days, the ED environment should simulate sunny weather, with swimming pools, sun lamps, palm trees and Beach Boys music.

Daniel K B Ou MB BS · The-Phung To BPharm, MClinPharm · David McD Taylor MD, MPH, FACEM

Clinical intensive care and acute medicine. 2nd ed. Kenneth M Hillman, Gillian F Bishop. Cambridge: Cambridge University Press, 2004 (xvi + 685 pp). ISBN 0 521 78980 X. The practice of intensive care medicine is forever evolving to meet the demands of critically ill patients. Of particular importance has been the recent increasing advocacy for critical care outreach through improved surveillance outside intensive care units, and the provision of medical emergency teams. The authors of this book have been pioneers in this evolutionary process, and in this second edition the reader is presented with a very practical, commonsense approach to the care of the acutely unwell patient. The format is very easy to follow, and information about both generic and specific aspects of critical care medicine is easily accessed. The major emphasis of the book, however, is on general, practical topics rather than comprehensive reviews of diseases or specific organ failures (although these are very adequately covered). A junior hospital doctor wanting to refresh his or her knowledge of fluid and electrolyte therapy is as well served as a consultant in a peripheral centre who needs to urgently review planning priorities before transporting a sick patient. The text is concise and contains the right balance between practical and theoretical issues. There are troubleshooting sections at the end of selected chapters, and there is a further reading section at the end of every chapter. Clinical intensive care and acute medicine will be used widely by postgraduate medical trainees rotating through intensive care but will also be a very welcome companion for critical care vocational trainees and consultant intensive care physicians. Although there is a chapter on quality assurance and clinical audit, there is relatively little information about complications. This is partly due to the deliberate omission of descriptions of procedural techniques. Importantly, the authors have managed to provide an authoritative, practical guide to clinical decision making in this rapidly changing area of acute medicine. Larry P McNicol Director of Anaesthesia, Austin Hospital, VIC

