Patients leaving an Accident & Emergency Department against medical advice are often considered a high-risk group. A prospective study was carried out in an Accident & Emergency Department (ED) to determine the characteristics of this distinct group of patients, their reasons for leaving against medical advice (AMA), and their subsequent outcome. Telephone or personal interview of patients by a clerk was attempted within 48 hours of the visit for all patients who left Against Medical Advice (AMA) based on a pre-set questionnaire. A follow-up call was used to ascertain health outcomes after the discharge. There were 210 AMA cases during the study period giving an incidence of 0.95%. Interview was successful in 186 (88.6%) patients. The mean age of the AMA group was around 36 years but there was no significant difference in sex. The major reasons for AMA included wanting to observe symptoms at home (78 of 186, 42 %), non-medical personal reason (64 of 186, 34%) and symptoms have abated (21 of 186, 11%). Eighteen (9.7%) patients left AMA because they wanted to seek treatment from other providers and among them three had private insurance coverage. Of the 5 (2.7%) patients who were dissatisfied with the management in ED, four disagreed with the diagnosis and treatment offered and the remaining one was unhappy with the attitude of the attending physician. About 12% (22) of patients returned within 48 hours for further treatment and 8 (36%) were admitted. The remaining 22% (40 of 186) sought further medical treatment from other sources. No formal patient complaint was received during the study period from this group.

This manuscript deals with the differences of several trauma systems in certain European countries, the USA and Australia. It aims to provide an overview of the peculiarities and influences of these systems on the clinical management. However, the effect of differences in organization in different countries on patient outcome is difficult to assess. There appears to be consensus on the fact that structured treatment for acute trauma care is beneficial for trauma patients. Thus, any kind of organization contributes to improved patient outcome.

Objectives: (1) To assess the normal range of thickness of the epiglottis by means of ultrasound measurement. (2) To evaluate inter-observer agreement in measuring the thickness of the epiglottis of normal individuals by ultrasound. (3) To assess the association between biological factors and the thickness of the epiglottis. Methods: Fifty adult volunteers working at a local accident and emergency department were recruited. The thickness of the epiglottis was measured by means of ultrasound examination, which was performed twice by two emergency physicians at different time. The study subjects' age, sex, height and body weight were recorded. Results: The mean thickness of the epiglottis was 0.236 cm and the standard deviation was 0.020. Male subjects had thicker epiglottis. Interobserver agreement of the two emergency physicians who performed the ultrasound scan was very good. Multiple regression models showed that sex and height were useful predictors of the thickness of the epiglottis. Conclusions: Bedside ultrasound assessment of the epiglottis is an easy, rapid and reliable method to evaluate its thickness. Further studies are needed to evaluate the thickness of the epiglottis in patients with epiglottitis before it can be put into clinical use.

To review the categorisation of patients who were transferred out from outlying islands to urban hospitals utilising casualty evacuation (CASEVAC), and to search for possible patient characteristics which might have contributed to mis-categorisation during the 'non-flying' hours. Methods: The medical records of 459 patients, who were transferred out in the year 2009 were reviewed. Correctness of categorisation was determined by 2 independent assessors according to the CASEVAC guidelines. The rates of mis-categorisation between 'clinic hours' and 'AED hours', and that between the 'flying' and 'non-flying' hours, were compared. The patients' demographic data and their presenting symptoms were collected and analysed using logistic regression models to identify factors contributing to mis-categorisation. Results: The mis-categorisation rate was 60.1%. Among them, all were over-categorised. The over-categorisation rates between 'clinic hours' and 'AED hours', and between 'flying' and 'non-flying' hours, were not significantly different (p=0.07 and 0.09, respectively). Abnormal pulse rate was significantly associated with over-categorisation (p<0.01). Patients at extremes of age and psychiatric/ drunk patients were significantly less likely to be over-categorised (p<0.05 and p<0.01, respectively). There was 20% disagreement between the two assessors when applying the existing CASEVACs guidelines (kappa score 0.58 or 'moderate agreement'). Conclusions: Over-triage in CASEVAC categorisation is common irrespective of the time of day. Revision of the current CASEVAC guidelines is recommended. (Hong Kong j.emerg.med. 2013; 20:327-336) 目的：檢討用緊急撤離(CASEVAC)將病人從離島轉送到巿區醫院的分類並尋找那些在「無飛行時 間」中可能會導致誤分類的病人特徵。方法：我們檢討了在 2009 年期間的 459 個轉院病人的醫療報告。 由 2 個獨立的評估人員根據緊急撤離的指引去決定分類正確與否。誤分類率在「門診時間」和「急症 時間」及「飛行時間」和「無飛行時間」之間都作了比較。我們搜集了病人的人口統計學數據和他 們的主訴症狀並運用邏輯回歸法去分析以達致找出引至誤分類的因素。結果：誤分類率是 60.1% 。所有誤 分類個案都分類過高。過高分類率在「門診時間」和「急症時間」及「飛行時間」和「無飛行時 間」之間沒有明顯的區別(分別是 p=0.07 和 0.09)。不正常的脈搏率與分類過高明顯有關(p<0.01)。 病人兩極化年齡和精神病／醉酒的病人與過高分類明顯有較少的關係(分別是 p<0.05 和 p<0.01)。當 使用現時的緊急撤離指引時兩個評估人員之間持不同意見有 20% (kappa 評分 0.58 或中度同意)。結論： 在緊急撤離分類中，過高的分流是常見的並且不受時間影響。我們建議再審視現時的緊急撤離指引。

To study the adequacy of trauma documentation in accident and emergency (A&E) attendance records. Method: We reviewed the A&E attendance records of major trauma requiring trauma-team care in the resuscitation room from January to June 1999 and July to December 2001. Thirty-eight items including the history, symptoms and signs of injury were scored with reference to the teaching of the Advanced Trauma Life Support course. The mean score and rate of documentation of each item were calculated. Additional items on biomechanics and environmental factors of injury were also examined. The performance of emergency medicine trainees and non-emergency medicine trainees was analysed. Results: A total of 128 records were included, 46 and 82 records being from 1999 and 2001 respectively. The maximum documentation score was 38. The mean documentation score in 2001 was 23.27; and this was significantly better than 20.37 in 1999 (p < 0.05). The documentation rates of pre-hospital, biomechanics and environmental items were poor. Notably, 15 out of the 38 items were preformatted in the A&E records and 11 of these preformatted items had documentation rates of > 80%. Emergency medicine trainees had better scores in 2001 than in 1999. However, non-emergency medicine trainees did not show improvement in their documentation. Conclusion: Trauma documentation has improved since 1999 for emergency medicine trainees. Preformatted charts may increase the rate of documentation. Information on pre-hospital care and injury mechanism was not well documented.