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Internal time bombs
Emergency physicians are not infrequently faced with individuals who are suspected of having swallowed packages of drugs or having inserted them into the rectum and/or vagina. Such actions may reflect an organised attempt to smuggle drugs across a border or simply to conceal drugs immediately prior to apprehension by the police or other authorities. The risks of drug leakage and rapid overdose can be considerable and are discussed in the review article in this issue. The emergency management of individuals suspected of having concealed internal packages is complicated by the legal process. There are few other presentations to the emergency department where emergency medicine, the law and ethical issues collide in such a potentially tricky fashion. For this reason, the review will be of great interest to specialists in both emergency and clinical forensic medicine (see page 316).
Helicopters in Tehran
Many readers will think of HEMS (helicopter emergency medical system) in terms of highly developed and integrated prehospital and hospital services. Indeed, much of the published research on the use of helicopters as part of an emergency medical system emanates from a small number of well-established and respected centres. But in an interesting report, Salimi and colleagues report on their experience of HEMS in Tehran, a city without this infrastructure. They use their results to argue the case for helicopters in cities beset with heavy traffic and potentially difficult and long prehospital transfer times by road (see page 361).
Many centres have already introduced intravenous thrombolytic therapy for ischaemic stroke, but there may be a degree of reluctance to set up such a service in some smaller centres. Hopefully, a report from Norway will go some way to allaying concerns about the practical problems of introducing and establishing stroke thrombolysis in a small inexperienced centre. The investigators found that door to needle times reduced significantly with the introduction of a flow chart which focussed upon the coordination of prehospital services, emergency room staff, neurologists and computed tomography facilities (see page 324).
Patients who present with an episode of syncope represent a considerable diagnostic challenge. Evidence from a survey of emergency departments in the UK and Republic of Ireland reveals that the management of syncope is currently quite varied. Clearly, it is important to try to identify those patients who are at risk of serious early outcomes after such events in the hope that they might be prevented. There appears to be a need to develop and introduce an evidence-based guideline to match the equivalent guidelines in the USA (see page 331).
Older people struggle to learn BLS
It is well recognised that prompt, good quality basic life support is important in helping to provide the best chance of a good outcome after out of hospital cardiac arrest. Two age groups in the community have been identified as being worthy of special attention for training—children and those aged over 40 years. Sim and colleagues report their experience of training 880 non-medical employees at a tertiary teaching hospital in Korea. After receiving a training session lasting three hours, those employees aged over 40 years were found to be significantly worse at performing basic life support. Perhaps members of this “old age” group require special (further) attention (see page 327).
Finger injections for healthy volunteers
It is remarkable what healthy volunteers will do to assist the advancement of science! Twelve volunteers agreed to receive a digital nerve block of either bupivacaine or lidocaine with epinephrine in order to investigate which injection agent caused the least pain. The latter choice as a local anaesthetic mixture is likely to intrigue practitioners who were brought up with the traditional dogma that the use of epinephrine should be avoided in the fingers. All of the fingers in this study remained attached and the authors explain that the supposed risks of epinephrine in this context are theoretical rather than real. The lidocaine with epinephrine mixture was significantly less painful than bupivacaine (see page 347).
A new irrigation device
Having established satisfactory anaesthesia, it is generally agreed that skin wounds require thorough irrigation under pressure to enable proper cleaning and reduce the rate of infection. Current methods for achieving this using a needle and syringe tend to carry a potential risk of splashback to the practitioner. A novel device is described which enables high pressure irrigation with built-in protection against splashback. It can be easily constructed from items which are already readily available and widely used to manage wounds (see page 354).
Not to be sneezed at
Among the cases presented this month, there is a report which shows just how dangerous it can be to sneeze. At least that is what appears to have precipitated symptoms attributable to vertebral artery dissection. The authors speculate that an asymptomatic tear in the artery’s intima may have developed several weeks prior to the sneezing episode, when the patient suffered a head injury. They summarise the treatment options for vertebral artery dissection and warn that early recognition is essential in order to minimise the risk of permanent neurological problems (see page 384).
Unusual seat belt injury
There is compelling evidence to show that seat belts have prevented many serious injuries and deaths. However, the use of seat belts has also been associated with a number of specific restraint injuries, such as sternal fracture. Add to this list a new problem—delayed colonic perforation and fistula to the skin. The case described is remarkable in that the patient underwent a computed tomography scan of her abdomen shortly after initial presentation to hospital which did not reveal any intra-abdominal injury, yet the colonic injury came to light two weeks later (see page 386).