1271careful examination showed no burns. He remained without a fever throughout his admission.He was nursed in bed and received benzylpenicillin 500 000 units four times daily for four days and oxygen via a nasal cannula. Chest radiography (figure) showed bilateral patchy consolidation, more noticeable on the left, with mediastinal and right supraclavicular surgical emphysema and no fractures. He made a rapid, uneventful recovery and was discharged home four days later with only a few persisting pulmonary crepitations. As is common in this region, he failed to attend for review. CommentInjuries resulting from electrical contact with lightning have included neurological effects,' burns,1 2 cardiorespiratory arrest,3 and severe localised tissue damage.4 A lightning bolt, however, also causes sudden heating and expansion of the air through which it passes, producing strongly positive then negative pressure waves, which result in the familiar thunder clap. The injuries sustained by this patient were attributable to this blast effect alone and were compatible with the pulmonary lesions reported by Zuckerman from experimental explosions.5 The patient had no burns; I suggest that the actual lightning strike was to a nearby object and that he was not actually in contact with the electrical discharge.No other clear case of pulmonary blast injury resulting from lightning has been described, but in one case reported by Hanson and McIllwraith the heart and ascending colon were found at necropsy to be extensively bruised, consistent with blast injury; the lungs, however, were normal.2 Oblique rib views after blunt chest trauma: an unnecessary routine?In recent years increasing attention has been focused on unnecessary radiographic examinations in the accident and emergency department.1-4 We think that a further topic for review is the oblique x ray view of the ribs after blunt chest trauma. Patients, methods, and resultsThe case notes of 1178 patients aged 6-95 who had had x ray examinations after blunt chest trauma were retrospectively reviewed. The time of presentation after injury varied from less than one hour to over a week. All of these patients had had a frontal chest x ray film and at least one oblique view of the ribs. Two hundred patients were identified who were thought to have had a rib fracture by the casualty officer interpreting the films at the time of presentation. The films of these patients were reviewed, the frontal chest and oblique views being evaluated separately. The relevant side of injury was known when the frontal film was viewed.Of In this series 44 patients were admitted, 27 of them for a consequence of another injury. In these cases the oblique view did not influence the admission. Thus there are 17 patients who were admitted for reasons relating to their rib injury alone. Of these, 15 had a complication of their injury (such as a pneumothorax) visible on the frontal view which would have indicated the need for admission.Hence out of the initial 1178 cases the decision was affected in only two b...

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