at university hospitals are staffed with interns, Emergency residents, and residents from various other specialties. RECs of nonuniversity hospitals are staffed with physicians from other specialties or general practitioners. Most AECs have no full-time physician in the ED. When a patient arrives at the ED, interns or nurses first see the patient and notify the emergency medicine resident. Emergency medicine residents provide immediate care and consult with residents from other specialties. Senior emergency physicians are also involved in patient care and supervise the emergency medicine residents. Many EDs have no triage area. Currently, continuous quality-improvement activities are very limited in emergency medicine. Also, without a designated organization to develop guidelines and educate lay people, there are no active educational programs.

The emergency medical system in Korea is still under development. Currently, only a basic framework for an emergency medical system is in existence. To provide an optimal level of emergency care, there is a need to increase the number of emergency personnel and implement medical control oversight for the EMSS. Furthermore, efforts to improve the quality of the EMS such as public education, continuous quality improvement, and development of a national database or registry are required. Although faced with many tasks and challenges, the future of the Korean EMSS is bright, especially with the continuing support of the government and the concern of the Korean people in emergency medicine.

Sung Oh Hwang MD Department of Emergency Medicine Wonju College of Medicine

Yonsei University Wonju, Korea

Christopher C. Lee MD Adam J. Singer MD

Department of Emergency Medicine Stony Brook University Hospital Stony Brook, NY 11794, USA

E-mail address: christolee@notes.cc.sunysb.edu

Tae Min Kim EMT-P

Department of Paramedic Education

Cheju Halla College

Cheju, Korea

doi:10.1016/j.ajem.2006.12.015

References

1. Alnold JL, Song HS, Chung JM, et al. The recent development of emergency medicine in South Korea. Ann Emerg Med 1998;32:730 – 5.
2. Kim Y, Jung KY. Utility of the international classification of diseases injury severity score: detecting Preventable deaths and

comparing the performance of emergency medical centers. J Trauma 2003;54:775 – 80.

1. Lee CC, Im M, Suh GJ. Time for change: the state of emergency medical services in South Korea. Yonsei Med J 2006;47:587 – 8.

Technetium Tc 99m methylene diphosphonate bone scintigraphy of rhabdomyolysis after near-drowning in cold seawater

To the Editor,

Because a variety of conditions can lead to rhabdomyol- ysis, it may be difficult to determine the disease’s cause. Especially in cases of rhabdomyolysis due to Near drowning in cold water, establishing the cause is more difficult because rhabdomyolysis can occur due to pneumonia, hypothermia, cold exposure without hypothermia, ischemia, and exercise while drifting [1-4]. We present a case of rhabdomyolysis after near drowning in cold seawater, in which case, technetium Tc 99m methylene diphosphonate bone scintigraphy was helpful in determining cause, severity, and treatment policy. Tc 99m methylene diphosph- onate bone scintigraphy has been reported as helpful in cases of rhabdomyolysis in several settings [5-7], and to our knowledge, this is the first report regarding Tc 99m methylene diphosphonate bone scintigraphy of rhabdomyol- ysis associated with near-drowning.

A 63-year-old man was transferred to our hospital from a regional hospital after experiencing near drowning. He had been shipwrecked and had drifted while holding a buoy for 3 hours in cold seawater before being rescued. The temperature of the seawater was 158C (598F). He had shaking chills and had aspirated a small amount of water. He neither lost consciousness nor needed cardiopulmonary resuscitation at the time of rescue. On initial examination in the emergency department 10 hours after the rescue, he was found to have an axillary temperature of 36.68C (97.98F), a pulse of 76/min, and a blood pressure of 116/70 mm Hg. His consciousness was clear. He felt slight discomfort of the left axilla because he had been holding the buoy for 3 hours. Laboratory examination of blood revealed serum creatine kinase, 5135 IU/L; Na, 139 mEq/L; K, 4.2 mEq/L; chloride, 100 mEq/L; blood urea nitrogen, 15 mg/dL; and creatinine, 0.6 mg/dL. We arrived at a diagnosis of rhabdomyolysis because of increased serum creatine kinase and performed Tc 99m methylene diphosphonate bone scan to estimate the severity and distribution of rhabdomyolysis and to speculate its cause. Because scintigram, performed 4 hours after injection of Tc 99m methylene diphosphonate, showed slightly increased uptake in the left shoulder region (Fig. 1A), we considered that rhabdomyolysis was due to the exercise involved in clinging to the buoy, and the prolonged exposure to the cold water or its aspiration were not the major cause of rhabdomyolysis, and that the disease in this case was not severe. Damage of the left

