A controversial term first described by Saunders and Harbaugh1 in 1984, Second Impact Syndrome (SIS) consists of two events. Typically, it involves an athlete suffering post-concussive symptoms following a head injury.2 If, within several weeks, the athlete returns to play and sustains a second head injury, diffuse cerebral swelling, brain herniation, and death can occur. SIS can occur with any two events involving head trauma. While rare, it is devastating in that young, healthy patients may die within a few minutes. Emergency physicians should be aware of this syndrome and counsel patients and their parents concerning when to allow an athlete to return to play. Furthermore, we present guidelines for appropriate follow up and evaluation by a specialist when necessary.

[WestJEM. 2009;10:6-10.]

As recent events highlight, a global requirement exists for evidence-based training in the emerging field of Disaster Medicine. The following is an example of an International Disaster Medical Sciences Fellowship created to fill this need. We provide here a program description, including educational goals and objectives and a model core curriculum based on current evidence-based literature. In addition, we describe the administrative process to establish the fellowship. Information about this innovative educational program is valuable to international Disaster Medicine scholars, as well as U.S. institutions seeking to establish formal training in Disaster Medical Sciences.

[West J Emerg Med. 2009;10(4):213-219]

Objectives: To assess current medical staffing levels within the Hospital Referral System in the City of Cape Town Metropolitan Municipality, South Africa, and analyze the surge capacity needs to prepare for the potential of a conventional mass casualty incident during a planned mass gathering.

Methods: Query of all available medical databases of both state employees and private medical personnel within the greater Cape Town area to determine current staffing levels and distribution of personnel across public and private domains. Analysis of the adequacy of available staff to manage a mass casualty incident.

Results: There are 594 advanced pre-hospital personnel in Cape Town (17/100,000 population) and 142 basic pre-hospital personnel (4.6/100,000). The total number of hospital and clinic-based medical practitioners is 3097 (88.6/100,000), consisting of 1914 general physicians; 54.7/100,000 and 1183 specialist physicians; 33.8/100,000. Vacancy rates for all medical practitioners range from 23.5% to 25.5%. This includes: nursing post vacancies (26%), basic emergency care practitioners (39.3%), advanced emergency care personnel (66.8%), pharmacy assistants (42.6%), and pharmacists (33.1%).

Conclusion: There are sufficient numbers and types of personnel to provide the expected ordinary healthcare needs at mass gathering sites in Cape Town; however, qualified staff are likely insufficient to manage a concurrent mass casualty event. Considering that adequate correctly skilled and trained staff form the backbone of disaster surge capacity, it appears that Cape Town is currently under resourced to manage a mass casualty event. With the increasing size and frequency of mass gathering events worldwide, adequate disaster surge capacity is an issue of global relevance.

[West J Emerg Med. 2010; 11(2):189-196.]

Emergency department (ED) crowding is a multifactorial problem, resulting in increased ED waiting times, decreased patient satisfaction and deleterious domino effects on the entire hospital. Although difficult to define and once limited to anecdotal evidence, crowding is receiving more attention as attempts are made to quantify the problem objectively. It is a worldwide phenomenon with regional influences, as exemplified when analyzing the problem in Europe compared to that of the United States. In both regions, an aging population, limited hospital resources, staff shortages and delayed ancillary services are key contributors; however, because the structure of healthcare differs from country to country, varying influences affect the issue of crowding. The approach to healthcare delivery as a right of all people, as opposed to a free market commodity, depends on governmental organization and appropriation of funds. Thus, public funding directly influences potential crowding factors, such as number of hospital beds, community care facilities, and staffing. Ultimately ED crowding is a universal problem with distinctly regional root causes; thus, any approach to address the problem must be tailored to regional influences.

[West J Emerg Med. 2009; 10:233-239].

Background: Ovarian torsion (OT) occurs primarily in women of child-bearing age, but is rare in the pediatric population. The clinical presentation often consists of nonspecific abdominal complaints making the diagnosis difficult. Radiologic and sonographic evidence can be misleading. Although the delay in diagnosis from symptom onset is common, rapid diagnosis of ovarian torsion is imperative to prevent morbidity.

Case Report: We present the case of a four-year-old female who presented to the emergency department (ED) with a five-day history of intermittent abdominal pain and emesis. Initial diagnosis was suspicious for intussusception; however, on operative exploration, she was found to have a right adnexal torsion secondary to an ovarian teratoma. A right salpingo-oophorectomy was performed.

Conclusion: Early diagnosis of ovarian torsion may increase ovarian salvage and reduce morbidity. Faced with abdominal pain of uncertain etiology in a female child, emergency physicians should include ovarian torsion secondary to an ovarian mass in the differential diagnosis.

[WestJEM. 2008;9:228-231.]