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The COVID-19 pandemic has demonstrated that emergency departments (EDs) need to reorganize their operations rapidly. This study investigated the impact of the pandemic on structural and logistical issues at EDs and the measures taken. Belgian EDs were surveyed on the implemented changes at the start of the pandemic in relation to the 4 S's in disaster medicine: Structure, Staff, Supplies, and System. The study demonstrated that Belgian EDs felt largely unprepared for this pandemic, but nevertheless dynamically restructured their organization. A 46% increase in ED beds was created in different types of structures and more than 50% of all ED beds were reserved for COVID-19 care, but overall the number of patient presentations dropped by 29%. EDs deployed extra personnel, additional training, and psychological support. More than 50% reported an acute shortage of personal protective equipment, and several reported a shortage of ventilatory equipment and medications. ispartof: DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS vol:16 issue:5 pages:2194-2197 ispartof: location:United States status: published

Background:Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism.Methods:Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.Results:There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings.Conclusion:Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

Objective:To analyze the evacuation preparedness of hospitals within the European Union (EU).Method:This study consisted of 2 steps. In the first step, a systematic review of the subject matter, according to the PRISMA flow diagram, was performed. Using Scopus (Elsevier, Amsterdam, Netherlands), PubMed (National Library of Medicine, Bethesda, MD), and Gothenburg University´s search engine, 11 questions were extracted from the review and were sent to representatives from 15 European Union (EU)- and non-EU countries.Results:The findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the EU or other non-EU countries in this study. A major shortcoming revealed by this study is the lack of awareness of the untoward consequences of medical decision-making during an evacuation. Some countries did not respond to the questions due to the lack of relevant guidelines, instructions, or time.Conclusion:Hospitals are exposed to internal and external incidents and require an adequate evacuation plan. Despite many publications, reports, and conclusions on successful and unsuccessful evacuation, there is still no common guide for evacuation, and many hospitals lack the proper preparedness. There is a need for a multinational collaboration, specifically within the EU, to establish such an evacuation planning or guideline to be used mutually within the union and the international community.

Introduction Historical changes have transformed Sweden from being an offensive to a defensive and collaborative nation with national and international engagement, allowing it to finally achieve the ground for the civilian–military collaboration and the concept of a total defense healthcare. At the same time, with the decreasing number of international and interstate conflicts, and the military’s involvement in national emergencies and humanitarian disaster relief, both the need and the role of the military healthcare system within the civilian society have been challenged. The recent impact of the COVID-19 in the USA and the necessity of military involvement have led health practitioners to anticipate and re-evaluate conditions that might exceed the civilian capacity of their own countries and the need to have collaboration with the military healthcare. This study investigated both these challenges and views from practitioners regarding the benefits of such collaboration and the manner in which it would be initiated. Material and Method A primary study was conducted among responsive countries using a questionnaire created using the Nominal Group Technique. Relevant search subjects and keywords were extracted for a systematic review of the literature, according to the PRISMA model. Results The 14 countries responding to the questionnaire had either a well-developed military healthcare system or units created in collaboration with the civilian healthcare. The results from the questionnaire and the literature review indicated a need for transfer of military medical knowledge and resources in emergencies to the civilian health components, which in return, facilitated training opportunities for the military staff to maintain their skills and competencies. Conclusions As the world witnesses a rapid change in the etiology of disasters and various crises, neither the military nor the civilian healthcare systems can address or manage the outcomes independently. There is an opportunity for both systems to develop future healthcare in collaboration. Rethinking education and training in war and conflict is indisputable. Collaborative educational initiatives in disaster medicine, public health and complex humanitarian emergencies, international humanitarian law, and the Geneva Convention, along with advanced training in competency-based skill sets, should be included in the undergraduate education of health professionals for the benefit of humanity.

