CORRESPONDENCE

how good a service a group of emergency physicians may be in their hospital, it is difficult to overcome the intran- sigence of hospital administrators and medical staffs on this issue. Without the "clout" of ACEP, the JCAH, and the AMA, committed emergency physicians will not wait 5, 10, or 15 years for this change to occur.

Finally, ACEP must explore ways of discovering and lis- tening to their rank and file members on the issues facing emergency medicine. The College is taking stands on issues that have not been presented to the members as a whole for their input. You need only look at the recent positions of ACEP on nuclear weapons, emergency physicians working in FECs, and multi-hospital groups to know that ACEP's s t a t ement s were made u n b e k n o w n s t to the members . Whether they are the proper positions of the majority of ACEP members, I do not know. But I do know that there were no discussions at the state or national level on these issues at which the individual member had an opportunity to have his/her say. The argument against this - - that those physicians who have different views should part icipate more actively on the state and national level - - is specious.

Those emergency physicians who raise questions different from those in leadership positions somehow never get ap- pointed to committees, and never get elected as delegates or council representatives. If you're not one of the "good ol' boys," if you don't "toe the line," then all your opinion and work is nothing more than a silent voice in the desert.

Dr Simon's comments must be honestly addressed by ACEP with an opportunity for all to have their opinions presented. Too many emergency physicians have sacrificed too much, have indentured themselves too long, have been ignored too long to just walk away or to be silent. The idea of a separate organization is no longer just speculation, but is being actively discussed and pursued. I pray that such a thing does not come to pass. The founding fathers of ACEP must surely be pained to see this happen. But there is a frustration out there in hundreds of emergency departments that is going unheeded!

Thaddeus J Malak, MD, Medical Director Porter County EMS Valparaiso, Indiana

Double.Exposed Radiograph Simulat ing C-Spine Fracture/Dislocat ion

To the Editor: The high incidence of skull and cervical spine fractures tures without evidence of cervical trauma. Up to 14% will

in severe trauma is well appreciated. Alker et aB report that have cervical spine fractures only, and 7% will have both 35% of victims of fatal traffic accidents will have skull frac- cervical and skull fractures. These statistics emphasize the

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Fig. 1. There is minor widening of C3-C4 interspinous dis- tance.

Fig. 2 The flexion view shows apparent gross subluxation of C3 on C4.

Fig. 3. This repeat C-spine radiograph taken immediately after Figure 2 shows normal alignment.

Fig. 4. The CT scan demonstrates an epiduraI collection of blood in the left side of the posterior fossa and soft tissue swelling along the right side of the cranium.

importance of careful scrutiny of the craniocervical region in the face of significant trauma.

Reported is an incident of a double-exposed radiograph that simulated a C-spine fracture/dislocation. The patient was unstable because of a severe closed head injury. To our knowledge, this type of coincidental double exposure has not been reported in the literature.

A 17-year-old man was struck by a truck while riding a

moped. He was not wearing a helmet. The rescue squad members noted that the victim had an occipital skull lac- eration with an altered level of consciousness (Glascow Coma Scale = 12). In the emergency department he was stable from a cardiorespiratory standpoint, and was noted to be combative. Lateral C-spine and A-P and lateral skull films showed a midline fracture in the occiput and C3-4 interspinous process widening (Figure 1).

Physical examination at this time revealed no neurologi- cal deficits other than an altered level of consciousness. He was taken for harther C-spine films, and a flexion view was obtained. Initial interpretation of this film showed subluxa- tion of C3 on C4 (Figure 2). He was immediately placed in Charlottesville tong traction, with no apparent neurological deficit. Repeat lateral C-spine films showed good alignment (Figure 3).

His level of consciousness further deteriorated. A CT scan obtained while he was in traction revealed a posterior fossa hematoma (Figure 4). The patient was taken to surgery while in traction, and a venous epidural hematoma was evacuated.

This case points out the potential problem of a double- exposed radiograph. The second radiograph (Figure 2}, when carefully examined, reveals several duplicated vertebral bodies as well as a duplicated tracheal air column. In addi- tion, the odd subluxation is probably physically impossible.

The errors in this situation were two. From a technical standpoint, the total number of radiographs should have been accounted for as routine procedure. From an interpre- tive standpoint, the overlapped and duplicated anatomical structures should have been appreciated. These errors

~caused the unindicated placement of Charlottesville tongs. This case serves to point out yet another area of potential error in the emergency setting.

Stephen Quinn, MD Department of Radiology

Sean Grady, MD Department of Neurosurgery University of Virginia Medical Center Charlottesville

1. Alker GJ, Young SO, Leslie EV, et al: Postmortem radiology of head and neck injuries in fatal traffic accidents. Radiology 1975; 114:611-617.

Spontaneous Tension Pneumothorax During

To the Editor: Pneumothorax may occur in the face of trauma or at-

tempted invasive procedures. A second setting is free of ob- vious insults to the chest wall or pulmonary parenchyma, and is described as a spontaneous pneumothorax.l-3 In 90% of patients, spontaneous pneumothorax develops during minimal or mild physical activity. The phenomenon is most common in young men, but can occur at any age. 1-4 Spontaneous tension pneumothorax is extremely rare. The exact incidence is unknown, but tension pneumothorax is reported in only 2% to 3% of all cases of pneumothorax.S

Sexual Intercourse

Presented is an unusual, potentially fatal case of spon- taneous tension pneumothorax developing in a middle-aged woman during sexual intercourse.

A 41-year-old woman presented to the emergency depart- ment complaining of sudden, sharp, left-sided chest pain and dyspnea which she felt was a "heart attack." The pa- tient described excellent health and no similar episodes of chest pain. She admitted to cigarette use of a half pack daily for 15 years. No history of pulmonary disease was elicited.

After some reassurance, the patient was able to relate

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