Showing papers in "European Journal of Emergency Medicine in 1999"

Decreased health care quality associated with emergency department overcrowding

Abstract: The objective of this study was to assess the influence of overcrowding on health care quality provided by emergency departments (ED). The study was carried out in an urban, university tertiary care hospital. All patients seen at the internal medicine unit (IMU) of the ED who returned during the following 72 hours, and those who died in the ED rooms were included in the study. During a consecutive period of 2 years (104 weeks), we prospectively quantified the number of weekly visits, revisits and deaths. We calculated revisit and mortality rates (in respect of percentage of all visited patients) for each week. Correlation between the number of weekly visits, and revisit and mortality rates was assessed using a simple linear regression model. We consigned 81,301 visits, 1137 revisits and 648 deaths; mean (+/- SD) number of weekly visits, revisits and deaths were 782 (68), 10.93 (3.97) and 6.23 (3.04) respectively; weekly revisit rate was 1.40% (0.48%) and weekly mortality rate was 0.79% (0.36%). We observed a significant, positive correlation between mortality rates and weekly number of visits (p = 0.01). Although a similar trend was also found for revisit rates, such an increase did not reach statistical significance (p = 0.06). It is concluded that since revisit and mortality rates constitute good health care quality markers, present data demonstrate that ED overcrowding implies a decrease in the health care quality provided by it.

Intravenous magnesium sulphate in the management of moderate to severe acute asthmatic children nonresponding to conventional therapy.

Abstract: Management of severe acute asthma attacks in children sometimes bring difficulties to the physician. Some current treatment strategies have focused on intravenous magnesium sulphate administration in patients nonresponding to therapy with beta-2 agonists and corticosteroids. The use and efficacy of this drug has been discussed in this randomized, double-blind, placebo-controlled clinical trial consisting of 20 children with moderate to severe acute asthma exacerbation admitted to the emergency department in Dicle University Hospital, Turkey. Magnesium sulphate infusion therapy of 40 mg/kg doses (maximum 2 g) or an equivalent volume of normal saline solution were administered to randomly assigned 10 patients in each group to the selected patients who were being treated for an acute asthma exacerbation with a peak expiratory flow rate (PEFR) less than 60% of the predicted value after receiving three beta-2 adrenergic nebulizer treatments (salbutamol) given at an interval of 20 minutes each. Vital signs, PEFR and physical examinations were serially recorded at 15 minutes intervals for a total of 90 minutes after the initiation of magnesium sulphate therapy. At 30 minutes, compared with the placebo group, the magnesium sulphate receiving group had lower clinical asthma scores (4.0+/-0.5 vs. 5.5+/-0.5, p = 0.0002) and a significantly greater percentage of improvement from baseline in PEFR (43.0+/-6.3% vs. 14.6+/-3.7%, p = 0.0002). These significant changes persisted at 45, 60, 75 and 90 minutes. No significant side effects were observed. In conclusion, severe asthmatic cases may benefit from magnesium sulphate therapy when beta-2 agonists are inadequate in preventing deterioration.

Evaluation of dispatcher assisted cardiopulmonary resuscitation

Abstract: The outcome of out-of-hospital cardiac arrest (CA) following cardiopulmonary resuscitation (CPR) initiated by dispatcher-provided telephone instructions (T-CPR) in the area of Gothenburg, Sweden was studied. During a period of 27 months, 475 cases categorized by the dispatchers at the Emergency Co-ordination and Dispatch Centre as being suspected CA were offered T-CPR and were included in one of the following groups: (1) T-CPR completed (caller without previous CPR training); (2) T-CPR completed (caller with previous CPR training); (3) T-CPR started, but not completed; (4) T-CPR declined by caller due to previous CPR training; (5) T-CPR declined by caller due to other reasons; or, (6) T-CPR not offered. Of the patients, 473 could be followed up and of them 427 fulfilled the criteria for CA on ambulance arrival. Among the latter cases, 10% were hospitalized alive, 4% could be discharged from hospital, and the distribution among groups was: (1) 7%; (2) 18%; (3) 5%; (4) 11%; (5) 3%; and (6) 1%. The study concludes that although more attention should be paid to the detection of CA patients by the dispatchers, when the dispatchers suspected CA, their accuracy was high. Half of the witnesses accepted the offer of T-CPR and one-third completed T-CPR. More efforts and research are needed, however, to increase the percentages of callers completing CPR. The impact of T-CPR on survival might be limited. Indeed, the comparison of 'resuscitable' patients in whom T-CPR played an important role in supporting bystanders (i.e. groups 1 and 2) with 'resuscitable' patients in whom T-CPR was not performed (i.e. groups 3, 5 and 6) suggests an increase in survival from 6% (groups 3, 5 and 6) to 9% (groups 1 and 2).