Larry P McNicol

Clinical records Patient 1 An intubated and ventilated 73-year-old woman was transferred to a tertiary referral hospital intensive care unit for investigation and management of coma after suspected drug overdose, complicated by pulmonary aspiration. Her initial 12-lead electrocardiogram showed acute changes consistent with tricyclic antidepressant-induced cardiotoxicity. She had normal international normalised ratio (INR; 1.0) and serum alanine aminotransferase (ALT) level (25 IU/L; reference range, ≤ 40 IU/L) at presentation. Her serum paracetamol concentration at 6 hours after ingestion was 2713 μmol/L (410 mg/L) (treatment level, 150 mg/L at 6 hours after ingestion) and intravenous N-acetylcysteine (NAC) was ordered. However, only 10% of the recommended intravenous NAC doses were ordered for each of the infusion bags (ie, 1200 mg loading dose instead of 12 000 mg, followed by 400 mg instead of 4000 mg in the first infusion, followed by 800 mg instead of 8000 mg in the second infusion). This error was not detected until 40 hours after presentation, by which time her serum ALT level was 4940 IU/L and INR was 2.2. The correct dose was commenced. The serum ALT level peaked at 5360 IU/L 52 hours after ingestion, and then decreased rapidly. The patient recovered fully after a prolonged stay in the intensive care unit complicated by aspiration pneumonia and sepsis. Patient 2 A 28-year-old woman presented to a regional hospital within 30 minutes of ingesting 35 g of paracetamol and 400 mL of rum, and was given activated charcoal. Her 4-hour serum paracetamol level was 2395 μmol/L (362 mg/L) (treatment level, 200 mg/L at 4 hours after ingestion) and intravenous NAC was commenced 5 hours after ingestion. Her INR (1.0) and serum ALT level (30 IU/L) were normal at presentation. The NAC infusion was ceased after the standard 20 hours. However, by 48 hours after ingestion her INR was 3.4 and serum ALT level was 9450 IU/L. She was transferred to a teaching hospital for further management. Review of the medical records on arrival 72 hours after the overdose revealed that only 10% of the recommended intravenous NAC dose had been given in each of the infusion bags (ie, 900 mg instead of 9000 mg, followed by 300 mg instead of 3000 mg, followed by 600 mg instead of 6000 mg). Intravenous NAC was recommenced at standard doses. Eighty hours after ingestion, her INR and ALT peaked at 3.5 and 11 500 IU/L, respectively, before normalising. She recovered well and was discharged to the regional hospital. Paracetamol is one of the most common agents involved in deliberate self-poisoning in Australia.1,2 N-Acetylcysteine (NAC; Parvolex, Mayne Pharma Pty Ltd, Parkville, Vic) is the specific antidote,3,4 and its administration is recommended to all patients judged to be at risk of developing hepatotoxicity following paracetamol overdose. The standard administration regimen in Australia is a dose of 300 mg/kg given by staged intra-venous infusion in 5% dextrose solution (150 mg/kg over 15–60 minutes, followed by 50 mg/kg over 4 hours, followed by 100 mg/kg over 16 hours). This is how staff in Australia routinely calculate doses of NAC for infusion. For these two patients, intravenous NAC was commenced but, because of either a miscalculation or transcription error, the final order involved a 10-fold underdosing error. In both cases, intra-venous NAC was ordered and commenced by staff who rarely initiate this therapy. N-Acetylcysteine for intravenous use is packaged as a liquid preparation in 10-mL ampoules, each containing 2000 mg. If NAC is prescribed in milligrams, the prescriber must calculate the correct dose based on the patient’s known or estimated weight. The person making up the infusion must then derive the volume of NAC required to add to the 5% dextrose solution. For an adult patient, multiple ampoules of NAC are typically required for each of the staged infusions. If a 10-fold error is made, then it is not surprising that the person preparing the infusion may not realise the volume is inappropriate. However, the Parvolex package insert and eMIMS contain a useful table that shows the volume in millilitres of NAC required for ranges of body weight (Box). This removes the need for calculations based on patient weight and conversion of milligrams to millilitres; use of this table should greatly reduce the potential for error. In our clinical toxicology service, all NAC infusion orders are prescribed in terms of NAC volumes directly derived from the package insert table. We strongly recommend that this practice be adopted elsewhere, particularly by inexperienced prescribers of NAC. Lessons from practice N-Acetylcysteine (NAC; Parvolex) is an effective antidote in the treatment of paracetamol poisoning. Prescription errors can occur when calculating the dose of NAC using the recommended milligram per kilogram dose. Using the supplied “Parvolex intravenous infusion dosage guide” allows prescribing a “dose in millilitres” of NAC to be administered and greatly reduces the potential for error. Parvolex intravenous infusion dosage guide Patient’s body weight (kg) Initial: 150 mg/kg in 200 mL of 5% glucose in 15–60 min Second: 50 mg/kg in 500 mL of 5% glucose in 4 hours Third: 100 mg/kg in 1 L of 5% glucose in 16 hours Total Parvolex (mL) Parvolex (mL) Parvolex (mL) Parvolex (mL) 50 37.5 12.5 25 75 60 45.0 15.0 30 90 70 52.5 17.5 35 105 80 60.0 20.0 40 120 90 67.5 22.5 45 135 x 0.75x 0.25x 0.5x 1.5x Consider a 60 kg patient requiring N-acetylcysteine (NAC; Parvolex). Conventionally, the first dose is calculated by: 60 kg ×150 mg/kg = 9000 mg NAC. The staff drawing up the NAC then have to ascertain what volume of NAC this is [9000 mg/200 mg/mL NAC = 45 mL, which is 4.5 ampoules of NAC]. Using this table, one can immediately see that a 60 kg person’s first dose will be 45 mL NAC, and subsequent doses are 15 mL and 30 mL. Reproduced with the permission of Mayne Pharma Pty Ltd

Mark Little DTM · Lindsay Murray MB BS, FACEM · David McCoubrie MB BS, FACEM · Frank F S Daly MB BS, FACEM

