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Physicians and the long arm of the law. How far does it reach?
dialysis, or frequency of dialysis. Prognosis was found to be directly r e l a t e d to associated injuries and complications, most commonly, due to sepsis. Major associated injuries leading to mortality included closed head injuries and intraabdominal injury. Four out of five patients with neither of these two injuries survived. All five patients with associated severe head injuries died, while 8 out of 12 with intraabdominal injuries did not survive: five fatalities were directly associated with sepsis. Of the four that survived, two had perforated bowels t h a t were treated with peritoneal antibiotic lavage. One case of this complication and recovery was presented. The conclusion was t h a t of the causes of death, the outcome of associative intraabdominal injury could be changed with aggressive management. Patients with posttraumatic renal failure and potential intraabdominal sepsis should be treated with peritoneal antibiotic lavage until proyen otherwise. (Editor's note: Peritoneal lavage with antibiotics strikes us as a mystic rite. However, the recognition and aggressive treatment o f bowel perforation, as this article points out, is more important for survival than concern about acute renal failure, which clears with time i f the patient is still alive.)
Albert Yee, MD
injury, abdominal.., blunt Physicians and the long arm of the law. How far does it reach? Gilwer W, J Leg Med 25-29, (Apr) 1977. Physicians t r e a t i n g patients who are residents of other states not uncommonly find themselves defendents in lawsuits brought against t h e m in t h a t foreign state. In this article, several such cases are presented. In the majority, the decision was t h a t the ~long arm" (extraterritorial) statute would not apply in the fortuitous circumstances of local residents who find themselves in need of or solicit services of a physician in a foreign state. The nature of a physician's localized practice precludes continuing efforts t o provide services that are felt necessary in another state. Decisions of this type, however, had many dissenting Opinions. One academic law journal concluded t h a t the traditional concepts of fair play and substantial justice would not be offended if the nonresident and physician were subject to jurisdiction of the courts in another state. Thus it appears t h a t the ultimate reach of the ~long arm" statutes continues uncertain and is still open to argument. (Editor's note: This is yet another caution for emergency physicians, who try to provide quality care, but whose practice precludes complete follow-up.)
Anne Salmon, PhD, MD
jurisprudence A simple stereotaxic method to isolate and remove foreign bodies. Ariyan S, Arch Surg 112:857-859, (Jul) 1977 Five c o n s e c u t i v e c a s e s i l l u s t r a t e a t e c h n i q u e w h e r e b y radiopaque foreign bodies are located with two 19-gauge venipuncture needles placed under aseptic conditions from opposite directions, guided by i n t e r m i t t e n t exposure with an x-ray image intensifier. The patient moves his extremity on command of the physician for the 3-dimensional stereoscopic effect. When located, a small incision is made between the two needles and the foreign body is removed under direct vision. Median time for isolations was two minutes. Median time for removal was 1V2 minutes. Failure to visualize the foreign body in a short period of time or proximity to important anatomical structures is an indication for removal in the operating room. The author points out t h a t almost all glass in common use is radiopaque. (Editor's note: On the other hand, the following abstract suggests a less invasive diagnostic technique.) Howard Lee, MD
foreign bodies, stereotaxis technics Detection of a relatively radiolucent foreign body in the hand by xerography. Carneiro RS, Okunski W J, Heffernan AH, Plast Reconstr Surg 59:862-863, (Jun) 1977. A case is presented in which a 50-year-old man sustained a puncture h a n d wound with a fragment of a dirty wooden stick. He removed the fragment himself and then went to a hospital
76/475
emergency department where he was given tetanus texoid a ~ radiograph was t a k e n which failed to show anything a b n o r ~ Four days later he presented with a swollen infected hand. 4 ~'~ t h a t time, a xerogram was obtained which clearly demonstrated a foreign body. (Editor's note. In this type o f case, in which a ~o~ tissue w o u n d is produced by wood or other objects of vegetabl~ origin, a n d especially when the object breaks on attempt at re. moral, xerography can be a very useful diagnostic tool to detect the relatively radiolucent material which would not be seen on conventional radiograph). Jeffrey B. Dubnow, MI)
