The current issue of the EMJ has an interesting article on the neurological signs associated with CO poisoning. (Lynch R, Laden G,
Grout P. Carbon monoxide poisoning: correlation of neurological findings between accident and emergency departments and a
hyperbaric unit. Emerg Med J 2001;18:95-98.) In essence, it noted that A&E units picked up an average of 3.2 neurological signs per
patient before referring the patient while the hyperbaric unit picked up 9.2. Although various hypotheses were put forward, the
underlying suggestion was that the A&E staff elected fewer signs because they did not know the physical signs (quite true in my case -
I am no wiser after reading the article on the difference between sharpened and ordinary Rhomberg's (sic*)test except I hadn't even heard
of the sharpened variety before) or failed to elicit them through inadequate examination and or documentation.

I felt a bit chastened by this initially, but then thought about it. I don't think we ever fully examine a patient. Indeed, I teach the juniors
not to examine patients exhaustively; once a management plan is clear they should stop examining and investigating, make sure the
patient is safe and refer or treat and send home.

For example, a patient is brought in unable to move the left side. There is no history of migraine, but the patient was started on aspirin a
month ago by the GP after a TIA. Quick examination shows a flaccid left arm and leg with facial drooping in a distressed anxious patient.
The reflexes are brisk and the left plantar is upgoing. The pulse rate is normal and the patient is not in AF. What more need I do? The
patient should have the diagnosis explained, be reassured as far as deemed reasonable, a drip put up to maintain hydration, bloods taken
when the drip is put up and then referred. I would not expect to perform (for example) a meticulous swallowing assessment in A&E,
although the patient will need one or more at some stage.

Are we being told something important? The very fact that the patients were sent to the hyperbaric unit suggests that the A&E staff had
gleaned enough information to send the patient. What more need they do? There is an unhelpfully woolly directive to A&E staff in the
middle of the discussion that if curtailment of examination took place it should not have done as we were failing clinical governance
requirements.

I am concerned that the implied criticism of A&E management of these patients is misplaced and should be challenged. What do others
think?

*Incidentally, the man's name was Romberg. MH Romberg (1795-1873) German neurologist. Stones and glass houses, eh?

Best wishes,


Rowley Cottingham

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