A 30-year-old woman with a history of bipolar disorder presented after ingestion of 4 g of carbamazepine and 40 mg of alprazolam in a suicide attempt. She became increasingly drowsy and eventually required intubation and mechanical ventilation. The patient received a total of 350 g of activated charcoal via a nasogastric tube over 25 hours. She experienced some charcoal-stained vomiting, but made an otherwise unremarkable recovery and was discharged home. The patient was hospitalised again 3 days later complaining of constant sharp abdominal pain, diagnosed on culture as a urinary tract infection. Over the next 4 days, she experienced multiple bouts of nausea, charcoal vomits and colicky central abdominal pain. A Gastrografin meal (Schering Pty Ltd, Sydney) and follow-through showed complete small bowel obstruction (Box 1). Subsequent laparotomy revealed a 2.5 × 5 cm bezoar in the distal small bowel, about 60 cm from the ileocaecal valve (Box 2). The bezoar was manually fragmented and passed through the ileocaecal valve into the caecum. The patient recovered well after the operation, and was discharged with psychiatric follow-up. Charcoal bezoars are a rare complication of activated charcoal administration. They have been associated with treatments for intoxication with carbamazepine,1 amitriptyline,2 theophylline,3 benzodiazepines and barbiturates.4,5 The parasympatholytic effects of the drugs can precipitate or contribute to paralytic ileus, allowing charcoal to accumulate (potentially with remnants of undigested tablets) and form bezoars. Additional factors that influence bowel obstruction secondary to charcoal administration include the dose and timing of activated charcoal therapy, patient age and comorbidities, and previous intra-abdominal surgery. Gastrointestinal complications should be considered whenever activated charcoal is administered. Prompt recognition and treatment at the first sign of ileus or obstruction may prevent bowel necrosis and subsequent perforation/peritonitis. Charcoal-stained vomiting, abdominal distension and ongoing pain should raise the suspicion of mechanical obstruction. We would advocate Gastrografin follow-through as both a diagnostic and potentially therapeutic tool in incomplete obstruction. However, complete obstruction may signal the need for early laparotomy. 1 Abdominal x-ray after Gastrografin meal, showing complete small bowel obstruction 2 Operative photograph of bezoar in distal small bowel

Justin C Y Chan MB BS BMedSci · Chaminda Saranasuriya MBBS · Bruce P Waxman MB BS, FRACS, BMedSci

Violence in emergency departments (EDs) has reached a level that requires concerted action and a shift in attitude — to eradicate a socially and professionally unacceptable peril. In some EDs, violence is a daily occurrence, with nursing staff reporting several episodes each week. Increased societal violence results in an increase in presentations for injury. Anger and pain and the influence of alcohol and drugs contribute to violence spilling over into the ED. The well known “system blockers” to reporting adverse events in hospitals result in under-reporting of violence episodes. Violence in EDs is different from other forms of violence — the aggressor has no overt dominance or power status and, in a setting of care, victims are likely to excuse the behaviour. Strategies to curb violence in EDs include modifying building design, providing security systems and personnel, and training staff in aggression management. The key to successful intervention is a strong preventive orientation that looks for high-risk indicators, and may extend to active physical and behavioural screening.

Marcus P Kennedy FACEM, FRACGP, DA(UK)

