Background-Patients over the age of 75 years comprise an increasing proportion of accident and emergency (A&E) department attendances. Within this group there is a high incidence of comorbidity, which mandates eVective discharge coordination from the A&E department. Objectives-The aims of this study were to assess the needs of these patients the day after discharge, target patients for appropriate interventions and identify critical incidents. Setting-The study was undertaken in a district general hospital A&E department that has 62 000 new patient attendances per year. Inclusion criteria-Patients aged 75 years or over who were discharged from the A&E department. Exclusion criteria-Nursing home patients. Patients without a telephone. Study design-Pre-discharge information was collected from the medical notes. A community liaison nurse (CLN) then contacted patients by telephone. A semistructured questionnaire was used to assess patients. Patients were risk stratified and appropriate interventions made. Interventions initiated by the CLN were scored from 1 to 6 based on the level of input required. Results-551 patients or their carers were contacted by telephone. Existing home support was felt to be insuYcient in 44 (8%) cases and in need of immediate intervention in a further 45 (8%) cases. Sixty five (11%) Category 1 patients required no intervention, 223 (42%) Category 2 patients required advice only, 107 (19%) Category 3 patients were referred to their GP, 127 (23%) Category 4 patients required a domicillary visit by a GP or a nurse, 26 (5%) Category 5 patients were at risk requiring urgent home assessment and three Category 6 patients had to re-attend A&E. Advice was given by the CLN on a broad range of issues and a wide range of health care services was accessed. Five hundred and fifty nine referrals were made by the CLN after telephone assessment. Conclusions-Telephone follow up of patients over 75 attending our A&E department identified a number of areas where care could be improved before and after discharge. This low cost, high quality intervention has the potential for decreasing inappropriate return visits to the department by a vulnerable group of patients as well as improving overall quality of care. (J Accid Emerg Med 2000;17:337-340)

A 31-year-old woman presented with spontaneous tension pneumothorax. This was initially treated with needle decompression, which led to massive haemothorax. Treatment and methods to reduce the likelihood of this complication are discussed.

Spontaneous renal artery aneurysm (RAA) rupture is a rare, but potentially fatal, cause of abdominal pain. A case is reported of a ruptured RAA in a previously well 45-year-old woman who presented with abdominal pain and syncope. Bedside ultrasound was unremarkable; however, a prompt abdominal computed tomography scan secured the diagnosis. Endovascular stenting was performed and the patient recovered.

This paper describes a previously unreported complication of chest tube thoracostomy: scalpel blade dislodgement within the pleural space. Techniques and complications of chest tube thoracostomy are then discussed. RÉSUMÉ :Le présent article décrit le cas d'une complication non signalée jusqu'à présent d'un déplacement dans l'espace pleural de la lame de scalpel utilisée pour une thoracotomie. Les techniques et les complications de la thoracotomie sont ensuite discutées. CASE REPORTS • OBSERVATIONS An unusual complication of chest tube thoracostomyHugo Poncia, MD;* John M. Ryan, MD † Case reportAn obese 67-year-old man with asthma, angina and hypertension presented to the emergency department (ED) complaining of having had a "cold" for 2 days, wheezing for 18 hours and experiencing acute shortness of breath that began 2 hours prior to presentation. On examination, he was diaphoretic and had difficulty speaking. Vital signs included a respiratory rate of 33 breaths/min, pulse of 100 beats/min and blood pressure of 224/119 mm Hg. Oxygen saturation was 88% on room air and improved to 94% with 60% mask oxygen. There was audible wheezing, a tracheal tug and intercostal recession. Peak expiratory flow rate was 100 L/min and arterial blood gas analysis revealed a pH of 7.31, a PCO 2 of 59.3 mm Hg and a PO 2 of 95.6 mm Hg.