IntroductionChildren, with their specific vulnerabilities and needs, make up to more than 20% of society, so they are at risk of getting involved in disasters. Are the specialists treating them for medical problems in daily life also capable to deal with them in disaster situations?Hypothesis/ProblemThe goals of this study were to evaluate perceived knowledge and capability of tertiary pediatricians to deal with disasters, to identify promoting factors, and to evaluate education need and willingness to work.MethodsA survey looking for demographics, hospital disaster planning, estimated risk and capability for disasters, training, and willingness to work, and a set of six content assessment questions to evaluate knowledge, were presented to emergency pediatricians and pediatric emergency physicians in specialized tertiary centers.ResultsThe response rate was 51%. Thirty-five percent had disaster training and 53% felt that disaster education should be obligatory in their curriculum. Risk for disasters was estimated from 2.4/10 for nuclear incidents to 7.6/10 for major trauma. Self-estimated capability for these situations ranged from 1.8/10 in nuclear incidents to 7.6/10 in major trauma. Unconditional willingness to work ranged from 37% in nuclear situations to 68% in pandemics. Mean score on the questions was 2.06/6. Training, knowledge of antidote and personal protective equipment (PPE) use, self-estimated capability, and exposure were significant predictors for higher scores. Willingness to work correlated significantly with age, self-estimated capability, and risk estimation. In case of chemical and nuclear incidents, there was correlation with knowledge on the use of decontamination, PPE, and radio-detection devices.ConclusionDespite a clear perception of the risks and a high willingness to work, preparedness is limited. The major conclusion is that basics of disaster management should be included in pediatric training.MortelmansLJM, MaebeS, DieltiensG, AnseeuwK, SabbeMB, Van de VoordeP. Are tertiary care paediatricians prepared for disaster situations?Prehosp Disaster Med. 2016;31(2):126–131.

IntroductionBeing one of Europe’s most densely populated countries, and having multiple nuclear installations, a heavy petrochemical industry, and terrorist targets, the Netherlands is at-risk for chemical, biological, or radionuclear (CBRN) incidents. Recent world and continental events show that this threat is real and that authorities may be underprepared.HypothesisThe hypothesis of this study is that Dutch hospitals are underprepared to deal with these incidents.MethodsA descriptive, cross-sectional study was performed. All 93 Dutch hospitals with an emergency department (ED) were sent a link to an online survey on different aspects of CBRN preparedness. Besides specific hospital information, information was obtained on the hospital’s disaster planning; risk perception; and availability of decontamination units, personal protective equipment (PPE), antidotes, radiation detection, infectiologists, isolation measures, and staff training.ResultsResponse rate was 67%. Sixty-two percent of participating hospitals were estimated to be at-risk for CBRN incidents. Only 40% had decontamination facilities and 32% had appropriate PPE available for triage and decontamination teams. Atropine was available in high doses in all hospitals, but specific antidotes that could be used for treating victims of CBRN incidents, such as hydroxycobolamine, thiosulphate, Prussian blue, Diethylenetriaminepentaacetic acid (DTPA), or pralidoxime, were less frequently available (74%, 65%, 18%, 14%, and 42%, respectively). Six percent of hospitals had radioactive detection equipment with an alarm function and 22.5% had a nuclear specialist available 24/7 in case of disasters. Infectiologists were continuously available in 60% of the hospitals. Collective isolation facilities were present in 15% of the hospitals.Conclusion:There is a serious lack of hospital preparedness for CBRN incidents in The Netherlands.MortelmansLJM, GaakeerMI, DieltiensG, AnseeuwK, SabbeMB. Are Dutch hospitals prepared for chemical, biological, or radionuclear incidents? A survey study. Prehosp Disaster Med. 2017;32(5):483–491.

OBJECTIVE: As one of Europe's most densely populated countries with multiple nuclear installations and a prominent petrochemical industry, Belgium is at some reasonable risk for terrorist attacks or accidental chemical, biological, radiation, and nuclear (CBRN) incidents. We hypothesize that local hospitals are not sufficiently prepared to deal with these incidents. MATERIALS AND METHODS: All 138 Belgian hospitals with an emergency department (ED) were sent a survey on their preparedness. Data on hospital disaster planning, risk perception, availability of decontamination units, personal protective equipment, antidotes, radiation detection, infectiologists, isolation measures, and staff training were collected. RESULTS: The response rate was 72%. Although 71% of hospitals reported being at risk for CBRN incidents, only 53% planned for the same in their disaster plans. Only 11% of hospitals had decontamination facilities in front of or at the ED entrance and only 6% had appropriate personal protective equipment for triage and decontaminating teams. Atropine was available at all centers, but more specific antidotes such as hydroxycobolamine, thiosulphate, or pralidoxime were less available (47, 47, and 19%, respectively). Six percent of hospitals had radiodetection equipment with an alarm function and 14% had a nuclear specialist available 24/7. Infectiologists were continuously available in 26% of the total EDs surveyed. Individual isolation facilities were present in 36% of the EDs, and isolation facilities capable of housing larger groups were present in 9%. University hospitals were significantly better prepared than community hospitals. CONCLUSION: There are serious gaps in hospital preparedness for CBRN incidents in Belgium. Lack of financial resources is a major obstacle in achieving sufficient preparedness. Language: en