Fig. 1 Scintigram performed 4 hours after injection of 740 MBq (20 mCi) Tc 99m methylene diphosphonate showed slightly increased uptake in the left shoulder region (arrows, A) and no massive uptake. Damage of the left subscapular muscle and no bone injury are confirmed by magnetic resonance imaging; the left subscapular muscle demonstrated isointensity on T1-weighted image (arrow, B) and high intensity on T2-weighted image (arrow, C).

subscapular muscle and no bone injury were confirmed by magnetic resonance imaging (Fig. 1B and C). After moderate hydration and diuretic therapy without hemodi- alysis, his serum creatine kinase level decreased to normal. Although he developed acute pneumonia, he recovered subsequently and was discharged without any symptoms after 14 days.

We believe that 2 diagnostic issues regarding rhabdo- myolysis associate with near-drowning remain, and that Tc 99m methylene diphosphonate bone scintigraphy can resolve these issues. One issue regards the cause of rhabdomyolysis. Because a variety of conditions includ- ing Crush injury; burns; infections; metabolic, inflamma- tory, and autoimmune muscle disease; medications; drugs; toxic; hypothermia; ischemia; and exercise can lead to rhabdomyolysis, it may be difficult to establish the cause of the disease. Especially in cases of rhabdomyolysis due to near drowning in cold water, determining the cause is more difficult because rhabdomyolysis can occur due to aspiration of water, hypothermia, cold exposure without hypothermia, ischemia, or exercise while drifting [1-4]. We believe that consideration of circumstantial evidence and findings of Tc 99m methylene diphosphonate scintigraphy are helpful for determining the cause of rhabdomyolysis even in cases of near drowning. Another issue regards the estimation of the severity of rhabdo- myolysis. This may be difficult in cases of near drowning because rhabdomyolysis can progress after the initial

evaluation [1-4]. Because Tc 99m methylene diphospho- nate bone scintigraphy has been reported as helpful in the estimation of the severity of rhabdomyolysis in several settings [5-7], we believe that taking into account the extent and degree of Tc 99m methylene diphosphonate is also helpful for estimating the severity of rhabdomyolysis in cases of near drowning. In addition, Tc 99m methy- lene diphosphonate bone scintigraphy can be performed repeatedly without adverse reaction in cases of rhabdo- myolysis developed later, although our patient did not develop Severe rhabdomyolysis and did not require repeated study. In conclusion, Tc 99m methylene diphosphonate bone scintigraphy should be performed in patients who are suspected of having rhabdomyolysis due to near drowning to obtain an accurate and objective evaluation of the distribution and severity of muscle damage and to aid in establishing the cause.

Naoya Yama MD Kazumitsu Koito MD, PhD Kenji Fujimori MD, PhD Masato Hareyama MD, PhD Department of Radiology School of Medicine

Sapporo Medical University Sapporo 060-8543, Japan

E-mail address: nyama@sapmed.ac.jp

Seiji Yoneta MD Satoshi Nara MD

Yoshihiko Kurimoto MD, PhD Eichi Narimatsu MD, PhD Yasufumi Asai MD, PhD Department of Traumatology and

