It is wrong for patients who are sick enough to require admission to hospital to be kept in the emergency department, and the entire health system must respond to their plight.

Failure to provide the service in a timely manner gives rise to patients leaving without receiving the medical assessment they came to obtain. This is a serious clinical problem and puts both those requiring care and those providing it at risk of adverse outcomes.

Background and objectives: In many emergency departments advanced life support (ALS) trained nurses do not assume a lead role in advanced resuscitation. This study investigated whether emergency nurses with previous ALS training provided good team leadership in a simulated cardiac arrest situation. Methods: A prospective study was conducted at five emergency departments and one nurses' association meeting. All participants went through the same scenario. Details recorded included baseline blood pressure and pulse rate, time in post, time of ALS training, and subjective stress score (1 = hardly stressed; 10 = extremely stressed). Scoring took into account scenario understanding, rhythm recognition, time to defibrillation, appropriateness of interventions, and theoretical knowledge. Results: Of 57 participants, 20 were ALS trained nurses, 19 were ALS trained emergency senior house officers (SHOs), and 18 were emergency SHOs without formal ALS training. The overall mean score for doctors without ALS training was 69.5%, compared with 72.3% for ALS trained doctors and 73.7% for ALS trained nurses. Nurses found the experience less stressful (subjective stress score 5.78/10) compared with doctors without ALS training (6.5/10). The mean time taken to defibrillate from the appearance of a shockable rhythm on the monitor by the nurses and those SHOs without ALS training was 42 and 40.8 seconds, respectively. Conclusion: ALS trained nurses performed as well as ALS trained and non ALS trained emergency SHOs in a simulated cardiac arrest situation and had greater awareness of the potentially reversible causes of cardiac arrest. Thus if a senior or middle grade doctor is not available to lead the resuscitation team, it may be appropriate for experienced nursing staff with ALS training to act as ALS team leaders rather than SHOs.

No abstract

The case of a patient with an unusual medical condition and an occult pneumothorax is presented. The evidence for management of occult pneumothorax particularly in patients with underlying lung disease is reviewed and solutions to the acute clinical problems that may arise are suggested.A 27 year old man with histiocytosis X presented to the emergency department with left posterior chest wall pain and marked dyspnoea. The patient previously had recurrent pneumothoraces, eight on the right and two on the left. He had undergone pleurodesis of the right lung. His medical history also included invasive bronchopulmonary aspergillosis and an embolisation of the right pulmonary vessels for life threatening massive hemoptysis. He was on two litres per minute of home oxygen, which usually maintained his oxygen saturations around 94%.On examination he was pale and sweaty with a heart rate of 160 per minute and a respiratory rate of 42 per minute. He had an oxygen saturation of 88% on 15 litres per minute of oxygen and a blood pressure of 76/45 mm Hg. Respiratory examination revealed diminished air entry bilaterally more marked on the left with increased resonance over the anterolateral left hemithorax. His trachea was noted to be central.Emergency chest radiography was performed but while awaiting the return of the film the patient decompensated further, his saturations decreased to 81%, and his trachea was now deviated to the right. An emergency needle decompression of his left hemithorax was performed. In the context of his complicated medical history and the clinical findings the needle was inserted at the point of poorest air entry and maximal resonance, which was the left sixth intercostal space in the anterior axillary line. Some 300 ml of air was aspirated from the left hemithorax and the patient clinically improved. The chest radiograph revealed bilateral infiltrates and underlying cystic and bullous disease but failed to reveal evidence of a pneumothorax (fig 1). A chest radiograph performed after the needle decompression also failed to show a pneumothorax. Computed tomography (CT) of the thorax revealed an anterior pneumothorax (fig 2). This was drained under CT guidance by the placement of a chest drain catheter.During the patient's in hospital stay his chest drain was removed as his chest radiograph showed no evidence of residual pneumothorax. The patient became markedly dyspnoeic within 24 hours. Because of the clinical impression of the recurrence of the tension pneumothorax the patient had a needle decompression performed in the classic manner. The needle placed initially at the second intercostal space in the left midclavicular line failed to permit aspiration of air. An attempted needle decompression at the fourth intercostal space in the mid-axillary line was also unsuccessful. Urgent CT again confirmed a left sided anterior pneumothorax. A chest drain catheter was placed under CT guidance. The patient was discharged from hospital 23 days later. Resolution of the pneumothorax was confirmed by CT before d...