OBJECTIVES: A mass carbon monoxide (CO) intoxication during an ice-hockey game is described. Two hundred and thirty-five patients were seen in different hospitals, 88 of them the same night at the nearby emergency department. To evaluate long-term implications and to identify relevant indicators, a follow-up study was organized 1 year after the incident. METHODS: Apart from the file data from the emergency departments, a 1-year follow-up mailing was sent to all patients. RESULTS: One hundred and ninety-one patients returned their questionnaire (86%). The mean age of the patients was 28 years, with 61% men. The mean carboxyhaemoglobin (COHb) was 9.9%. COHb levels were significantly higher for individuals on the ice (referee, players and maintenance personnel). There was a significant relationship with the initial presence of dizziness, fatigue and the COHb level. Headache, abdominal pain, nausea and vomiting were not significantly related to the COHb levels. The relationship between symptoms and CO level, however, should be interpreted with caution as there was a wide range between exposure and blood tests. 5.2% of patients had residual complaints, all including headache, with a significant higher incidence with high COHb levels. Only two patients had an abnormal neurological control (one slightly disturbed electroencephalography and one persistent encephalopathic complaint). Work incapacity was also significantly related to COHb levels. CONCLUSION: CO mass poisonings remain a risk in indoor sporting events. Although it causes an acute mass casualty incident, it is limited in time and delayed problems are scarce. Symptomatology is a poor tool for triage. The best prevention is the use of nonmineral energy sources such as for example electricity. Language: en

In recent years, the world has been rocked repeatedly by terrorist attacks. Arguably, the most remarkable were: the series of four coordinated suicide plane attacks on September 11, 2001 on buildings in New York, Virginia, and Pennsylvania, USA; and the recent series of two coordinated attacks in Brussels (Belgium), on March 22, 2016, involving two bombings at the departure hall of Brussels International Airport and a bombing at Maalbeek Metro Station located near the European Commission headquarters in the center of Brussels.This statement paper deals with different aspects of hospital policy and disaster response planning that interface with terrorism. Research shows that the availability of necessary equipment and facilities (eg, personal protective clothing, decontamination rooms, antidotes, and anti-viral drugs) in hospitals clearly is insufficient. Emergency teams are insufficiently prepared: adequate and repetitive training remain necessary.Unfortunately, there are many examples of health care workers and physicians or hospitals being targeted in both political or religious conflicts and wars. Many health workers were kidnapped and/or killed by insurgents of various ideology. Attacks on hospitals also could cause long-term effects: hospital units could be unavailable for a long time and replacing staff could take several months, further compounding hospital operations. Both physical and psychological (eg, posttraumatic stress disorder [PTSD]) after-effects of a terrorist attack can be detrimental to health care services. On the other hand, physicians and other hospital employees have shown to be involved in terrorism. As data show that some offenders had a previous history with the location of the terror incident, the possibility of hospitals or other health care services being targeted by insiders is discussed.The purpose of this report was to consider how past terrorist incidents can inform current hospital preparedness and disaster response planning.De CauwerH,SomvilleF,SabbeM,MortelmansLJ.Hospitals: soft target for terrorism?Prehosp Disaster Med.2017;32(1):94–100.

Medical care systems will be overwhelmed if a human H5N1 pandemic should occur. Several national disaster plans, including that of Belgium, focus on maximal treatment at home with senior medical students supporting frontline care. To evaluate the knowledge and preparedness of Belgian senior medical students, an e-mail survey of senior medical students (last two years of education) attending Flemish universities was conducted.A total of 243 students (30%) replied. Only 21.8% of them were aware of the possibility of being involved in this planning. A total of 77.4% estimated H5N1 to be a possible threat to national health. Seventy percent of respon-dents reacted positively towards the idea of being involved in implementing primary care, and only 9.5% were absolutely opposed to the idea. A total of 82.3% would care for pandemic patients if necessary, but only 41.2% would do so if these patients were children. Only 18.9% estimated themselves to be suf-ficiently educated regarding H5N1. Ninety-one percent were convinced that care for H5N1-influenza patients should be incorporated into their regular curriculum. Several antiviral products were reported by the students to be effi-cient for treating H5N1, but only 34.6% correctly chose oseltamavir and/or zanamavir and 35.4% replied “I don't know”. A total of 95.5% correctly answered that the regular influenza vaccination doesn't protect against H5N1. The risk for human-to-human transmission was rated to be small by 50.6% (none 21%, high 27.6%). The human infection risk was rated to be small by 74.1% (none 1.6%, high 23%).There is a high level of willingness to participate among senior medical students. However, in the case of pediatric patients they're more reserved. It would be useful to incorporate a focused session on preparedness in the regular teaching program. A legal base for their actions should also be provided. Ethical guidelines on rights and duties in case of a pandemic should be prepared by an international, multidisciplinary group of experts.

