Adjustment of roster acco”>Correspondence

More about the adjustment of roster according to ED census

To the Editor,

In “Regarding the Adjustment of Roster According to ED census,” the author has rightly pointed out that a solution to ED overcrowding cannot be solely be the responsibility of the ED but must involve addressing issues like lack of physical space in the ED, excessive Boarding of patients in the ED, limitation of in-Hospital beds leading to hospital bed- block, and other Hospital administrative issues. We agree wholeheartedly with this sentiment.

Having said this, it is my personal conclusion that for such arguments to have weight, we in the emergency medicine community must also be seen to be willing to do what it takes to address the issue of overcrowding. In a modern 24/7 society, the ED can no longer be seen as an “office hours” facility but rather a 24/7 service, just like police, fire, emergency medical service, and other emergency services. Thus, the reality of needing different types of shifts and adjustED shift hours is but a logical step forward. What are needed are adequate compensation, incentives, and “hard- ship” adjustments like overtime pay, shift allowance, or “off- in-lieu” to make it work. Most important is Hospital administration recognition and support for the vital role that the ED plays as a 24/7 emergency care provider.

I would even venture to say that perhaps it is time for inpatient services to reconsider the traditional way things are run in the wards. It is all too often that wards are running on skeletal staff after office hours, yet this is precisely when the most experienced and senior physicians are needed to make critical decisions for acutely ill patients.

Marcus Eng Hock Ong MD Department of Emergency Medicine Singapore General Hospital

169608 Singapore E-mail address: [email protected]

doi:10.1016/j.ajem.2009.01.008

The effect of pulmonary contusions on Lung sliding during bedside ultrasound

To the Editor,

Ultrasound is highly sensitive for ruling out a pneu- mothorax in Supine patients by identifying lung sliding, a to- and-fro movement along an echogenic line observed when the visceral pleura slides on the parietal pleura during respiration (Fig. 1) [1-4]. However, concern exists that the presence of pulmonary contusions may affect lung sliding and limit the usefulness of ultrasound to exclude a

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Fig. 1 Sagittal still image of a hyperechoic pleural line (arrow) and 2 ribs (*). Lung sliding can be observed as to-and-fro movement along the pleural line.

pneumothorax under these circumstances [3]. We sought to investigate in a pilot study the potential influence of pulmonary contusions on lung sliding.

This was a prospective, observational study performed in the emergency department of a level 1 trauma center in Ohio over a 6-month period. A convenience sample of blunt trauma patients with suspected pulmonary contusions under- went bedside ultrasonography of the chest during their initial evaluation in the emergency department. Patients were imaged by 4 emergency physicians with significant ultra- sound experience.

All patients were scanned with a Philips Envisor HD ultrasound system (Philips Medical Systems, Bothell, WA) with a linear (12-3 MHz) or a curvilinear (5-2 MHz) transducer. The protocol included sonographic evaluation of the anterior and lateral chest. B-mode ultrasound clips of the right and left hemithorax were recorded in real time. Patients were enrolled in the study if subsequent computed tomography (CT) of the chest demonstrated pulmonary contusions without associated pneumothorax based on attending radiologist interpretation. Video clips of each hemithorax were independently reviewed for presence of lung sliding by 3 emergency physicians with significant ultrasound experience who were blinded to both the CT results and the video clip interpretation of the other reviewers. The absence of lung sliding for the entire hemithorax was defined as any area without lung sliding in that hemithorax. Reviewers were also permitted to comment on any additional B-mode findings. Patients’ charts were reviewed for Demographic and clinical data. Written consent