foreign bodies, xeroradiography
Bacterial meningitis secondary to abscess of the nasal septum. Eavey RD, M a l e k z a k e h M, Wright HT Jr, Pediatrics 60:102-104, (Jul) 1 9 7 7 . . . Nasal septal abscess is uncommon but carries severe potential complications, including septal destruction with resulting de. formity of the nose, as well as intracranial infection, A case i~ described of an 11-month-old female with an upper respiratory infection, who presented with bilateral nasal obstruction secon. dary to a septal abscess. The findings were initially misiden. ti~ed as "swelling of the turbinates." This is a common error even though the turbinates are situated laterally while the swel. ling of a nasal septal abscess arises medially. Treatment consist s of immediate incision and drainage, and" administration of ca. tibiotics intravenously. Even when therapy is initiated prompt. ly, intracerebral complications may still occur, presumably because of the venous and lymphatic communication between the area of the nose and the dural sinuses and meninges. (Editor's note: This sort o f picture, because o f its rarity, is most often realized only in retrospect. I n pediatrics as in adult emergency medicine, potentially life-threatening conditions should be ruled out). Jeffrey S. Menkes, MO
nasal septum, abscess
Location and size of acute transmural myocardial in. farction e s t i m a t e d from Thallium-201 scintiscans. Wackers FJT, Becker AE, Samson G; Circulation 56:7278, (Jul) 1977. In this clinicopathological study involving 23 patients who died from acute t r a n s m u r a l myocardial infarction, the location and size of infarction obtained from scintiscan in vivo was compared w i t h a c t u a l p o s t m o r t e m f i n d i n g s . A l l . p a t i e n t s had acute myocardial infarction with typical history o f chest pain and typical serial enzyme rises. Twenty p a t i e n t s had diagnostic electrocardiogram (EKG) changes, one had lei~ bundle branch block, and in two; no diagnostic EKG changes were observed. Scintigraphy with Thallium-201 was performed as soon as possible after admission. In all patients, the scintiscans obtained during life showed a defect or area of decreased Thallium-201 activity, which was interpreted as the site of infarction. In 91% of the cases, there was good a g r e e m e n t b e t w e e n scintigraphic and postmortem location of infarction versus good agreement in only 70% of E K G and postmortem findings. The size of infarction as d e t e r m i n e d from c o m p u t e r processed schematic drawings of postmortem slices of the heart correlated well with the size de- • termined from processed schematic drawings of the scintiscans. Thallium-201 scintigraphy was found to be a useful diagnostic aid in recognizing patients with acute myocardial infarction at high risk, especially in patients with abnorma~ ventricular activation p a t t e r n s (left bundle b r a n c h block, Wolff-Parkinson° White syndrome, p a c e m a k e r r h y t h m ) , w h e r e EKG diagnosis a n d localization of infarction is difficult, (Editor's note: The EKG is only a measure o f electrical activity, not o f anatomy. A s we become able to "see" inside the body with various scanning techniques, diagnostic accuracy increases.)
Jeffrey B. Dubnow, MD
scintigraphy, myocardial infarction 6:10 (Oct) 1977 J ~ P
Albert Yee, MD
injury, abdominal.., blunt Physicians and the long arm of the law. How far does it reach? Gilwer W, J Leg Med 25-29, (Apr) 1977. Physicians t r e a t i n g patients who are residents of other states not uncommonly find themselves defendents in lawsuits brought against t h e m in t h a t foreign state. In this article, several such cases are presented. In the majority, the decision was t h a t the ~long arm" (extraterritorial) statute would not apply in the fortuitous circumstances of local residents who find themselves in need of or solicit services of a physician in a foreign state. The nature of a physician's localized practice precludes continuing efforts t o provide services that are felt necessary in another state. Decisions of this type, however, had many dissenting Opinions. One academic law journal concluded t h a t the traditional concepts of fair play and substantial justice would not be offended if the nonresident and physician were subject to jurisdiction of the courts in another state. Thus it appears t h a t the ultimate reach of the ~long arm" statutes continues uncertain and is still open to argument. (Editor's note: This is yet another caution for emergency physicians, who try to provide quality care, but whose practice precludes complete follow-up.)