The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful 'bedside' decision-making tool, based on laboratory results readily available at the emergency department.Retrospective study design. Analysis of a consecutive series of all children (age 0-15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005.Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a 'bacterial meningitis score' based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics.We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.

Clearing the cervical spine after blunt trauma remains a challenge. Even in the computed tomography era many emergency departments worldwide still use classical X-rays in first evaluation. Low odontoid fractures are frequently missed, especially in unconscious patients where an open mouth view is not available. Evaluation of the Harris ring in the lateral view can improve identification rate. We studied the diagnostic values of this sign and the educational effect on trainees. Lateral views of 12 computed tomography confirmed low-axis fractures and 13 controls were randomly presented to 17 residents (traumatology, neurosurgery and emergency medicine) and five experienced radiologists. After the residents were taught the use of the axis ring, they had to review the set. Diagnosis was scored with a degree of certitude from 5 to 1. The specificity and sensitivity for the radiologists was 88% (confidence interval 80-96) and 82% (confidence interval 72-91), respectively. The effect of the education on the scores of the residents was evaluated using the Wilcoxon ranking test with a significant effect for the traumatologists (P=0.0008), emergency physicians (P=0.0005) as well for the neurosurgeons (P=0.0087). The axis ring can be a useful diagnostic tool in identifying low odontoid fractures on cross-table cervical spine X-rays. It is easy to teach and should be included in X-ray-based C-spine clearing protocols.

Virulent airborne diseases can be a real burden to a nation's health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission.A survey aimed at determining 'availability and preparedness' was sent by e-mail to the different Belgian Emergency Departments.Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.

Diaphragmatic rupture is an uncommon and frequently missed complication in blunt thoraco-abdominal trauma. Symptoms usually become apparent in a delayed phase, up to years after the trauma. An acute presentation is extremely rare and acute tension gastrothorax in which trapping of air in the intrathoracic stomach causes mediastinal shift and lung compression, as in tension pneumothorax, is exceptional. We only found two cases in the literature. We present here two other cases from our practice, with a review on the literature on post-traumatic diaphragmatic hernias.

Two regional hospitals were struck by lightning during a one-month period. The first hospital, which had 236 beds, suffered a direct strike to the building. This resulted in a direct spread of the power peak and temporary failure of the standard power supply.The principle problems, after restoring standard power supply, were with the fire alarm system and peripheral network connections in the digital radiology systems. No direct impact on the hardware could be found. Restarting the servers resolved all problems. The second hospital, which had 436 beds, had a lightning strike on the premises and mainly experienced problems due to induction. All affected installations had a cable connection from outside in one way or another. The power supplies never were endangered. The main problem was the failure of different communication systems (telephone, radio, intercom, fire alarm system). Also, the electronic entrance control went out. During the days after the lightening strike, multiple software problems became apparent, as well as failures of the network connections controlling the technical support systems. There are very few ways to prepare for induction problems. The use of fiberoptic networks can limit damage. To the knowledge of the authors, these are the first cases of lightning striking hospitals in medical literature.

The appropriateness of family witnessing resuscitation (FWR) is an ethical dilemma with most emergency care providers being opponents. We hypothesized that patients and their families prefer to witness resuscitation of their loved ones.One hundred and fifty patients treated for potential life-threatening conditions in our emergency department were presented with a survey on FWR in the reconvalescence phase. They were asked to give their opinion supposing their situation had worsened, requiring a resuscitation effort. Their closest relatives were asked to complete a related questionnaire.Mean age was 67 years (patient group) and 55 years (relatives group). Fifty-eight percent of the patients were males with only 33% males in the relatives group. Seventy-two percent of the patients preferred the presence of a relative during resuscitation, although 35% estimate that this could be quite a traumatic experience. Forty-one percent had a history of serious medical problems. In the relatives group, 75% expressed their wish to stay with their loved ones and 49% did not fear that this would be too traumatic. There was a good match in patient and family attitude towards FWR (P0.001). Relatives of a patient with a serious medical history were significantly more in favour of FWR (P0.01).Our study showed that patients and relatives preferred family presence in emergency department during resuscitation, even when the fear of traumatic effects is considered. It will be a great challenge training emergency care providers for this situation. Staff shortages might compromise the essential support of family members in such situations.