Is there a gender difference in aetiology of chest pain and symptoms associated with acute myocardial infarction

Abstract: Many previous studies have shown that there is a gender difference in terms of the use of diagnostic procedures and the treatment of patients with chest pain. The mechanisms behind these observations are less well described. This survey describes gender differences in the aetiology of chest pain and symptoms associated with acute myocardial infarction (AMI). Among the patients with symptoms of acute chest pain, in the emergency medical department women less frequently develop an AMI and are less frequently given a diagnosis of ischaemic heart disease. Among patients developing an AMI, women differ from men by less frequently reporting chest pain, more frequently reporting nausea, vomiting, abdominal complaints, fatigue and dyspnoea and less frequently reporting sweating. With regard to the localization of pain in AMI, women differ from men by more frequently reporting pain in the back, neck and jaw. In terms of electrocardiographic changes, women seem to have less marked ST deviations than men. However, we do not believe that these differences between women and men are substantial enough and, as a result, we do not recommend that the initial medical care of patients seeking medical attention with chest pain or other symptoms raising a suspicion of AMI should be differentiated with regard to gender. The differences described here might partly explain the prolonged delay until hospital admission in women suffering from AMI.

Road traffic accidents with vehicular entrapment: incidence of major injuries and need for advanced life support.

Abstract: Road traffic accidents (RTAs) with entrapment are perceived as a challenge to emergency systems because of the severity of the ensuing traumas and the inherent complexity of the rescue procedures. To clarify these two aspects this prospective cohort study enrolling 244 entrapped trauma patients was conducted by a Regional Medical Helicopter Service. Forty-six victims (18.9%) were found dead, 101 (51%) of the 198 patients who reached the hospital alive had an injury severity score (ISS) > or = 16. The use of seat belts was associated with lower trauma severity. Out of the 101 severely traumatized patients (ISS > or = 16), 46 (42.6%) were intubated at road side, 12 required decompression of a tension pneumothorax on the scene and in 15 cases a pneumothorax was drained during the early intrahospital phase. Thirty-six (34.7%) patients had the first systolic blood pressure (SBP) Language: en

Out-of-hospital cardiopulmonary resuscitation: a population-based Norwegian study of incidence and survival.

Abstract: The Trondheim region's (315 km2, population 154,000) emergency medical service (EMS) provides advanced cardiac life support (ACLS) with combined paramedic and physician response. This EMS system is commonly employed in Norway, yet no population based study of outcome in cardiac arrest has been published to date. This retrospective study reports incidence and outcome from every attempted out-of-hospital cardiopulmonary resuscitation (CPR) during 1990 through 1994 according to the Utstein template. Information on the patient's pre-morbid conditions and final outcome was obtained from hospital records. The incidence of cardiac arrest and CPR from all causes was 68 per 100,000 per year, with 83% primary cardiac aetiology. The median alarm to patient arrival interval for ambulance and emergency physician was 8 minutes and 11 minutes, respectively. The presenting rhythm was ventricular fibrillation or tachycardia in 51%, asystole in 34%, pulseless electrical activity in 8% and undetermined in 8%. Definite return of spontaneous circulation occurred in 211 patients (40%, 27 per 100,000 per year) and 57 patients (11%, 7.4 per 100,000 per year) survived to discharge. Most patients made a favourable cerebral outcome, although nine were severely disabled. This is the first population-based Norwegian study of outcome from out-of-hospital cardiac arrest in this combined paramedic/physician staffed EMS. Incidence, survival and neurological outcome are comparable with results obtained in other EMS systems.

Electrocardiographic abnormalities in acute pancreatitis.