Objective: To reduce pethidine prescribing in hospital emergency departments (EDs).Design: Multi-centre drug use evaluation (DUE) process.Setting and participants: Emergency departments in 23 public hospitals (22 in New South Wales, 1 in Victoria) from 1 September 2002 to 31 August 2003. Participating hospitals included seven principal referral hospitals, six major non-teaching hospitals and 10 district or community hospitals. Data for comparison were collected from 12 non-participating hospitals.Interventions: Hospital coordinators at each participating hospital were provided with support to implement a range of prescribing interventions in their ED in each of three DUE cycles. Interventions included educational materials (guidelines, posters, prescribing reminders), audit and feedback, and small-group discussions. Three audits of pethidine prescribing were undertaken. Prescribing was compared with evidence-based guidelines and non-concordance identified.Main outcome measures: Number of dosage units of parenteral analgesics issued to the ED from each hospital’s pharmacy department was recorded monthly and aggregated in 3-month periods.Results: In the 12 months between the preintervention period and the equivalent post-intervention period, pethidine use decreased by 62% in project hospitals (4669 to 1793 units) and 56% in control hospitals (1476 to 648 units). Six months after project completion there was a significantly greater reduction from baseline in participating hospitals (71%; 4669 to 1348 units) compared with non-participating hospitals (64%; 1476 to 532 units; P < 0.001). There was a concurrent increase in use of both morphine and tramadol.Conclusion: There was a sustained reduction in pethidine use during the study period, which may indicate successful promotion of safer analgesic prescribing. It is not clear whether changes were a result of collaborative DUE methods or other factors.

Karen I Kaye BPharm, DHP · Susan A Welch BPharm · Sharon R Davis BPharm, DipNut · Linda V Graudins BPharm, DHP, FSHPA · Andis Graudins FACEM, PhD · Tai Rotem BSOCSCI · Richard O Day MD, FRACP

Fractures in children are common, but the plasticity of children’s bones means that they may be incomplete. If a child has deformity, swelling or bony point tenderness in a limb after a fall, it is likely to be fractured. A fractured limb that appears deformed will most probably need to be reduced. Effective splinting, using whatever means is readily available, and early, adequate analgesia, can ameliorate the severe pain associated with a fracture. In young children with open growth plates, Salter–Harris type I injuries of the distal fibula are more common than ligament injuries of the ankle. After an ankle ligament injury, functional treatment — brace or tapes, with active physiotherapy — results in a better outcome than immobilisation. A child with a head injury, who does not lose consciousness, has only one or no episodes of vomiting, and is stable, alert and interactive, and neurologically normal, is extremely unlikely to have sustained an intracranial injury.

Simon J Young MB BS, DipCrim, FACEM · Peter L J Barnett MB BS, FRACP, FACEM · Ed A Oakley MB BS, FACEM

Minor injuries in children (those that could reasonably be expected to heal with minimal medical intervention) are extremely common. The possibility of more serious injuries should be considered and excluded early. Successful examination requires gaining the child’s trust, relieving pain early, and using a flexible and creative examination technique. Bruising may suggest a more serious underlying injury, or the bruising pattern may indicate non-accidental injury or a bleeding disorder. Superficial abrasions and lacerations can be safely cleaned with good quality water, and all foreign material should be removed. Deeper wounds with suspected damage to nerves, tendons or circulation need formal exploration under a general anaesthetic. Good local anaesthesia can be produced by topical preparations, and many wounds can be closed with tissue adhesives with an excellent cosmetic result. Antibiotics should be prescribed for specific circumstances, such as wounds with extensive contamination or tissue damage, and all children with injuries should be checked for adequate tetanus cover for prophylaxis.

Simon J Young MB BS, DipCrim, FACEM · Peter L J Barnett MB BS, FRACP, FACEM · Ed A Oakley MB BS, FACEM

