than 100 accredited programs in existence cannot keep up with the need for specialty-trained emergency physicians.

Let’s turn for a moment to the social development of this new specialty now perhaps reaching its early adulthood. Twenty years ago the ER “doctor” was literally a tough, well-seasoned night nurse who guarded the hospital like a sentry. Later, physicians dissatisfied with other specialties started trickling down into the “pit” on a full-time basis. These physicians developed into two major classes. Some were like medical mercenaries traveling from hospital to hos- pital seeking their fortunes. The shift would end and they would be off like Vikings, but with less allegiance to each other or their flag. Others with more business sense devel- oped groups and became less nomadic. They behaved more like vassal lords and remained to negotiate territory with their medical staffs.

Then a third group, the emergency specialist, started to come of age. These physicians had a defined armamentarium of technical skills and scientific knowledge. Would they too become a nomadic race, or would they become more inte- grated in the medical community?

The demographic trend will be based on several factors. Emergency medicine is a bona-fide specialty, using the same criteria applied to define any of our other medical disci- plines. Our colleges now understand the merit of the emer- gency specialist with his or her specific talents providing the medical community with indispensable services. This recog- nition will no doubt encourage physicians to become more permanent members of medical staffs. One can draw an anal- ogy to other contemporary fields where technology has de- veloped at a rapid pace. Continued development is based on social progress keeping in step with technology.

RICHARD M. SOBEL, MD Winter Haven Hospital Winter Haven, Florida

INTERNATIONAL NOTES

To the Editor:-It is with some interest that I leaf through my new issue of The American Journal of Emergency Med- icine every 2 months. Besides the numerous articles relating to various aspects of emergency medicine, one section in particular always attracts my attention-“International Notes.”

In the entire time that I have been reading the journal’s “International Notes,” I have yet to notice any (even one) abstract from anywhere but Japan. This is not to denigrate or belittle the importance of Japan’s contribution to the field of emergency medicine, but one would think that somewhere, in the rest of the world, there are other articles of interest to emergency physicians.

MARC S. NELSON, MD Stanford University Hospital Stanford, California

The Editor replies:-While a number of different types of contributions with international authorship appear in our “International Notes” section, Dr Nelson’s observant com- ments reflect the generosity of the Japanese Society for Acute Care Medicine to translate abstracts for our English- speaking audience, a service not otherwise available. There

is ample opportunity for exposure to the British, Canadian, and even Scandinavian literature, either through the jour- nals themselves or through review and abstract services. (One must be aware, however, that the latter can be most selective and reflect one individual’s taste.) Our thrust has been to provide a comprehensive exposure to relevant arti- cles/abstracts not currently in translation, and we seek to develop the same capability with regard to the Spanish, Ger- man, Russian, and French literature in the future. We hope to identify bilingual emergency physicians with such inter- ests from our readership, and Dr Nelson’s inquiry is most timely.

J. DOUGLAS WHITE, MD Editor

ACUTE TRAUMATIC ABDOMINAL WALL HERNIA

To the Editor:-A 46-year-old man was seen in the trauma unit at Fairfax Hospital after sustaining a blunt injury to the abdomen. The injury occurred when a length of pipe resting on the bed of a stationary truck was struck by an approach- ing vehicle traveling at approximately 30 miles, per hour. The patient was pinned in a scissors-like fashion against the sta- tionary truck with sufficient force to significantly deform the cargo door. All vital signs were stable on the scene and remained stable throughout transport. On admission, the pa- tient complained of excruciating abdominal pain localized to the right lower quadrant near the flank. At this site a large mass was noted, measuring approximately 15 centimeters in diameter, with overlying ecchymosis. It did not appear to be expanding after repeated examinations.

Gross hematuria was apparent after the patient voided spontaneously. An abdominal computed tomography (CT) scan with intravenous contrast (Fig 1) demonstrated an ab- dominal wall defect in the right upper quadrant, lateral to the rectus sheath, with protrusion of loops of small bowel into the subcutaneous tissues. A small laceration of the inferior pole of the right kidney with surrounding hematoma was also noted.

Exploratory celiotomy via a midline incision was per- formed. The herniated small bowel was reduced. There was disruption of the peritoneum along with a large defect of the internal and external muscles. A small laceration of the in- ferior pole of the spleen at the attachment of the spl.enocolic

FIGURE 1. CT scan demonstrating small bowel extruded outside the abdominal cavity and a right perinephric hematoma.

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AMERICAN JOURNAL OF EMERGENCY MEDICINE w Volume 7, Number 6 ??November 1989

ligament was noted and repaired. The ruptured peritoneum was oversewn with continuous absorbable suture. The per- inephric space was explored through Gerota’s fascia, reveal- ing a small laceration of the inferior pole of the right kidney which was not actively bleeding. The remainder of the ab- dominal exploration was unremarkable.

The abdomen was closed and a transverse “counterinci- sion” was made over the site of abdominal wall disruption. After debridement of devitalized tissues and control of minor hemorrhage from torn muscle, the abdominal wall was re- constructed in layers. The patient’s convalescence was un- eventful. The gross hematuria resolved promptly.