Abstract: It has been reported that electrocardiographic abnormalities may be associated with acute pancreatitis. However, the data are lacking or sketchy. The aim of this study was to assess the frequency and type of electrocardiographic abnormalities present in patients with acute pancreatitis. Fifty-six consecutive patients with acute pancreatitis and without previous history of heart disease were studied. Eleven patients had arterial hypertension. Forty-one patients had mild pancreatitis and 15 had the severe form of the disease. On admission, all patients underwent a standard 12-leads electrocardiogram and a serum electrolyte determination. Nineteen healthy subjects were also studied as controls. Twenty-seven patients (48.2%) (10 with severe pancreatitis and 17 with mild pancreatitis) had a normal electrocardiogram. In the remaining 29 patients (51.8%), one patient with severe pancreatitis had atrial extrasystoles and eight had bradycardia (less than 60 beats/minute) (two with severe pancreatitis and six with mild pancreatitis); 14 patients had changes of the T-wave and/or the ST-segment (two with severe pancreatitis and 12 with mild pancreatitis); seven patients showed disturbances of the intraventricular conduction (one with severe pancreatitis and six with mild pancreatitis): four had left anterior hemiblock, two had complete left bundle branch block and one had left anterior hemiblock and incomplete right bundle branch block; one patient with mild pancreatitis had atrioventricular block (first degree). No differences in heart rate, RR interval, PR interval and QT interval were found when patients with acute pancreatitis were compared with healthy subjects, nor when patients with severe pancreatitis were compared with those having the mild form of the disease. Seventeen of the 29 patients with electrocardiographic abnormalities (52.6%) also had serum electrolyte alterations. More than 50% of the patients with acute pancreatitis had electrocardiographic abnormalities and electrolyte alterations were also present in about one-half of these.

Order in chaos: modelling medical management in disasters.

Abstract: The medical aspects of disaster management, also referred to as disaster medicine, is a relatively new medical specialty, the roots of which are to be found in war surgery and traumatology. The main content of disaster medicine is based on empiricism. During the past couple of years, a mathematical

Violence against doctors: 1. A study of violence against doctors in accident and emergency departments.

Abstract: The risk of violence directed at health care professionals in their working environment has aroused widespread concern in recent years. Clinical areas most associated with violence are accident and emergency departments, psychiatry, and general practice. Surveyed physicians reported rates of violence against them to vary from 54% to 79%. Violence, however, is difficult to quantify and there is wide variation between the severity of incidents recorded by different workers. This study was an attempt to measure the incidence and the severity of violence against doctors in accident and emergency departments in Kuwait. Eighty-seven (86%) out of 101 of our doctors reported having experienced verbal insults or imminent threat of violence; in addition, 28% had also experienced physical attacks, and 7% had experienced physical assaults likely to have caused serious or fatal injury. Similarly, out of a total of 781 violent incidents reported by our doctors, 73 involved physical attacks, and eight involved physical assaults likely to have caused serious or fatal injury. Language: en

Violence against doctors: 2. Effects of violence on doctors working in accident and emergency departments.

Abstract: There is abundant evidence to suggest that doctors are increasingly being exposed to violent incidents at their workplace. The possible effects of aggression on an individual are varied and likely to depend on the severity and frequency of episodes and the perceived vulnerability to further episodes. The reported sequaelae of violent incidents towards doctors include varied psychological disturbances, and changes in behaviour, such as increasing prescribing, ongoing fear of violence at work, and poor staff morale. We investigated the effects of violence against doctors in the accident and emergency departments in Kuwait. Seventy-five (86%) out of 87 doctors exposed to violent incidents reported one or more of the symptoms consisting of: depression, reliving experience (flashbacks), insomnia, and taking 'time off'. The effects lasted for more than 4 weeks in 25, for 3-4 weeks in 17, and for 2-3 weeks in 21. The duration of symptoms was longer in doctors exposed to verbal insults or threats of imminent violence coupled with incidents involving single acts of violence. Out of a total of 101 doctors; 90 (89%) remained worried about violence at work and 72 (71%) thought training to deal with potentially violent situations would be useful. Language: en

Emergency medical assistance during a mass gathering.

Abstract: The Thunderdome-party was a mass gathering of 14000 young people. Many of them were under influence of drugs (amphetamine and ecstasy (MDMA)). The organization of on-site emergency medical assistance was essential in order to avoid overload at the local emergency department and to avoid a disequilibrium of the local emergency medical system, the 'call 100' system in Belgium. The benefit of a prehospital medical team at the event is illustrated by the description of the population treated on-site. Toxicological screening of blood and urine was not necessary to safely treat drug intoxication during the Thunderdome-party.

Relevance in the emergency department of a decisional algorithm for outpatient care of women with acute pyelonephritis.

