Emergency medicine (EM) is also undergoing change in Cuba. The only description of the status of EM in Cuba in the US or European medical literature was published in 1997 [2]. At that time, there was no organized emergency medical services, no organized training in EM, and no specialists practicing EM. Some Tertiary care hospitals had no emergen- cy department (ED) and patients were admitted by referral only, and others were considered primary care hospitals for obstetrics and gynecology and pediatrics only. Many hospital EDs were divided into 2 sections, medical/pediatrics and polytrauma, and were staffed by interns and residents. Then and now, one of the realities of the Cuban health system is that much of the emergency care that is provided is done in the clinic setting, rather than in hospital EDs.

Recently, emergency medical services have become more centralized and offer a higher standard of care than previously. Ambulances are summoned in situations of major trauma or acute severe medical illness by the police or bystanders. Patients usually do not call for an ambulance on their own. Patients are expected to contact their physician or local polyclinic, and an ambulance is sent to the patient’s home for transfer to the polyclinic or hospital if deemed necessary by the polyclinic nurse or physician.

Emergency medicine specialty training in is now formalized in postgraduate physician education in Cuba. A new program that trains physicians in critical care and EM was begun in 2000. This training is 4 years in length if started immediately after medical school or 3 years if another residency has already been completed.

The focus of the EM/intensive care unit (ICU) training program is in 2 major areas. The first area of concentration is a basic training (during year 1) primarily performing emergency care at an intermediate care unit. The second focus (during years 2 and 3) is on intensive care in the ICU setting. This also encompasses other medical special- ties including internal medicine, pediatrics, nephrology, cardiology, and traumatology (including burns). Residents receive 1 month of training in each of these areas. Residents choosing the adult profile train at general hospitals and those choosing the pediatric profiles train at pediatric hospitals. New modifications and changes in the EM/ICU program are ongoing. As an example, a new 3- week course in toxicology has been added this year.

The effort to establish specialization in EM/ICU care began with the recognition that the emergency system in Cuba needed improvement, and the Integrated Emergency medical care System (IEMCS) was created. The goal of the IEMCS is to improve the quality of emergency medical care in which all the entities involved (emergency medical services, hospitals, providers) will be integrated and coordinated by the IEMCS. The IEMCS initiative also provided the basis for specialized training in EM/ICU care. Many family physicians are showing interest in starting EM/ICU training. Currently, about 50 physicians have finished the specialization, and this number is expected to double in the next few years.

Robert Partridge MD, MPH

Assistant Professor Division of International Emergency Medicine Department of Emergency Medicine

Brown University School of Medicine Providence, RI 02903, USA

Iva’n Justo Roll MD

Department of Teaching and Research

Policlinic Toma’s Romay Old Havana, Cuba

doi:10.1016/j.ajem.2005.03.006

References

1. World Health Organization. Accessed at http://www.who.int/countries/ cub/en/ [January 2005].
2. Richards JR. Emergency medicine in Cuba: report from a country in isolation. Am J Emerg Med 1997;15:424 - 6.

Atypical cardiac tamponade mimicking acute abdomen

To the Editor,

Dr Jabr [1] indirectly raises in his interesting report the problem of patients with large pericardial effusion who present with atypical clinical or hemodynamic features. This may represent a cause of delayed or missed diagnosis even under the life-threatening circumstances of cardiac tamponade.

We cared for a 62-year-old man with end-stage renal disease who had the abrupt onset of abdominal pain and vomiting 3 hours after he was brought back from the hemodialysis suite; hemodialysis was started 2 weeks earlier because of poorly controlled hyperkalemia and fluid overload. The patient appeared fully alert and oriented but severely distressed because of excruciating abdominal pain; his Vital parameters were normal. On physical examination, heart sounds were mildly distant, no friction rub was heard, jugular veins were not distended with no evidence of prominent x-wave descent, and paradoxical pulse was not recognized; there was abdominal guarding and rebound with hypoactive bowel sounds. Rectal examination revealed no masses, liver and spleen were normal, and a stool sample was guaiac negative. Laboratory tests showed a leukocyte count of 19 x 10⁹ cells per liter, 85% of which were neutrophils; crea- tinine level was 6.7 mg/dL, and blood urea was 156 mg/dL; electrolytes, amylase, lipase, and liver function tests were normal. An electrocardiogram was also normal, and an emergency computed tomography did not disclose any abnormality except for a large pericardial effusion. A cardiac ultrasonography confirmed this finding and showed signs of an impending cardiac tamponade. We urgently

drained 700 mL of straw-colored pericardial fluid, and abdominal pain along with physical signs of peritonitis completely subsided over a few hours after the procedure. The subsequent course was complicated by sepsis with multiorgan failure, and the patient died on the 33rd day of hospital stay.