Objective: To investigate species-specific envenoming rates and spectrum of severity of funnel-web spider bites, and the efficacy and adverse effects of funnel-web spider antivenom.Data sources: Cases were identified from a prospective study of spider bite presenting to four major hospitals and three state poisons information centres (1999–2003); museum records of spider specimens since 1926; NSW Poisons Information Centre database; MEDLINE and EMBASE search; clinical toxinology textbooks; the media; and the manufacturer’s reports of antivenom use.Data extraction: Patient age and sex, geographical location, month, expert identification of the spider, clinical effects and management; envenoming was classified as severe, mild–moderate or minor/local effects.Data synthesis: 198 potential funnel-web spider bites were identified: 138 were definite (spider expertly identified to species or genus), and 77 produced severe envenoming. All species-identified severe cases were attributed to one of six species restricted to NSW and southern Queensland. Rates of severe envenoming were: Hadronyche cerberea (75%), H. formidabilis (63%), Atrax robustus (17%), Hadronyche sp. 14 (17%), H. infensa (14%) and H. versuta (11%). Antivenom was used in 75 patients, including 22 children (median dose, 3 ampoules; range, 1–17), with a complete response in 97% of expertly identified cases. Three adverse reactions were reported, all in adults: two early allergic reactions (one mild and one with severe systemic effects requiring adrenaline), and one case of serum sickness.Conclusions: Severe funnel-web spider envenoming is confined to NSW and southern Queensland; tree-dwelling funnel webs (H. cerberea and H. formidabilis) have the highest envenoming rates. Funnel-web spider antivenom appears effective and safe; severe allergic reactions are uncommon.

Geoffrey K Isbister BSc, MD, FACEM · Michael R Gray MSc, PhD · Corrine R Balit BPharm, MB BS · Robert J Raven BSc, PhD · Barrie J Stokes BSc, MMath · Kate Porges FACEM · Alan S Tankel BSc, FACEM · Elizabeth Turner MAIBiol · Julian White MD, FACTM · Malcolm McD Fisher MD, FANZCA, FJFICM

Ariella Glaser,* Dwight Arakaki,† Gar Ming Chan,‡ Robert S Hoffman§ * Resident, Mount Sinai Medical Center, New York City, NY, USA; † Resident, Beth Israel Medical Center, New York City, NY, USA; ‡ Fellow (and corresponding author), § Director, New York City Poison Control Center, New York City, NY, USA. garchanATpol.net To the Editor: Two aspects of the recent article by Kelly et al comparing intranasal with intramuscular naloxone in suspected opioid overdose1 make their study difficult to interpret. The methods allowed for a great deal of bias. There was no attempt to blind evaluators to therapy, and knowing which therapy is to be used a priori may influence both therapy selection and perceived outcome. The second flaw we noted was the use of the Glascow Coma Scale (GCS) in a non-trauma patient.2 An improvement in GCS score may represent increased wakefulness or even withdrawal. The use of the GCS does not make it possible to determine what degree of improvement or worsening the therapy resulted in. In the opioid-intoxicated patient, the “alert/verbal/pain/unresponsive” (AVPU) scale is more appropriate. We agree that the use of needles in a high-risk patient is dangerous. However, if these patients do not respond to painful stimuli, there should be no danger at all.

Ariella Glaser · Dwight Arakaki · Gar Ming Chan · Robert S Hoffman

Anne-Maree Kelly,* Debra Kerr,† Paul Dietze‡ * Director, † Deputy Director, Joseph Epstein Centre for Emergency Medicine Research, Western Hospital, Private Bag, Footscray, VIC 3011. ‡ Research Fellow, Turning Point Alcohol and Drug Centre, Fitzroy, VIC. Anne-Maree. KellyATwh.org.au In reply: The prehospital setting for research poses challenges that require some flexibility in study design. While it would have been preferable to have used blinded naloxone and placebo solutions for both routes of administration in our study, financial and operational constraints made this impossible, so some bias in evaluations is possible. However, this is not necessarily in favour of the intranasal route, as before the study many paramedics were very sceptical about the intranasal naloxone preparation. Therapy selection was by random allocation in sealed envelopes as described in our article. The Glasgow Coma Scale score was chosen as an outcome measure because it was the parameter used operationally for treatment and disposition decisions in the ambulance service within which our study was conducted. We acknowledge its limitations in non-trauma patients. The potential for needlestick injury in this situation is real. Patients with opioid intoxication may be in cramped locations and may be irritable on waking, increasing the risks involved with handling a “sharp”. Given the prevalence of blood-borne viruses in the injecting drug user population, strategies to reduce the risk of needlestick injury are highly desirable. Additionally, a strategy that has been suggested for preventing opioid-overdose-related deaths is to make naloxone more widely available in the community. 1 The intranasal formulation of naloxone may be appropriate for this, as it has significant advantages including reducing risks of blood-borne virus transmission and minimising the requirement for training and the secure storage of syringes and needles. 2