Anne Salmon, PhD, MD
jurisprudence A simple stereotaxic method to isolate and remove foreign bodies. Ariyan S, Arch Surg 112:857-859, (Jul) 1977 Five c o n s e c u t i v e c a s e s i l l u s t r a t e a t e c h n i q u e w h e r e b y radiopaque foreign bodies are located with two 19-gauge venipuncture needles placed under aseptic conditions from opposite directions, guided by i n t e r m i t t e n t exposure with an x-ray image intensifier. The patient moves his extremity on command of the physician for the 3-dimensional stereoscopic effect. When located, a small incision is made between the two needles and the foreign body is removed under direct vision. Median time for isolations was two minutes. Median time for removal was 1V2 minutes. Failure to visualize the foreign body in a short period of time or proximity to important anatomical structures is an indication for removal in the operating room. The author points out t h a t almost all glass in common use is radiopaque. (Editor's note: On the other hand, the following abstract suggests a less invasive diagnostic technique.) Howard Lee, MD
foreign bodies, stereotaxis technics Detection of a relatively radiolucent foreign body in the hand by xerography. Carneiro RS, Okunski W J, Heffernan AH, Plast Reconstr Surg 59:862-863, (Jun) 1977. A case is presented in which a 50-year-old man sustained a puncture h a n d wound with a fragment of a dirty wooden stick. He removed the fragment himself and then went to a hospital
76/475
emergency department where he was given tetanus texoid a ~ radiograph was t a k e n which failed to show anything a b n o r ~ Four days later he presented with a swollen infected hand. 4 ~'~ t h a t time, a xerogram was obtained which clearly demonstrated a foreign body. (Editor's note. In this type o f case, in which a ~o~ tissue w o u n d is produced by wood or other objects of vegetabl~ origin, a n d especially when the object breaks on attempt at re. moral, xerography can be a very useful diagnostic tool to detect the relatively radiolucent material which would not be seen on conventional radiograph). Jeffrey B. Dubnow, MI)
foreign bodies, xeroradiography
Bacterial meningitis secondary to abscess of the nasal septum. Eavey RD, M a l e k z a k e h M, Wright HT Jr, Pediatrics 60:102-104, (Jul) 1 9 7 7 . . . Nasal septal abscess is uncommon but carries severe potential complications, including septal destruction with resulting de. formity of the nose, as well as intracranial infection, A case i~ described of an 11-month-old female with an upper respiratory infection, who presented with bilateral nasal obstruction secon. dary to a septal abscess. The findings were initially misiden. ti~ed as "swelling of the turbinates." This is a common error even though the turbinates are situated laterally while the swel. ling of a nasal septal abscess arises medially. Treatment consist s of immediate incision and drainage, and" administration of ca. tibiotics intravenously. Even when therapy is initiated prompt. ly, intracerebral complications may still occur, presumably because of the venous and lymphatic communication between the area of the nose and the dural sinuses and meninges. (Editor's note: This sort o f picture, because o f its rarity, is most often realized only in retrospect. I n pediatrics as in adult emergency medicine, potentially life-threatening conditions should be ruled out). Jeffrey S. Menkes, MO
nasal septum, abscess
Location and size of acute transmural myocardial in. farction e s t i m a t e d from Thallium-201 scintiscans. Wackers FJT, Becker AE, Samson G; Circulation 56:7278, (Jul) 1977. In this clinicopathological study involving 23 patients who died from acute t r a n s m u r a l myocardial infarction, the location and size of infarction obtained from scintiscan in vivo was compared w i t h a c t u a l p o s t m o r t e m f i n d i n g s . A l l . p a t i e n t s had acute myocardial infarction with typical history o f chest pain and typical serial enzyme rises. Twenty p a t i e n t s had diagnostic electrocardiogram (EKG) changes, one had lei~ bundle branch block, and in two; no diagnostic EKG changes were observed. Scintigraphy with Thallium-201 was performed as soon as possible after admission. In all patients, the scintiscans obtained during life showed a defect or area of decreased Thallium-201 activity, which was interpreted as the site of infarction. In 91% of the cases, there was good a g r e e m e n t b e t w e e n scintigraphic and postmortem location of infarction versus good agreement in only 70% of E K G and postmortem findings. The size of infarction as d e t e r m i n e d from c o m p u t e r processed schematic drawings of postmortem slices of the heart correlated well with the size de- • termined from processed schematic drawings of the scintiscans. Thallium-201 scintigraphy was found to be a useful diagnostic aid in recognizing patients with acute myocardial infarction at high risk, especially in patients with abnorma~ ventricular activation p a t t e r n s (left bundle b r a n c h block, Wolff-Parkinson° White syndrome, p a c e m a k e r r h y t h m ) , w h e r e EKG diagnosis a n d localization of infarction is difficult, (Editor's note: The EKG is only a measure o f electrical activity, not o f anatomy. A s we become able to "see" inside the body with various scanning techniques, diagnostic accuracy increases.)
Jeffrey B. Dubnow, MD
scintigraphy, myocardial infarction 6:10 (Oct) 1977 J ~ P