Objective-Since March 1992, intravenous nalbuphine hydrochloride has been used prehospital by paramedics in the Plymouth area. This study assesses the impact of this intervention. Methods-A prospective study of the parenteral analgesic requirements of 1000 consecutive patients arriving by ambulance at the accident and emergency (A&E) department of a large district general hospital. Where parenteral analgesia was given in the A&E department but not by ambulance personnel, a questionnaire was sent to the ambulance crew concerned to ascertain the reasons for not having given nalbuphine. Results-Of 1000 consecutive patients arriving by ambulance, 87 (8.7%) had been given parenteral analgesia either prehospital, in A&E, or in both places.. Seventy five (7.5%) needed parenteral analgesia in the A&E department, 29 (2.9%) had been given prehospital intravenous analgesia by paramedics, and a further seven (0.7%)

Objective-To investigate conditions where, after initially negative plain x rays following trauma, there subsequently proves to be fracture, and to explore ways in which the management might be improved. Design-A 16 month prospective study. Patient details were collected from accident and emergency (A&E) review clinics and returns, A&E ward admissions, correspondence from other services, and discussions at a weekly clinicoradiological conference. The inclusion criteria comprised A&E trauma patients with normal initial plain x rays and proven fractures on subsequent imaging for the same patient event.Setting--A large A&E department seeing 65 000 new attendances per annum with full back up services. Results-55 cases were identified: 41 fractures were identified on subsequent plain x ray, six on bone scan, six on CAT scan, and two on MRI scan. The commonest regions involved were the wrist, pelvis/hip, ankle/foot, and leg. Follow up had not been arranged at the initial attendance in 17 instances and between two and 135 days were required for definitive fracture rec-

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