Abstract: The outcome of three types of management for patients with acute pyelonephritis, in an emergency department is assessed. This was carried out by a prospective enrolment of patients with acute pyelonephritis. Through a decisional algorithm, doctors were encouraged to discharge female patients under 60 years with acute uncomplicated pyelonephritis, either directly from the emergency ward or after a short stay in the observation unit. All received a single intravenous dose of pefloxacin, after urine and blood cultures were obtained; before discharge a normal ultrasonography of the abdomen and the pelvis was required. Conversely, hospitalization was advised for patients who did not fit the criteria of uncomplicated pyelonephritis. Only females with positive urine cultures qualified. Of 83 patients enrolled, 70 were females with positive urine cultures, 60 of whom had uncomplicated pyelonephritis. At 3 weeks, two of 70 patients were lost to follow-up. In the remaining 68, favourable outcome was observed in 98% of 48 patients discharged from the observation unit (95% CI: [94%; 100%]), 90% of 10 discharged from the emergency ward (95% CI: [73%; 100%]) and 70% of 10 hospitalized (95% CI: [50%; 93%]). A decisional algorithm was useful in determining that over 85% of women who present to our emergency department with pyelonephritis have an uncomplicated form and may be safely treated as outpatients, if necessary after a brief stay in the observation unit. Prospective controlled trials are needed to determine duration of antimicrobial therapy, length of follow-up and finally, to compare tolerance and cost-effectiveness of outpatient vs. inpatient care of acute uncomplicated pyelonephritis.

Emergency department information: does it effect patients' perception and satisfaction about the care given in an emergency department?

Abstract: The aim of this study was to find out if informing the patients about the facts of an emergency department (ED) on arrival influences their behaviour and satisfaction about the care given in the ED For 5 days an information form was distributed on arrival to all patients visiting the ED and a questionnaire directed at all patients when leaving the ED For a former 3 days the same questionnaire directed at the patients was distributed without giving them the information form This form contained information about how the ED functions, how long and why the patients wait, and which patients are taken care of first The patients who were not given the information form served as the control group; the patients who were given an information form but did not read it were also included in the same control group Questionnaires of the informed group and the control group were compared A total of 397 patients were given a questionnaire; 288 of them were given an information form and 109 did not receive a form The number of the patients who read the information form was 178 and the rest (219 patients) served as controls The informed group was more satisfied about the care given to them (p = 01), the total time spent in the ED (p = 03), and the information given to them (p = 01) More patients in the informed group stated that they would prefer this ED next time or recommend it to others (p = 002) The overall degree in satisfaction of the informed patients was better (p = 003) The differences in the overall satisfaction and preference of this ED's parameters were statistically significant, the other parameters were not so significant These results proved that giving general information to patients visiting the ED can influence the degree of their satisfaction

Equestrian injuries in the paediatric age group: a two centre study

Abstract: This study's objective was to examine the nature, cause and frequency of injury resulting from equestrian sport in paediatric patients attending two accident and emergency departments. We recorded the attendances of patients aged less than 16 years with equestrian-related trauma in 1 year. Demographic details, injury, mechanism of injury, rider experience and use of protective equipment were noted. There were 41 attendances (39 female, two male, median age 12 years). Thirty-one were injured while mounted, 10 while dismounted. The commonest group of injuries were soft tissue injuries of the lower limb (13 cases), soft tissue injuries of the upper limb (12 cases), fractures of the upper limb (nine cases), and minor head injury (seven cases). There was one case of severe head injury. Two patients required admission to hospital. The commonest mechanism of injury in the mounted group was a fall or throw (23 cases), in the dismounted group injuries were most commonly the result of being trodden on or being kicked (seven cases). The majority of equestrian-related trauma was minor in this study. The possibility of severe trauma exists. Emergency physicians working in areas where equestrian sport is popular should be aware of the likely injuries and their treatment.

Two-level non-invasive positive pressure ventilation in the initial treatment of acute respiratory failure in an emergency department.