Critical Care Medicine School of Medicine Sapporo Medical University Sapporo 060-8543, Japan

doi:10.1016/j.ajem.2006.11.049

References

1. Lester JL. Rhabdomyolysis: a late complication of near-drowning. J Emerg Nurs 2002;28:280 – 3.
2. Agar JWM. Rhabdomyolysis and acute renal failure after near drowning in cold salt water. Med J Aust 1994;161:686 – 7.
3. Bonnor R, Siddiqui M, Ahuja TS. Rhabdomyolysis associated with near-drowning. Am J Med Sci 1999;318:201 – 2.
4. Hegde SN, Anupama YJ. Acute renal failure secondary to rhabdo- myolysis following near-drowning in sea water. J Assoc Physicians India 2003;51:512 – 3.
5. Kaida H, Ishibashi M, Nishida H, et al. Rhabdomyolysis induced by psychotropic drugs. Clin Nucl Med 2005;30:569 – 70.
6. Murray IPC, Mansberg VJ, Rossleigh MA. Intense muscle uptake of Tc-99m MDP and Ga-67 citrate in massive rhabdomyolysis. Clin Nucl Med 1997;22:463 – 6.
7. Bykov S, Garty I, Ahnaider A. Bilateral triceps rhabdomyolysis: an incidental finding on bone scintigraphy. Clin Nucl Med 2004;29: 110 – 1.

The Alvarado score and antibiotics therapy as a corporate protocol versus conventional clinical management: randomized controlled pilot study of approach to acute appendicitis^B

To the Editor,

Acute appendicitis is one of the most common Surgical emergencies [1]. Instinctively, antibiotics can postpone emergency operation [2]. Adding span of time in Nonoperative management of appendicitis, antibiotics ensure that surgeons observe the patients for a more extended time. This study aimed to compare incorporating the Alvarado score and outpatient antibiotics with conven- tional clinical management.

This randomized controlled pilot study was approved by the ethics committee and financially supported by a research grant of 22-Bahman Hospital, Masjedsoleiman, Iran. It was carried out from September 1, 2005, to December 15, 2005, on 42 eligible consecutive patients referred to the emergency service with impermanent diagnosis of acute appendicitis.

B This investigation received technical and financial support from the Department of Surgery, 22-Bahman Hospital, Masjedsoleiman, Iran.

Patients were included if they were older than 6 years and admitted initially for the current abdominal pain. They were excluded if they had evidence of generalized peritonitis; were suspected of having any Abdominal mass or any abdominal involvement of degenerative or systemic dis- eases; had evidence of any mental disturbances, acute confusional state, or dementia; had already had any imaging document including Plain radiography, ultrasonography, or computed tomographic scan; or if patients, children’s parent(s), or admitting surgeon repudiated entry into the study. Written informed consent was obtained for enrollment to the study. The patients were randomized according to a computer-generated randomization list into case and control group. The Alvarado score (Table 1) [3] was calculated for both groups by a general practitioner not involved in other stages of the study. The Alvarado scores of the patients in the control group were not known to the admitting service and surgical team. They continued with conventional clinical assessment and management. The admitting service and the surgical team were informed of the Alvarado scores of patients in the case group. Afterward, patients of the case group were divided into 3 management subgroups according to their own Alvarado scores [4]:

Subgroup 1–Alvarado score 4 or less. Discharge, no follow up

Subgroup 2–Alvarado score 5 to 7. Outpatient antibiotics and observation if practicable They were prescribed one dose of intravenous gentamicin, 6 mg/kg, and metronidazole, 500 mg for adults or 15 mg/kg as a loading dose for children. Afterward, patients were discharged on a 10-day course of co-amoxiclav 625 tablets 3 times daily for adults and oral suspension of co-amoxiclav 312.5, 25 mg/(kg d) in divided doses every 8 hours for children (Farabi Pharmaceutical Co, Isfahan, Iran). They were asked to attend 1 day in the clinic.

Subgroup 3–Alvarado score 8 to 10. Immediate opera- tion. They were immediately arranged to undergo emergency surgery after intravenous injection of antibiotics loading dose as men- tioned above.