Min-Shan Tsai MD Cheng-Chun Hsieh MD Hung-Ren Chen MD

Wen-Jone Chen MD, PhD Chien-Hua Huang MD

Department of Emergency Medicine National Taiwan University Hospital and

College of Medicine Taipei 100, Taiwan

E-mail address: [email protected] doi:10.1016/j.ajem.2006.01.007

References

1. Hsueh PR, Liu YC, So J, et al. Mycobacterium tuberculosis in Taiwan. J Infect 2005 [electronic publication ahead of print].
2. Hadad DJ, Pignatari AC, Machado MA, et al. Mycobacterium tuberculosis bacteremia diagnosed in an HIV-negative patient in Brazil: a rare or an under-reported event? Braz J Infect Dis 2004;8: 184 - 5.
3. Archibald LK, Den Dulk MO, Pallangyo KJ, et al. Fatal Mycobacte- rium tuberculosis Bloodstream infections in febrile hospitalized adults in Dar es Salaam, Tanzania. Clin Infect Dis 1998;26:290 - 6.
4. Kuisma M, Alaspaa A. Out-of-hospital cardiac arrests of non-Cardiac origin: epidemiology and outcome. Eur J Heart 1997;18:1122 - 8.
5. Tsai MS, Chiang WC, Lee CC, et al. Infections in the survivors of out- of-hospital cardiac arrest in the first 7 days. Intensive Care Med 2005; 31:621 - 6.

Malpractice and criminal responsibility in Japan

To the Editor,

Medical malpractice lawsuits in Japan can be tried under either civil, criminal, or administrative law. Not only civil but also criminal lawsuits have been increasing in recent years in Japan. In March last year, both the attending physician and a professor were convicted of negligence in a criminal case on overdosing of an anticancer drug that occurred in a Medical university hospital.

According to a report by the National Police Agency, 183 cases of malpractice were reported to the police by patients or medical institutions last year, 9 times more than the number of cases reported 6 years ago, and an increasing number of cases are being tried [1]. Various measures have been taken by the National Police Agency to deal with the increasing number of malpractice cases. For example, a police team specializing in malpractice cases has recently been set up. Physicians were convicted of negligence in 7 criminal cases last year. All of these cases were simple accidents, such as accidents during surgery (damage to blood vessels or overdose of an anesthetic), administration of an overdose of a drug, and inappropriate insertion of a tube.

Criminal trials of more complex malpractice cases have also been increasing in recent years in Japan. Most criminal cases are cases of negligence during the performance of

duties, but the definition of negligence can also extend to bfailure to execute appropriate procedures.Q Such a case of negligence was recently tried in Japan: a physician was charged with negligence in failing to perform a computed tomography scan on a boy with a chopstick lodged in his throat. The boy was sent home after simple treatment and died the following morning from intracranial damage.

It is rare for physicians in the United States and in European countries to face criminal charges in court for malpractice. This is because cases of malpractice are usually sufficiently dealt with by medical associations and state committees, which have supervisory powers over physicians and play important roles in both protecting and penalizing physicians. Medical licenses can be revoked in serious cases of malpractice. In Japan, the Ministry of Welfare and Labor has administrative powers over physicians, its main duties include penalizing physicians and medical institutions and paying compensation to victims in civil lawsuits. However, penalties handed out by the Japanese Ministry of Welfare and Labor are usually lenient, such as suspension of medical practice for 1 to 3 months in most cases. No medical licenses have been revoked by the ministry in recent cases of malpractice, and physicians involved in some apparently serious cases of malpractice have not been penalized at all. The inability of the Ministry of Welfare and Labor to deal sufficiently with cases of malpractice may result in an increase in criminal lawsuits against physicians in the future. The Japanese Ministry of Welfare and Labor must consider measures to ensure that physicians involved in cases of malpractice are appropriately penalized and to ensure that victims are sufficiently compensated and that measures are taken to prevent reoccurrence of such malpractice. If such measures are not taken by the ministry, the current vicious cycle of overly lenient penalties that are not acceptable for the victims and reoccurrence of the same

accidents will continue.

Takashi Yokota MD, PhD Seiichi Kojima MD Department of Surgery

National Sanatorium Tohoku Shinseien Tome, Miyagi 989-4601, Japan

E-mail address: [email protected]

Shu Kikuchi MD Hidemi Yamauchi MD Department of Surgery Sendai Medical Center Sendai 983-8520, Japan

Masahito Hatori MD Department of Orthopedic Surgery Tohoku University School of Medicine

Sendai 980-8574, Japan

doi:10.1016/j.ajem.2006.01.006

Reference

1. Hashimoto K, Komata R. Doctor and criminal responsibility. Nikkei Medical 2003;32(6):44 - 55.

Postdural puncture headache after lumbar puncture: Do the gauge and the design of a spinal needle matter?