Abstract: There are few data on the use of two-level non-invasive positive pressure ventilation (two-level nIPPV) in the initial treatment of severe acute respiratory failure in emergency departments (ED). In a prospective, non-randomized, pilot study, we assessed (1) the feasability of this method in an ED, (2) its effect on clinical and laboratory data, and (3) its effect on the need of intubation and the final outcome of patients. During a 1-year period all eligible patients admitted for acute respiratory failure, with absence of improvement after periods of specific classic treatments, were included in the study. Each patient received a specific classic treatment and two-level nIPPV with a two-level positive pressure ventilator through a face mask. We recorded parameters on admission, after 15 and 45 minutes of nIPPV and at the end of nIPPV. Sixty-two patients were included: 29 with acute pulmonary oedema (APO), 16 with acute exacerbation of chronic obstructive pulmonary disease (COPD), four with asthma, and 13 with various diseases. In the APO-group, we observed a statistically significant improvement of respiratory and pulse rates, diastolic blood pressure, pH, PaCO2 and SaO2. In acute exacerbation of COPD, we observed only a statistical improvement of respiratory and pulse rates without any significant change of PaCO2 and pH. In the two other groups, there was a clinical, gasometric and haemodynamic improvement in all patients. Four patients were intubated and 10 died, but none in the ED or in the first 24 hours after hospital admission. We were able to institute two-level nIPPV for severe acute respiratory failure in an ED without complications. Its addition to the rest of classic specific treatment seems to bring about a rapid improvement of various clinical and laboratory parameters in most patients. We found no deleterious effect of nIPPV when implemented for short periods of time in the emergency department setting.

Analysis of time management in stroke patients in three French emergency departments: from stroke onset to computed tomography scan.

Abstract: The aim of this study was to determine and identify the factors associated with shortening or lengthening time interval from stroke onset to performance of computed tomography (CT) scan in stroke patients admitted to three French emergency departments. All suspected stroke patients were eligible (n = 317). The time intervals between stroke onset and presentation to the emergency department and between CT scan request and CT scan performance were determined. Twelve variables likely to influence time interval before presentation to the emergency department, and five variables likely to influence time interval before CT scan performance were evaluated using stepwise regression analysis. Of the 317 patients included in the study, the mean time interval from stroke onset to CT scan performance for 180 patients was 7 hours 46 minutes (466 minutes). The mean time interval between stroke onset and presentation to the emergency department was 4 hours 36 minutes (276 minutes), varying according to the study site, level of initial severity, medical contact before admission, witnesses at stroke onset, and mode of transportation. The mean time interval between request and CT scan performance was 2 hours 14 minutes (134 minutes), varying upon the site, hour of CT scan request, type of stroke and level of severity at admission. It is concluded that current delays in stroke management are often incompatible with early treatment. The public needs to be informed and admission procedures reorganized. Improved response to the urgency of ischaemic stroke is required as well as direct access to the scanner during periods of scheduled use.

Extrication of entrapped victims from motor vehicle accidents: the crew concept.

Abstract: Improper handling during extrication of entrapped motor vehicle accident victims may increase the time spent at the scene and expose the victim to unnecessary risk for additional injures. Previous studies report a significant number of neurological injuries that appear to be a result of the extrication process or inadequate immobilization during transport. Recent studies also underline the need for appropriate and situation-adapted advanced life support procedures to improve outcome after prehospital trauma resuscitation. This paper presents a method for training in advanced extrication of trauma victims and shows the results obtained after five consecutive courses. The training focuses on enhanced liaison between medical and technical team members to optimize synchronization of operations. The course consists of both theoretical lectures and practical training in different crash scenarios. The complexity of the scenarios increases throughout the course and different extrication techniques and strategies are practiced. During the three-day course, therapeutic interventions and handling of the patient were improved in terms of early recognition of medical and technical risk and reduction of the time of no therapy. Both the times to extrication and on-scene times were also reduced.

Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey.

Abstract: The objective of this study was to assess, by questionnaire survey, national practice in respect of radiological assessment of the cervical spine in the conscious adult patient with suspected neck injury. The physicians in charge of accident and emergency departments with more than 25000 new patients per year were sent a questionnaire. One hundred and ninety-one replies were received from 243 physicians (79%). Sixty-five per cent of departments have written protocols for imaging the cervical spine. Seven per cent of departments use fewer than the three standard views for clearing the cervical spine. If adequate views do not visualize the cervicothoracic junction, 89% use swimmer's views and 12% use supine oblique views, prior to computerized tomography scanning. It is concluded that the majority of departments use three standard views in the first instance. Swimmer's views are the most common additional X-rays taken if the C7-T1 junction is not visualized, even though supine oblique views give better information about spinal alignment. Imaging of the cervical spine following trauma is difficult and guidelines should be drawn up to address these problems.

Comparison of four drugs for local treatment of burn wounds.

