Background and Purpose: Chest tube thoracostomy is the definitive treatment for suspected tension pneumothorax; however, the effectiveness of prehospital tube thoracostomy remains controversial with associated issues. This study aimed to evaluate the effectiveness of chest tube thoracostomy in patients treated by a physician-staffed helicopter emergency medical service. Methods: We retrospectively reviewed 22 patients with blunt chest injury who underwent prehospital chest tube thoracostomy. Result: We inserted 25 chest tubes (unilateral, 19 cases and bilateral, 3 cases) in the fourth and fifth intercostal spaces in the midaxillary line. On chest tube insertion, an air leak was observed in all the patients. Physician-staffed helicopter transportation decreased the duration of first aid to 31.2 ± 21.7 minutes; this was lower than that assumed for ambulance transportation. In 8 initial shock patients (systolic blood pressure below 90 mmHg at the scene), the systolic blood pressure after thoracostomy and on ED arrival was significantly higher as compared to the corresponding values at the scene (p<0.05). The revised trauma score on ED arrival was significantly higher as compared with that at the scene (p<0.05). Pleural infections were observed in 2 patients (9.1%). In all, 17 patients survived and 5 died. Massive hemorrhaging caused the death of 4 patients. Conclusion: Prehospital tube thoracostomy for traumatic hemopneumothorax performed by a physician-staffed helicopter emergency medical service is particularly effective for hemodynamically unstable patients such as those with tension pneumothorax. Moreover, it may prevent the occurrence of tension pneumothorax in patients who require tracheal intubation and artificial ventilation for respiratory support.

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The emergency doctors' job in Japan has traditionally been to care for critically ill patients presenting to the Emergency Department (ED). Recently, US style emergency medicine, called as ER-style Emergency Medicine in Japan, not unsimilar to that practiced in western countries such as the United States (U.S.), has been adopted. In this practice, emergency physicians take care of all patients presenting to the ED regardless of the severity of the injury or illness. The aim was to report the status of implementation of US-style emergency medicine in Japan. Questionnaires were sent in June, 2006 to 60 facilities where active members of the ER committee of Japanese Association for Acute Medicine serve. Valid responses obtained from 28 facilities were analyzed. US-style emergency medicine was provided in 22 facilities and 12 of them (55%) operate 24 hours a day, seven days each week. In 17 of 22 facilities (73%), both high severity and low severity emergency patients were cared in an emergency room. In the 22 medical facilities, staffing of emergency medicine was limited, as shown by mode values in each facility for emergency doctors were 6-10, and for emergency physicians were 1-3. Mode value for rotating first-year post-graduates in each facility was 10-20 and all of them rotate US-style emergency medicine. Seven facilities provide a residency training program in emergency medicine and another 11 facilities plan to build up it. In conclusion, US-style emergency medicine operates in some medical facilities in Japan; however, its staffing is inadequate.

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At 09:18 on April 25, 2005, a train derailment occurred on the JR-Fukuchiyama Line in Western Japan. In this incident, 107 people died and 549 people were injured. At 10:01, we arrived at the scene of the accident by the doctor car as a first medical team and carried out triage and treatment at the casualty cleaning station. After the successive arrival of more medical teams, the role of “medical commander” of other medical teams was established. Because the doctor car system was available and well known at daily emergency system, a medical team could be dispatched in an early stage immediately after the incident's occurrence. In general, all medical teams were well organized and well managed at the incident site. So, it is supposed that “preventable deaths” were avoided. However, some problems, especially communication and intelligence, came to light, so in the future, we hope that information sharing and coordination with the fire and police departments through the incident control units will improve, and that an uninterrupted chain of triage, treatment and transfer will be available to casualties. By examining the issues of this incident and improving the problems we accoutered, we hope that a better and more effective disaster medical system in Japan will be established.

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While conservatively treating a blunt liver injury we encountered a case of intrahepatic biloma that was compressing the patient's inferior vena cava (IVC). The 20-year-old Japanese male fell from a height of 1 m to the floor, hitting his face and chest. He was diagnosed with a fractured zygomatic bone and then released. However, persistent right hypochondralgia brought him back to our hospital for further examination on the 17th day after injury. A contrast-enhanced abdominal CT revealed liver injury (S5,7,8 JAST Ib, OIS Grade III), an IVC showing a flattened shape, and a low density area surrounding the portal vein and the gallbladder. On the 40th day after injury he complained of dizziness while walking and went into shock. The biloma was drained percutaneously of approximately 1,200 mL of fluid that contained bile. IVC flatness and the periportal low density area had disappeared from a CT obtained on the following day. The exact cause of shock was not determined; however, it is possible that compression of the IVC by the biloma have decreased venous return. The possibility of compression of the IVC by the biloma should be considered during the treatment of blunt liver injury.

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Pulmonary arteriovenous malformation (PAVM) was diagnosed in a twenty-one-year-old woman when she was fifteen years old. Transcatheter embolotherapy had been performed repeatedly. Symptoms of bloody sputum, dyspnea, emotional instablility and muscular weakness of the lower limbs appeared during the second pregnancy. After considering the risks of radiological exposure, it was decided not to perform treatment for PAVM during pregnancy. Thereafter, similar symptoms persisted, and once the patient lost consciousness transiently, was diagnosed as having psychiatric disease, hospitalized and treated. About one month after the birth of the second baby, the patient suddenly fainted in a psychiatry hospital. She was transferred to our hospital due to consciousness disturbance of uncertain cause. On admission, her consciousness level was E2V2M4 (GCS). Brain MRI demonstrated cerebral infarction, and chest CT demonstrated PAVM. Intensive care for cerebral infarction was performed. Though consciousness level improved gradually to E4V4M6, she suddenly developed cardiopulmonary arrest 42 days after hospitalization, and died four days later. Pulmonary arteriovenous fistula deteriorates during pregnancy. When symptoms of breathing problems and consciousness disorder appear during pregnancy, it is necessary to investigate PAVM as a possible cause.

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A 64-year old man in drink fell and dislocated his incisor. Two days after he complained about pain in the posterior cervical region. He had been diagnosed at a local hospital with a sprained cervical vertebrae, but the treatment was not effective. Nine days after he had fallen he developed his paresis in his arms and paralysis in his legs after waking up from a nap, so he was brought to our hospital by ambulance. We conducted a thorough cervical MRI for quadriplegia. It confirmed a T1 low signal and T2 high signal area in the C5-6 intervertebral disc and epidural fluid collection image in the area connecting the intervertebral disc. We diagnosed him with cervical purulent spondylitis and an epidural abscess. The patient regained almost normal muscle strength in his arms about one month after surgery, but the paralysis in his legs persists and he is wheelchair-bound. Therefore, we recommend the consideration of cervical purulent spondylitis and immediate blood tests and MRI when a patient has cervical pain combined with a fever in order to avoid serious complications such as spinal paralysis and sepsis due to delayed diagnosis and treatment.

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Non-clostridium gas gangrene (NCGG) is a fatal disorder associated with a high incidence of sepsis, disseminated intravascular coagulation (DIC), and multiple organ failure. Here, we reported a recovered case of a 29-year-old male with NCGG due Lactobacillus sp. infection during prolonged coma after carbon monoxide poisoning. On admission, the patient showed severe swelling with flare involving the right cervix, right shoulder, right buttock and right femur, and was diagnosed as having acute phlegmon. NCGG developed from right shoulder phlegmon on day 9. NCGG at the right shoulder responded well to early surgical treatment and antibiotic administration. Early diagnosis and antibiotic therapy are important for NCGG prognosis.

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