Anne-Maree Kelly · Debra Kerr · Paul Dietze

1 Tsunami damage in Kandholhudoo on the Raa atoll Photograph: Andrew Robertson. Mention “the Maldives” and everyone immediately conjures up images of unspoiled coral islands, holiday resorts, spectacular diving sites and great surf. The Maldives (from the Sanskrit “mala-dvipa”, meaning “garland of islands”)1 is all that and more, from the bustling capital city of Malé to the 200 serene inhabited islands where the traditional occupations of fishing and boat building continue as they have for centuries. When the earthquake and subsequent tsunami struck Aceh on 26 December 2004, most Australians were contemplating the public holidays ahead of them. The tsunami, travelling at speeds of up to 800 kilometres per hour, struck countries around the Bay of Bengal and across the Indian Ocean. Tremors were felt in the Maldives at about 06:25 local time, and the tsunamis hit the Maldive atolls between 09:00 and 09:30. As the 1–4-metre waves struck the islands, 82 people died, 200 people were severely injured and a further 1100 required treatment. Twenty-six people remain missing. An estimated 2167 households (15 000 people or almost 5% of the population) were displaced from their homes,2 as over half the inhabited islands sustained damage (Box 1). The Australian responseLike many on Boxing Day, we had missed the early reports of the evolving disaster in Asia. However, we were soon thrust into its midst by the early morning news on 27 December 2004, and by an urgent teleconference of the Australian Health Disaster Management Policy Committee, as we considered what medical support might be needed. This Committee, chaired by the Commonwealth Department of Health and Ageing, and with State, Defence Force and Emergency Management Australia representation, played a key role in advising the Australian Government on what response could be mounted quickly. By early on 28 December, it became obvious that we needed to send civilian medical teams into the tsunami-affected areas. While the Australian Defence Force had prime responsibility for deploying medical teams into areas affected by both the 1998 Aitape (Papua New Guinea) tsunami and 2002 Bali bombing,3,4 Australia has not often deployed civilian medical teams into disaster areas. Most states and territories base their internal disaster relief medical teams around major hospitals; this is a practice which has been questioned since the 1997 Thredbo disaster.5 However, as the Western Australian State Health Coordinator in times of disaster, I knew we could put a medical team together at short notice. For the first teams, we relied on advice from Chief Health Officers and Directors of Medical Services within Australia as to who might be appropriate, available within hours and experienced in providing health care in developing countries. While effective, personal preparations were ad hoc, the initial choice of team members has since been debated, and issues such as in-country operating funds, team expenditure and telephone costs are still being resolved. 2 Destruction on Vilufushi in the Thaa atoll Photograph: Gavin Coppinger. Our key problems were time and distance, particularly as teams comprising members from different states were all leaving from Sydney (28 in two teams to Aceh and one team of 17 to the Maldives).2 For once, the “red-eye” overnight flight for those travelling from Perth to Sydney was to our advantage, enabling us to get the team to Sydney rapidly. The logistics of assembling a team, equipping it (for medical work and to live in the field), reassembling it when its role changed from surgical care to public health, and deploying it in it the 24 hours after arrival, was challenging. The team bound for the Maldives included a team leader (Andy Robertson), three general practitioners (Mark Adamski, Vince Duffy, and Grahaeme Hatfield), two public health physicians (Krishna Hort and Danny Csutoros), three emergency physicians (Colin Myers, Michael Novy and Peter Roberts), an infectious diseases physician (Dominic Dwyer), an anaesthetist (Gavin Coppinger), three nurses (Muriel Leclercq, Jeff Williams and William Kerr), a paramedic (Greg Gibson), an environmental health officer (Paul Miller) and a logistics officer (Chris Sykes). With great assistance from the NSW Ambulance Counter Disaster Unit, Westmead Hospital, Queensland Health, the NSW Fire Brigade and Emergency Management Australia, this team, along with tonnes of cargo, deployed on a loaned QANTAS 747 early on 30 December 2004, and arrived in Malé that evening. During this flight, it became clear that a doctor was required to accompany 70 injured Australians from Colombo back to Sydney, and emergency physician Peter Roberts readily volunteered. 