Abstract: Effective local treatment is very important in preventing wound infection and its generalization and ensuring successful skin grafting. The aim of our study is to compare the activity of four topical agents [deflamol (20 patients), polyvidone-iodine (21 patients), flammazine (silver sulphadiazine--SSD) (28 patients) and flammacerium (SSD with cerium nitrate) (five patients)] for treatment of patients with burns by confirming our clinical observations of their efficacy with comparative bacteriological investigations. The final estimation of our results showed the undoubted priority of flammazine and flammacerium over deflamol and polyvidone-iodine, as the treatment of all the patients with these two drugs gave very good and good results, respectively. In contrast, the results in 70% of the patients from the deflamol group and in 52.4% of those from the polyvidone-iodine group were unsatisfactory. At this stage we cannot find any significant differences in the antibacterial activity between flammazine and flammacerium. However, the excision of the firm eschars formed by flammacerium is easier and it gives the opportunity to postpone operation for a month or more. In conclusion we found suitable indications for preference of each of the topical agents included in our study.

Foreign body aspiration in childhood: management algorithm

Abstract: Foreign body inhalation is still a major cause of morbidity and even mortality in the under-fives. To reduce its frequency, more severe preventative measures must be imposed and to allow for early diagnosis, a low threshold for bronchoscopy is necessary. This retrospective study is based on 33 children referred to us for suspicion of inhaled foreign body. Symptomatology, clinical and paraclinical data are reviewed. Based on our practice and on the experience gained from the literature, we propose a management algorithm which will need to be further assessed by a prospective study.

The puzzle of neuronal death and life: is mannitol the right drug for the treatment of brain oedema associated with ischaemic stroke?

Abstract: Brain oedema is a major factor contributing to the poor outcome of subjects with acute ischaemic stroke but the use of mannitol and other hyperosmolar agents in this setting is controversial and hardly debated. Recent data have demonstrated that mannitol at concentrations which may be achieved in clinical conditions and hyperosmotic stress itself can activate the process of apoptotic cell death. This could have important clinical implications as apoptosis is involved in the more gradual loss of neurons in the penumbra zone surrounding the core of ischaemic stroke where neurons die immediately from oxygen starvation. Mannitol has the potential to activate inflammatory mediators, induce oxidant stress and produce rebound cell swelling and, through these mechanisms, can further aggravate the neuronal injury due to ischaemia. Furthermore, apoptosis in ischaemic areas closely parallels the timing of brain oedema and this suggests that a cause-effect relationship links the two phenomena rather than simply a temporal correlation. On this basis, it is crucial that emergency-physicians critically rethink the management strategy of brain oedema associated with ischaemic stroke.

Myocardial contusion as a result of isolated sternal fractures: a fact or a myth?

Abstract: Isolated sternal fractures are seen with an increasing frequency in traffic road accidents especially after the introduction of the seatbelt legislation. In most cases, the victims are young, otherwise healthy individuals. The medical records of all patients who were treated with a diagnosis of sternal fracture over the past 10 years were retrospectively reviewed. All patients with a radiologic diagnosis of sternal fracture were admitted for cardiac monitoring for at least 24 hours. ECG, determinations of cardiac enzyme levels CK (creatinephosphokinase) and CK-MB and evaluation by a cardiologist were routinely performed. An echocardiography was performed when indicated by the cardiologist. A total of 86 patients had sustained a sternal fracture during the 10-year study period. There were 39 males and 47 females with a mean age of 50 years (range 15-97 years). Serial 12-lead electrocardiograms, which were performed in 83 (97%) patients, revealed no information about myocardial contusion or cardiac arrhythmias with consequent therapy. In eight patients, a significant elevation in cardiac enzyme levels (elevation of CK-MB fraction above 10% of CK) was observed. All were normalized within 24 hours without development of any arrhythmias. Echocardiography was performed in 31 patients. In two patients, dyskinesia of the right ventricle (without enzyme elevations or arrhythmias) was observed. Within 24 hours these abnormalities resolved. The cardiac rhythm was monitored in 61 (71%) patients for a total of 1550 hours. No arrhythmias were observed. The cardiac enzyme studies, ECG and echocardiography revealed no consequent information about arrhythmias. In case of a sternal fracture, we recommend a chest X-ray to exclude other associated intrathoracic injuries. If no abnormalities are identified, admission to hospital is not necessary.