To the Editor,

More than a century has passed since the initial description of the postdural puncture headache (PDPH), also known as the spinal headache [1]; however, this unique clinical entity still remains a disabling complication of needle insertion into the subarachnoid space [2].

There is considerable variability in the incidence of PDPH, which is affected by a number of factors including age, gender, pregnancy, and needle type and size [2,3]. In clinical practice, PDPH may be observed following inten- tional dural puncture associated with the Diagnostic lumbar puncture (DLP), or an unintentional dural puncture during Epidural anesthesia.

It is with interest that I read the recent article by Seupaul et al [4] discussing the prevalence of PDPH in patients undergoing DLP in the emergency medicine departments (EMD). Although I am in agreement with the authors’ find- ings and conclusions, I would like to point out that the issue of (relatively large-gauge) needle choice for DLP is not unique to the EMD settings. Many neurologists still believe that the adequate flow of the cerebrospinal fluid can only be achieved with spinal needles of 22 or larger (eg, 20) gauge [5].

Birnbach et al hypothesized that atraumatic spinal needles are rarely used by members of specialties outside of anesthesiology [5]. A questionnaire, which included items pertaining to age, practice setting, knowledge of pencil-point (atraumatic) spinal needles, and DLP practices, was mailed to all 7798 members of the American Academy of Neurology listed in the membership directory. Only a fraction (2%) of the neurologists surveyed routinely used atraumatic spinal needles. Almost half of the responding neurologists reported having no knowledge of pencil-point spinal needles. Among those who did have knowledge of these new spinal needles, the most common reasons given for not using them were nonavailability and/or expense [5]. The authors concluded that the use of pencil-point spinal needles (a standard of practice among anesthesiologists) has not been widely adopted by neurologists as it may lead to unnecessary morbidity among patients undergoing DLP.

The obstetric patient is at particular risk for PDPH because of sex, young age, pregnancy, and the widespread application of regional anesthesia in this population [2,3]. The incidence of epidural needle-induced PDPH in partu- rients following dural puncture with a large bore (eg, 18- gauge) needle has been reported to range from 76% to 85% [6]. It is also known that symptoms of PDPH are more likely if there has been a preceding PDPH [7].

In our Labor and Delivery suite at the University of California, San Diego, we recently encountered an otherwise healthy parturient at 35 weeks gestation who presented with fever of unknown origin and a history of previous PDPH (specifically post-DLP-headache 14 years ago, which required epidural blood patch to treat severe cephalgia) [8]. Given the above history and a working diagnosis of meningitis, DLP was performed with a 27-gauge Pencan spinal needle. It is noteworthy that DLPs at our institution are routinely performed (by either neurologists or EMD physicians) with 22-gauge spinal needles. Cerebrospinal fluid was obtained on the first attempt; however, it took approximately 15 to 20 minutes to fill the culture vials. No PDPH was reported.

Krzysztof M. Kuczkowski MD Department of Anesthesiology University of California San Diego San Diego, California, USA Department of reproductive medicine University of California San Diego San Diego, CA 92103-8770, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2006.01.018

References

1. Bier A. Versuche uber Cocainisirung des Ruken Markes. Dtsch Z Chir 1989;51:361 - 9.
2. Turnbull DK, Shepherd DB. Post-dural puncture headache: pathogen- esis, prevention and treatment. Br J Anaesth 2003;91:718 - 29.
3. Kuczkowski KM, Benumof JL. Decrease in the incidence of post-dural puncture headache: maintaining CSF volume. Acta Anaesthesiol Scand 2003;47:98 - 100.
4. Seupaul RA, Somerville GG, Viscusi C, et al. Prevalence of postdural puncture headache after ED performed lumbar puncture. Am J Emerg Med 2005;23:913 - 5.
5. Birnbach DJ, Kuroda MM, Sternman D, Thys DM. Use of atraumatic spinal needles among neurologists in the United States. Headache 2001;41:385 - 90.
6. Collier CB. Complications of regional anesthesia. In: Birnbach DJ, Gatt SP, Datta S, editors. Textbook of obstetric anesthesia. New York7 Churchill Livingstone; 2000. p. 504 - 23.
7. Kuczkowski KM, Benumof JL. Once a post-dural puncture headache patient always post-dural puncture headache patient? Acta Anaesthesiol Belg 2003;54:167 - 8.
8. Kuczkowski KM, Hope RD, Eisenmann UB. Diagnostic lumbar puncture in the parturient with history of previous post-lumbar puncture headache. Ann Fr Anesth Reanim 2005;24:70 - 1.

Comment on bIs prehospital blood glucose measure- ment necessary in suspected cerebrovascular accident patients? Q

To the Editor,

We read with interest the recent article by Abarbanell [1] regarding prehospital blood glucose measurement in