A 37-year-old man with type I diabetes mellitus and chronic renal failure presented to the emergency department complaining of hallucinations. He was 5 days postoperative for left pars plana vitrectomy and intra-ocular lens implantation and had been taking ophthalmic atropine, tobramycin and prednisolone. He had presented 5 months earlier, on the same ophthalmic medications, with postoperative hallucinations after a right pars plana vitrectomy. Visual hallucinations are a major side effect of anticholinergic poisoning. Ophthalmic instillation of atropine has been documented to cause many central nervous sytstem symptoms, including hallucinations.

Diagnostic ultrasound (U/S) has been used in medicine for over 40 years, and reports describing the use of abdominal U/S in trauma date back to 1971. Recently, however, trauma ultrasonography has become a controversial issue in Canada.

U/S provides the speed and accuracy we associate with diagnostic peritoneal lavage (DPL) in a noninvasive format. It is safe, inexpensive, repeatable, accessible at the bedside, and requires little patient preparation. U/S is now the initial test for the assessment of blunt abdominal trauma in most European and Australasian centres. More recently U/S has become common in US trauma centres.

Africa’s first conference on emergency medicine was held in October 1998 in Johannesburg, South Africa. Attended by 305 delegates from 13 countries, it was an important milestone in the development of Africa, emergency medicine’s last frontier. The violence of South Africa’s post-apartheid society was portrayed in mock scenario demonstrations of the private sector emergency medical services (EMS) system. Many of the presentations had a distinctly African flavour; they dealt with penetrating trauma and with making the best of extremely limited resources. A session reviewing the activities of traditional healers was not only terrifyingly revealing, it also upset and offended a segment of the African audience. The conference ended positively with the creation of the Emergency Medicine Society of South Africa, a step toward recognition of emergency medicine as a specialty in Africa.

Although diagnostic imaging is, for the most part, the domain of radiologists, exceptions to this rule have developed. Cardiologists perform cardiac catheterization and echocardiography. Obstetricians have developed expertise in transvaginal ultrasound and fetal assessment. Why have some specialties embraced areas of imaging as theirs, while others — such as orthopedics and medicine — continue to rely on radiology? One reason is that radiologic expertise in these latter specialities is rarely required on a 24-hour basis and it can be provided without taking on an overwhelming workload. ED bedside ultrasonography, on the other hand, must be available 24 hours a day. Conditions requiring immediate (within 15 to 20 minutes) ultrasound (U/S) include expanding or leaking abdominal aneurysm, suspected ectopic pregnancy, and traumatic hemoperitoneum. When patients with these conditions are unstable they require even more rapid imaging — “real imaging” in the operating room.

Welcome to the first section on “Resident Issues” in our new journal. With this section, CAEP reaffirms its commitment to the future of Canadian emergency medicine and future leaders in our specialty. Resident Issues will focus on work by and about future emergency physicians in Canada. The overall goal of this section is to promote

Gastric volvulus is a rare but potentially life-threatening cause of upper gastrointestinal obstruction. Emergency physicians must maintain a high index of suspicion in patients who present with signs and symptoms suggesting foregut occlusion. We report an illustrative case and review the pathogenesis, classification, diagnosis and treatment of this rare entity.

Many published papers report excellent sensitivity, specificity and accuracy when non-radiologists employ ultrasound (U/S) to detect free intraperitoneal fluid in cases of blunt abdominal trauma (BAT). In this setting, it is best to view the FAST (focused abdominal sonogram in trauma) as a noninvasive diagnostic peritoneal lavage (DPL): It tells us whether there is free intraperitoneal fluid but does not determine the specific parenchymal injury. In other words it is a screening tool.

An informal discussion of the possibilities of combining emergency medicine and international work during a residency program. A brief summary of emergency medicine related illness in the international setting is presented. An example of a successful combination of international work during residency is given. A list of tips and a starter’s list of resources are provided.

Practically speaking, bedside ultrasound is well within the scope of emergency physicians (EPs) and is gaining acceptance. The literature supports the use of limited, goal-directed ultrasound in the diagnosis of many emergent conditions. EPs should use ultrasound as a tool to answer specific questions (e.g., Is there blood in the belly?); they should not surf the body for clues. ED ultrasound offers rapid evaluation of potentially life-threatening conditions

Canada is the only country with two colleges governing emergency medicine (EM) certification. Does this serve us well or does it divide us and our resources? If most CCFP(EM) graduates practise strictly EM, with no family or rural practice, then reform in the certification process may be necessary. At the same time, FRCPC residencies seem excessively long and lack the numbers to develop “critical mass.” Shortening the length of training would allow more residency positions to be created, thus advancing the goal of optimum emergency care for the Canadian public. Canadians deserve one standardized, certified, accredited EM training program that produces the highest quality emergency physicians.

Prior to the 1998 Vancouver Asian Pacific Economic Summit, emergency physicians were briefed on the possibility of terrorist-related biological or chemical weapons incidents. As part of a training exercise, the “victim” of a chemical weapon attack was brought to our ED. Because of confusion and ignorance, the “victim,” the physician, several members of the ED staff, and a number of other patients also became “casualties.”

Ah, the ultrasound controversy. Every emergency department (ED) that I’m aware of goes through this struggle. The radiology department resists the introduction of ultrasound (U/S) because, and I don’t want to oversimplify a complex issue, they are worried they will lose money.