Costing of an ambulance system in a developing country, Turkey: costs of Ankara Emergency Aid and Rescue Services' (EARS) ambulance system.

Abstract: The purposes of the study were to determine the total cost of Ankara Emergency Aid and Rescue Services (EARS), to calculate the cost of a single ambulance response and the cost per patient responded to. A descriptive study was planned to find out the cost of Ankara EARS, conducted between 1 October 1995 and 30 September 1996. The main variables of the study were the capital and recurrent costs of the system. The data relating to the costs were obtained from financial registries of various health institutes and personnel working in the system. The data was collected by two of the researchers. The total and average costs--cost per one ambulance run and cost per one patient--were determined. The total cost of Ankara EARS ambulance system in the period between 1 October 1995 and 30 September 1996 was US$918,877.90. The total capital costs of Ankara EARS was US$85,171.10 (9.3% of the total cost). The total recurrent costs of Ankara EARS was US$833,706.80 (90.7% of the total cost). The cost per one ambulance run was US$163.00. On the other hand the cost per patient or injured person was US$180.50. In Ankara, Turkey, the costs of such ambulance services could not be afforded by the private sector. The ambulance service activities should continue to be a part of primary health care services and the Ministry of Health should continue to serve in this field.

Motor cortex excitability changes within 8 hours after ischaemic stroke may predict the functional outcome.

Abstract: Motor evoked potentials after magnetic transcranial stimulation and the excitability of the motor cortex to increasing magnetic stimulus intensities were evaluated in six patients with hemiparesis after ischaemic stroke within 8 hours after stroke. The latencies of motor evoked potentials were normal in all patients. After stimulation of the ischaemic hemisphere we obtained responses comparable with the contralateral ones in two patients (mean NIH score 2 (SD 0)) and this group was completely asymptomatic after 15 days (NIH score 0). In four patients the excitability of the motor cortex involved by the ischaemia was reduced and magnetic motor threshold was higher than that of the spared motor cortex. This finding was associated with a poor motor recovery and the NIH score after 15 days was unchanged (NIH score 1.75 (SD 1.5)). The present data suggest that the evaluation of the excitability of motor cortex may offer a mean of predicting functional outcome following stroke.

Emergency department patients who leave the department without being seen by a doctor.

Abstract: When waiting times in accident and emergency (A&E) departments become too long, some patients leave the department before seeing a doctor. This study was designed to investigate the characteristics and outcome of this group of patients in one A&E department. We identified all patients who left the department without seeing a doctor on 12 randomly selected days in October and November 1997. These patients were contacted by post and non-responders followed up by telephone. During the study period 3097 patients registered for treatment, and of these 102 (3.26%) left before being seen. Of these 102 patients, 77 were contacted. The duration of their symptoms was less than 24 hours in 56 patients (73%). Their mean waiting time was 2.44 hours. Of the patients reviewed, 45 (58%) sought medical attention afterwards and one required hospital admission. The majority of patients were satisfied by the explanation given for the delay in seeing a doctor. This limited study suggests that patients are able themselves to gauge the severity of their symptoms and safely defer medical consultation.

Does the length of stay in the intensive care unit influence the diagnostic accuracy? A clinical-pathological study.

Abstract: To evaluate the rate of diagnostic errors leading to preventable deaths among patients admitted to our intensive care unit (ICU), we retrospectively reviewed the medical and autopsy records of all patients who died in the ICU between 1 January 1991 and 31 December 1993. Excluded were patients with traumatic injuries, cerebrovascular accidents and primary cardiac arrest. According to their length of stay (LOS) in the ICU, patients were subdivided into Group A (LOS 0-24 hours), Group B (LOS > 24 hours-14 days), and Group C (LOS > 14 days). Errors were divided into Type 1 (failure to recognize a treatable life-threatening condition); Type 2 (failure to recognize a life-threatening condition, which treated, however, would unlikely alter the outcome), and Type 3 (failure to recognize a condition unrelated to the outcome). Overall, 159 consecutive patients were enrolled. Type 1 errors were 5% in Group A, 4% in Group B and 9% in Group C. Type 2 errors were 18% in Group A, 34% in Group B, and 30% in Group C. Fully correct diagnoses or Type 3 errors were present in 77% of patients in Group A, 62% of patients in Group B, and 61% of patients in Group C. Clinical errors of any type were not related with the LOS in the ICU or in the hospital, age and the number of underlying chronic diseases.