3 Members of one of our small teams being conveyed in a small fishing boat (dhoni) Photograph: Colin Myers. In the MaldivesThe significant number of dead and injured had been well managed in the central Indira Gandhi Memorial Hospital in Malé and in regional hospitals and island medical centres.6 Having survived the initial onslaught, the Maldivians were now concerned about subsequent epidemics and other public health issues (including food and water supply), as well as primary care; our team, with its public health and infectious diseases physicians, environmental health officer and GPs had been structured with that in mind. The damage to the affected islands and the bravery of the people was noteworthy. Many reported the tsunami hitting from both sides of their island, leaving them with nowhere to run. There was a strong sense of community among the Maldivians, who banded together in this time of devastation. Maldivians pride themselves on cleanliness, and many went to neighbouring islands to help clean up. On islands such as Vilufushi and Madifushi, where near total destruction reigned and rubble lay everywhere (Box 2), “Where do you start?” was the question in everybody’s mind. The enthusiasm of the Maldivian people meant the teams were universally well received and the communities were keen to work with the teams to address local issues. Health care delivery across 200 islands was never going to be easy (Box 3). Moving personnel, equipment and resources and patients was a challenge, as virtually all transport meant traversing water. The teams used everything from small fishing boats (dhonis), Coastguard landing craft, hospital boats and ocean-going ships to seaplanes and Indian Airforce transports. 4 Reviewing patients at a clinic in Madifushi, Thaa atoll Photograph: Vince Duffy. It was critical to work closely with Maldivian Ministry of Health staff to “value add” to their efforts. This meant working in small teams with local staff throughout the Gaafu Alifu, Thaa and Raa atolls, south and north of Malé.6 Several islands had not seen medical staff since the tsunami and many were running short of pharmaceuticals — we were able to provide both (Box 4). There was a range of public health issues that needed addressing, from discouraging the use of chlorine on dead fish and animals, with resultant shortages of chlorine for the wells (Box 5), to monitoring the populations for outbreaks of dengue, scrub typhus and diarrhoeal diseases. Public health team members worked closely with the Ministry of Health’s Water and Sanitation division to implement strategies for accommodation, children’s health, water and sanitation, solid waste management and asbestos disposal. Strategies included acquiring bedding for islanders evacuated to other islands and arranging the supply of fruit and vegetables, especially for children, where local crops had been destroyed. There were also continuing problems with tsunami-related injuries. Many people on the worst affected islands had been swept out to sea, and presented with chest infections in resultant “near drowning” syndromes. Infected wounds, abrasions and crush injuries were also evident. Outbreaks of gastroenteritis and respiratory disease were fortunately uncommon, and exacerbation of locally endemic infectious diseases (including dengue and scrub typhus) had not occurred. Anxiety and depression, as the islanders struggled to come to terms with the destruction, were common. In giving health support, it was important not to become a burden on the local government. There were unfortunate cases of well-intentioned, but misguided, attempts by other international medical teams to take over the local health system or provide services that weren’t needed (eg, trauma surgery), and this placed further strain on Ministry of Health staff. 5 Damage to wells in Viligili, Gaafu Alifu atoll Photograph: Michael Novy. Courtesy of WA Health Department. ConclusionThe health response by the Maldives government was one of the few success stories after the tsunami. This rested on a well-organised, pre-existing infrastructure encompassing effective inter-island transport and island-based health care centres. Many issues remained, however, including profound anxiety about further waves; loss of the breadfruit, guava and other fruit trees following salt water contamination; contamination of drinking water; future withdrawal of foreign health care personnel; and concern that the Maldives may be forgotten in its recovery phase by both tourists and charities. Australia’s health response was rapid, effective and appropriate, but we did learn some lessons (Box 6). In the future, our response could be improved with the establishment of pre-selected state-based Disaster Medical Assistance Teams.7 Teams that later went to Aceh were state-based, and had the benefit of enough time to select, prepare and equip their personnel before deployment. The multi-jurisdictional nature of the earlier teams, however, captured the spirit of the Australian desire to assist all those affected by the tsunami. 6 Lessons learnt for team deployment Health intelligence Accurate health information needs to be provided to the teams before deployment. Team selection Military, developing country and/or rural and remote medical experience and disaster medicine training is useful. Team member flexibility is critical, especially being able to improvise and adapt to constantly changing circumstances. Interpreters, or team members who speak the local language, are highly desirable. Equipment National modular checklists of both self-sufficiency and medical stores need to be further developed, incorporating sections on primary care, paediatrics, chronic care and public health (including vaccines). There is a need for team-identifying clothing, principally vests and headwear. Communications A clear command and control structure is essential. Satellite phones with international coverage, and international roaming mobile phones are critical. Logistics Funding, insurance and indemnity issues should be resolved before deployment, including cash advances (US dollars were widely accepted) and credit cards. Guidelines on what will be funded on deployment (eg, mobile phone use, purchase of clothing) are necessary. Transport Agreements with commercial airline companies to rapidly deploy team members should be explored further.