Objective To assess the opinion of Belgian Emergency Department (ED) staff regarding family-witnessed resuscitation (FWR). Methods All 142 Belgian EDs were sent a questionnaire on hospital-related data and personal questionnaires for the ED staff concerning their opinion on FWR. Opinions of physicians, nurses and other emergency care providers were compared and related with hospital or sociodemographic data. Results Eighty-five ED services (60%) responded with a total of 1143 personal questionnaires: of these 79% were nurses, and 19% physicians. Eighty percent of the hospitals had a prehospital intervention team. Only two departments (2.5%) practiced structured FWR; 21% put the relatives in the corridor. Eleven percent did not give any information at all to relatives. Fourteen percent organized 'training in coping with relatives'. Forty-one percent of the staff members had been asked for FWR but only 33% were positive about it. Fifty-six percent thought that relatives could be of use in the shock room. Sixty-six percent experienced it as a burden. Sixty-five percent thought that FWR helps in grieving but 93% feared traumatic distress. Sixty-four percent would like to attend the resuscitation of their own relatives. Thirty-five percent fear a high risk of complaints. Prehospital experience, higher workload, seniority and male staff are significant advantages towards FWR. Emergency physicians are more positive towards FWR, nurses less so, followed by other physicians. Conclusion The Belgian ED staff is still unconvinced about FWR. Despite evidence-based data they still think that resuscitation is traumatizing for relatives. Experience, both in as well as out of hospital, is a positive factor.

We describe a case of epileptic seizures after a massive intake of diet coke. Apart from the hyponatremia due to water intoxication the convulsions can be potentiated by the high dose of caffeine and aspartame from the diet coke. To our knowledge this is the first report of seizures due to excessive diet coke intake.

The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs.To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department.In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result.The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros.In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result.

Although exercise-induced hematuria is a well known finding in long distance running, it is extremely rare in cycling. We describe a case of gross atraumatic hematuria after mountainbiking. The only pathologic finding in our patient was a small hyperemic zone in the bladder mucosa suggesting a local traumatic origin due to repeated contact of the flaccid bladder wall against the bladder base. This in contrast with the renal origin commonly seen in marathon runners. It is a benign hematuria that usually resolves within a day without specific treatment. The best treatment is prevention by means of good bladder filling. Neoplasm of the urothelium should be ruled out in differential diagnosis.

Ecstasy is a very popular and widely used party drug with known complications such as agitation, hyperpyrexia, rhabdomyolysis or renal failure. A 16-year-old boy was admitted to our Emergency Department with a spontaneous pneumomediastinum (SPM) after Ecstasy ingestion, complicated by myocarditis. To our knowledge this is the first case described with the combination of Ecstasy ingestion, SPM and myocarditis. Although SPM is well known in inhalation drug users who try to enhance alveolar resorption with repeated valsalva manoeuvres, it is rather rare after the ingestion of party drugs. The probable causative event is the prolonged and excessive dancing in this party drug culture. The course is usually benign, with spontaneous resorption. Emergency physicians should be aware of the risk, especially if a drug user presents with neck emphysema, difficulty in swallowing, and precordial crepitations or thoracic pain. Ecstasy, similarly to cocaine, can induce cardiac symptoms.

Personal experience and reports of colleagues made the authors aware of a possible problem of carbon monoxide exposure in indoor carting arenas. Symptoms such as nausea, headache and altered coordination are not uncommon. This prompted us to register carbon monoxide levels in 15 healthy volunteers in a recreational carting event in a random arena. After two sessions of 10 min and a finale of 20 min we measured a clear increase in carboxyhaemoglobin levels, up to a 16.5-fold increase. The mean rise in the carboxyhaemoglobin level (expressed as a percentage) was 2.06 (mean start carboxyhaemoglobin 0.49%, mean end carboxyhaemoglobin 2.55%). Nausea was noted in 53% of the drivers, headache and altered coordination in 33%, and 13% had a vague abdominal pain. The effects of carbon monoxide exposure during indoor carting should thus not be underestimated, and healthcare workers should be aware of the possible risks.

Objective: To present our experience of diagnosing fractures of the odontoid process on lateral radiographs of the cervical spine that show the Harris (axis) ring. Design. Retrospective study. Setting: Teaching hospital, Belgium. Subjects: 12 patients with multiple injuries, including cervical spine, 8 of them unconscious or uncooperative. Interventions: Cross table lateral view of the cervical spine. Main outcome measure: Identification of otherwise hidden type 3 axial fractures. Results: Diagnosis of low odontoid fractures in all cases. Conclusion: The Harris ring is disrupted in low odontoid fractures and intact in fractures of the odontoid process. Awareness of this sign will allow diagnosis of otherwise hidden axial fractures.