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OBJECTIVE: To determine the risk of suicide in patients attending an accident and emergency (A&E) department with deliberate self harm. METHODS: Information was obtained on suicides and open verdicts from the coroner's office and cross checked with computerised records in the A&E department. RESULTS: There was a trend to suicide among younger socially isolated males and older females. CONCLUSIONS: There is a significant association between suicide and a previous attendance at A&E with deliberate self harm. Appropriate assessment of these patients is an efficient way of managing self harm.

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OBJECTIVE: To review the case records of patients admitted to an accident and emergency (A&E) observation ward following deliberate self harm. METHODS: The hospital notes of 568 patients admitted during one year following episodes of deliberate self harm were reviewed. The study was retrospective. RESULTS: The majority of these patients had taken an overdose and were between 18 and 35 years of age. Most patients were admitted to the observation ward after midnight or in the evening and were subsequently managed by an A&E based deliberate self harm team. Only 20% of admissions required evaluation by a psychiatrist. Most patients were discharged the next day without further follow up. CONCLUSIONS: The use of a specialised A&E based team and an A&E observation ward is appropriate for the management of many deliberate self harm patients.

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Patients who deliberately harm themselves can present with a variety of disorders. The case is reported of a patient who deliberately self-harms by inducing hypoglycaemic episodes. This patient has placed great demands on the emergency services over the last 9 years. Early involvement by senior accident and emergency staff is advised.

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We reviewed the effectiveness of a strategy involving paramedic ambulances and community education to reduce the delay to thrombolytic therapy in patients admitted with acute myocardial infarction, by analysing delay times recorded during routine treatment. Rapid identification and treatment of patients with acute myocardial infarction who were eligible for thrombolysis was carried out in the Accident and Emergency and Cardiac Care Units. Two hundred seventy-four patients were admitted with acute myocardial infarction over an 18-month period and treated with anistreplase (168) or streptokinase (106). The following median times were recorded: symptom onset to administration of thrombolytic therapy, 142 min (range 43-980 min); symptom onset to ambulance arrival, 60 min; ambulance with patient to arrival in hospital, 35 min; time to treatment in hospital ('door to needle time'), 25 min; in-hospital delays were notably shorter for patients given anistreplase as opposed to streptokinase. Shortened delays for the delivery of thrombolytic therapy can be achieved by a strategy involving public education, the availability of resuscitation ambulances, and close liaison with the Accident and Emergency Department.

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A 48-year-old man accidently swallowed the ring pull from a soft drink can. He complained of pain in his chest. Chest radiographs were normal. A metal detector emitted a strong response when passed across the front of his chest. Oesophagoscopy was carried out and the ring pull was successfully removed. We recommend the wider use of metal detectors by accident and emergency (A&E) department staff particularly when dealing with patients who have ingested metals of low radiodensity.

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This paper reports a retrospective criterion based audit which reviewed head injury management in two accident and emergency (A&E) departments. Management was compared with regionally agreed criteria for ordering a skull radiograph (SXR) and a computerized tomogram (CT scan) and for admission, and the quality of medical documentation was assessed. A total of 158 patients were reviewed and 132 patients (84%) satisfied the three key areas of recommended head injury management. Failures to satisfy recommended guidelines were present in 19 patients (12%) for SXR, four (2%) for admission and three (2%) for CT scanning. Three skull fractures (two in young babies) would have been missed if the criteria had been adhered to strictly. There was one adverse outcome when a patient who should have been admitted returned to A&E 8 days after initial attendance with a subdural haemorrhage and died shortly afterwards. Apart from 'loss of consciousness', the quality both in content and legibility of the medical documentation was poor. The result of 84% correctly managed patients may be over-optimistic according to the criteria used. Although criteria have a valuable role to play, there are problems with prescriptive standard setting. A recommendation was made to develop a head injury pro forma to address the poor quality medical documentation and it was also recommended that the SXR, CT scan and admission criteria for babies and young children be reviewed.

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The aim of this study was to assess the quality of documentation of head-injured patients seen in three accident and emergency (A&E) departments using a specially designed head injury pro forma. A 4-week prospective study of a single head injury pro forma was followed by a second similar study with an improved version (two head injury pro formas, one for young children and babies, the other for older children and adults). The main outcome measures were the degree of completion of the pro forma and questionnaire responses from receptionists, nurses and doctors. A total of 1260 patients had their details completed on the pro forma in both studies. Compared with standard hand written A&E notes, the degree of completion of clinical details specific to the head injury were high, eg. over 95% for symptoms. The pro forma was generally well received by A&E staff, particularly after recommended improvements were made, and the majority of staff felt it should be introduced permanently into the A&E department. Concern about its use in cases of very minor head injury and multiple injuries were raised. As well as improved documentation, the pro forma facilitates the process of audit and may have an important role to play in information technology and computers in the future.

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The response to major trauma in Britain has been demonstrated to be inadequate. One of the suggested approaches to tackling the problem has been the setting up of rapid response trauma teams at district general hospitals. We set up such a team in Brighton and report on its first year of operation. Numbers of patients were not sufficient to draw any firm conclusions, though no dramatic improvement in outcome was evident. Problems in setting up such a team are discussed.

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Despite the importance of early thrombolysis in the treatment of acute myocardial infarction, unacceptable delays in drug administration still occur in hospital. From March 1989 we decided to monitor our performance, and thereby to reduce avoidable in-hospital delay to a minimum. Potential candidates for thrombolytic therapy were identified by paramedic ambulancemen whenever this was feasible. Rapid check-lists were used for inclusion and exclusion criteria in the Accident and Emergency Department. A target of 15 min was set for time to treatment, and reasons for any gross deviation (greater than 30 min) were explored in each instance. As a result of these strategies, we achieved a median time from admission to initiation of thrombolysis in 50 consecutive patients of 17 min. The 39 patients treated with injections of APSAC as opposed to infusions of streptokinase had a median in-hospital delay to treatment of only 13 min.

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Lower esophageal pH was continuously monitored for 15 hours in 10 asymptomatic subjects and 27 patients with symptoms of gastroesophageal reflux, and the pH measurements in symptomatic patients were compared with the results of other esophageal investigations. Symptomatic patients had significantly longer periods of reflux in the pH test than asymptomatic subjects (P less than 0.01), but there was no significant correlation between the pH measurements and the results of esophageal manometry, acid-perfusion, and acid-clearing tests. Ten patients had evidence of esophagitis at esophagoscopy, but there was no correlation between pH measurements and the findings at esophagoscopy. Two patients with esophagitis had no evidence of reflux in the pH monitoring test. The results indicate that the pH-monitoring test has a useful role in the diagnosis of gastroesophageal reflux in patients who do not have endoscopic signs of esophagitis. However, negative pH tests do not exclude the diagnosis of symptomatic reflux, and it appears that the test has no value in assessing the severity of esophageal inflammation.

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The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.

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