Andrew G Robertson CSC, FAFPHM, FRACMA · Dominic E Dwyer MD, FRACP, FRCPA · Muriel G Leclercq BSc(Nursing)

Fiona M Wood,* Bess V Fowler,† Daniel McAullay,‡ Jocelyn R Jones§ * Plastic Surgeon and Director, † Epidemiologist, Burns Service of Western Australia, Royal Perth Hospital, GPO Box X2213, Perth, WA 6847; ‡ Senior Policy Officer, § Manager, Office of Aboriginal Health, Health Department of Western Australia, Perth, WA. FionawATmccomb.org.au To the Editor: People with major burn injuries (50% total body surface area or more) now have an improved likelihood of survival with the implementation of aggressive treatment regimens, including supportive therapy, nutrition, and advances in the control of sepsis. Technological developments and treatments, particularly expedient wound closure, early surgical debridement, covering of large burn wounds, early skin repair,1 use of cultured epithelial autograft2 and ventilation,3 have also contributed to improved outcomes for people with these injuries. In Australia, there are inequities in access to health services which may particularly affect Aboriginal people.4 We therefore undertook a retrospective, observational study to compare the incidence of major burn injuries, clinical and demographic characteristics of patients with burns, as well as treatment and outcomes between Aboriginal and non-Aboriginal children and adults in Western Australia between 1992 and 2002. Potential cases were identified using data linkage from the Western Australian Department of Health. Raw data came from clinical records. Of the 84 people identified with major burn injuries, nine were Aboriginal (11%) and 75 were non-Aboriginal (89%). The incidence of major burn injury among Aboriginal people is greater than expected, as data from 2001 show that 3.5% of the WA population are Aboriginal. Aboriginal people with major burn injuries were younger than non-Aboriginal people with those injuries (mean, 21 v 35 years). Eight of the nine Aboriginal people (89%) had flame-only burns, compared with 33 of 75 non-Aboriginal people (44%). No statistically significant difference was seen between the groups in the percentage of total body surface area affected, provision of treatment (including number of operative procedures, applications of cultured epithelial autografts, units of blood products used, nasogastric feeds, and antibiotic doses) or length of hospital stay. We found that, although a greater percentage of Aboriginal people sustained major burn injuries, after this group entered the hospital system they experienced comparable levels of service and outcomes to non-Aboriginal people. Further research into burn care is warranted, from culturally and environmentally appropriate prevention through to critical appraisal of outcomes.

Fiona M Wood · Bess V Fowler · Daniel McAullay · Jocelyn R Jones