Our experience with this case illustrates the important point that patients with a large pericardial effusion that is evolving toward the catastrophic syndrome of cardiac tamponade may present with the clinical features of acute abdomen and peritonitis. We found none of the classic physical signs of tamponade except for faint heart sounds, but this is a rather nonspecific finding because it is also commonly recognized in several different disorders other than cardiac tamponade. Our Medline search yielded 3 other cases of pseudo- acute abdomen associated with cardiac tamponade; 2 of them were children with a purulent pericardial effusion, and the third patient had a rheumatoid pericarditis [2,3].

Mechanisms of pseudo-acute abdomen in our patient may have been related to visceral plethora or liver and Mesenteric ischemia caused by the rapidly progressing cardiac tamponade. The close temporal relationship with the hemodialytic session suggests that a low-pressure tamponade did occur in the setting of relative Volume depletion. Under these circumstances, cardiac output falls at lower ventricular diastolic pressure and hypovolemia would attenuate any compensatory increases in venous blood volume and pressure; this could explain the lack of systemic hypotension, jugular vein distension, and diag- nostic Pulsus paradoxus [4,5]. Other cases of cardiac tamponade with atypical clinical or hemodynamic pre- sentations have been reported, most of which were due to selective chamber compression by loculated fluid or clot [6-10].

Clinical diagnosis of Pericardial tamponade remains a hard challenge and a high index of suspicion is required in the appropriate setting even when classic physical signs are not recognized.

Giuseppe Famularo MD, PhD Giovanni Minisola MD Department of Internal Medicine

San Camillo Hospital 00152 Rome, Italy E-mail address: [email protected]

Claudio De Simone MD Department of Experimental Medicine University of L’Aquila, L’Aquila, Italy

doi:10.1016/j.ajem.2005.05.002

References

1. Jabr FI. intractable vomiting as the initial presentation of pericardial effusion. Am J Emerg Med 2004;22:624.
2. Donnelly LF, Kimball TR, Barr LL. Purulent pericarditis presenting as acute abdomen in children: Abdominal imaging findings. Clin Radiol 1999;54:691 - 3.
3. Kuteifan K, Sechet A, Martin-Barbaz F, Descamps JM. State of shock and abdominal pain revealing tamponade caused by rheumatoid arthritis. Presse Med 1994;23:716.
4. Spodick DH. Physiology of cardiac tamponade. In: Spodick DHThe

pericardium: a comprehensive textbook. New York7 Marcel Dekker; 1997180 - 90.

1. Spodick DH. Pulsus paradoxus. In: Spodick DH, editor. The

pericardium: a comprehensive textbook. New York7 Marcel Dekker; 1997. p. 191 - 9.

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Mitral valve replacement: case presentation with hemodynamic and echocardiographic observations. Catheter Cardiovasc Diagn 1977;3: 297 - 303.

1. Young SG, Gregoratos G, Swain JA, Joyo CI. Delayed postoperative

cardiac tamponade mimicking severe Tricuspid valve stenosis. Chest 1984;85:824 - 6.

1. Russo AM, O’Connor WH, Waxman HL. Atypical presentations and

echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993;104:71 - 8.

1. Vayre F, Lardoux H, Bourdarias JP, Pezzano M, Dubourg O.

Tamponade in patients with systolic left ventricular dysfunction. An atypical presentation. Presse Med 1998;27:567 - 70.

1. Sharma N, Panchal V, Kalaria VG. Atypical hemodynamic manifes-

tations of cardiac tamponade. Catheter Cardiovasc Interv 2004;63: 339 - 45.