Traumatic herniation of the abdominal wall is a relatively uncommon occurrence. Less than 50 cases have been re- ported in the literature to date. Blunt trauma usually results in injury to the abdominal viscera as well as to retroperito- neal structures. Reported cases of traumatic abdominal wall hernia include “scissor-type” injuries such as in this case,l,* lap seat belt deceleration injuries,3 handlebar injuries4s5 falls onto wooden posts,4 and gorings.6 The characteristic com- mon to all the injuries is extreme force transmitted to the abdomen through an essentially blunt but focused object. This causes rupture of the abdominal wall musculature with preservation of the more deformable integument. When cou- pled with a sudden elevation of intra-abdominal pressure, the net result is herniation of abdominal contents into a sub- cutaneous position.4

Criteria for diagnosis of acute traumatic abdominal wall herniation have been established and include preservation of the skin and a timely presentation of the defect (in order to confirm its traumatic origin).’ A useful corollary of these is the absence of a peritoneal sac in the hernia at the time of surgery, the presence of which would indicate a nontrau- matic etiology.* Our case demonstrated complete disruption of all layers of the abdominal wall, including the peritoneum.

The differential diagnosis of acute traumatic abdominal wall herniation is not extensive. A hematoma of the abdom- inal wall is frequently suspected after blunt trauma. Needle aspiration should not be attempted in the diagnosis of sus- pected hematoma because of the risk of puncturing the bowel in the setting of an abdominal wall hernia. A mass existing prior to injury should be identified by history when- ever possible. Abdominal wall tumors and preexisting non- traumatic hernias may be ruled out in this manner.

Diagnosis in the emergency setting is dependent on imag- ing studies. Although auscultation of bowel sounds and dem- onstration of a reducible defect are suggestive, confirmation before surgical intervention is warranted. This is especially important given the frequent occurrence of associated intra- abdominal injury in the setting of acute traumatic hernia. Although ultrasound will rule out a rectus sheath hematoma and plain films may demonstrate the presence of air-tilled bowel outside of the peritoneal cavity,’ CT is the only im- aging modality available that can also effectively diagnose associated intra-abdominal injury. Such injury is signifi- cantly more likely when the injury is located above the level of the umbilicus rather than below.‘,3*8-11

Regardless of the level of fascial disruption, early surgical intervention is advisable in the management of acute trau- matic hernia. This obviates the risk of incarceration and strangulation of the bowel. It is also necessary to control hemorrhage from damaged muscles and to debride devital- 668

ized tissue. A midline celiotomy incision is recommended for full exploration of the abdominal cavity and reduction of the hernia,‘,3s~‘0 followed by a counterincision over the site of the hernia for primary repair of the defect and debridement.

Various authors have classified traumatic abdominal wall hernias according to their severity, location, and etiology.2*‘2 These classifications may be helpful in deter- mining the urgency with which further intervention should be pursued, although these injuries are unique enough that future presentation may require a reworking of the various classifications.

LAISE V. bNES, MD JUAN A. SANCHEZ, MD DAL VINH, MD Fai$ax Hospital Falls Church, Virginia

References

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Metzdorff MT, Miller SJ, Smiley P, et al: Blunt traumatic rupture of the abdominal wall musculature. Ann Plast Surg 1984;13:63-66

Qtero C, Fallon WF Jr: Injury to the abdominal wall muscu- lature: The full spectrum of traumatic hernia. South Med J 1988;81:517-520

Payne DD, Resnicoff SA, States JD, et al: Seat belt abdom- jnal wall musculature avulsion. J Trauma 1973;13:262-267

Guly HR, Stewart IP: Traumatic hernia. J Trauma 1983;23:250-252

Peters JC, Reinertson JS, Polansky SM, et al: CT demon- stration of traumatic ventral hernia. J Comput Assist To- mogr 1988;12:710-711

Clain A: Traumatic hernia. Br J Surg 1964;51:549-550 Atiemo EA, Goswami G: Traumatic ventral hernia. J Trauma

1974;14:181-182 Malangoni MA, Gondon RE: Traumatic abdominal wall her-

nia. J Trauma 1983;23:356-357 Dubois PM, Freeman JB: Traumatic abdominal wall hernia.

J Trauma 1981;21:72-74 Dajee H, Nicholson DM: Traumatic abdominal hernia. 3

Trauma 1979;19:710-711 Dreyfuss DC, Flanchbaum L, Krasna IH, et al: Acute trans-

rectus traumatic hernia. J Trauma 1986;26:1134-1136 Wood RJ, Ney AL, Bubricj MP: Traumatic abdominal hernia:

A case report and review of the literature. Am Surg 1988;54:648-651

THE INEFFECTIVE USE OF DIGITALIS TO CONTROL RAPID VENTRICULAR RESPONSE IN A PATIENT WITH ATRIAL FIBRILLATION IN SEPTIC SHOCK

To the Editor:--Digitalis is commonly used to control the rapid ventricular response in patients with atrial fibrillation. We present a case in which digoxin was unsuccessful in significantly slowing the rapid ventricular response in a pa- tient with chronic atria1 fibrillation and sepsis.

An 81-year-old white woman presented to the emergency department (ED) by ambulance after nursing home person- nel noted that she was less responsive than usual with an unobtainable blood pressure. The patient’s medical history was significant for chronic obstructive pulmonary disease and chronic atrial fibrillation with past hospitalizations for pneumonitis and urinary tract infections. The patient had