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LETTERS LETTERS potential benefit in presenting medication Pony Club riders, of which there were benefits before discussion of possible 22 000 in New South Wales in 1996. adverse effects. Such an approach might Neither had there been an ASCI in those apply to medical practitioners and other who participated in Riding for the Disabled. healthcare professionals when counselling In the context of these comments, it is patients. It might also be a consideration in relevant to briefly revisit the contentious the format of written information, such as topic of Down syndrome children taking Consumer Medicine Information. part in Riding for the Disabled and in sport generally. Since 1970 (from when accurate 1. Herrier RN, Boyce RW. Talking to patients about potential side effects. Am Pharm 1995; NS35: 11-12. records are available), no child with Down 2. Asch S. Forming impressions of personality. J Abnorm Soc syndrome in NSW has had an ASCI in any Psychol 1946; 41: 258-290. 3. Cunnington JPW, Turnbull JM, Regehr G, et al. The effect sport, let alone in a well-defined non- of presentation order in clinical decision making. Acad sporting accident. There is simply no case Med 1997; 72(10 Suppl 1): S40-S42. for the radiological screening of the cervical 4. Kerstholt JH, Jackson JL. Judicial decision making: order of evidence presentation and availability of background spine for atlanto-axial instability in asymp- information. Appl Cogn Psychol 1998; 12: 445-454. tomatic children with Down syndrome 5. de Almeida Neto AC, Benrimoj SI. Information provision and the order effect. Aust J Pharm 1999; 80: 861. ❏ before they undertake Riding for the Disabled. The indications for this examina- tion have been set down.4 We hold that the public and the medical Spinal cord injuries profession can continue to be reassured by this information. Certainly, a child wearing in horse riding a lap seat belt or other poorly fitting Thomas K F Taylor,* Justin P Roe† restraint in the rear passenger compartment * Chairman, Board of Directors (and Emeritus of a car is at infinitely greater risk for spinal Professor of Orthopaedics and Traumatic Surgery, cord injury than when astride a horse at The University of Sydney), † Orthopaedic Surgeon, Pony Club. Further, as Holland et al have Spinecare Foundation, PO Box 3003, Ryde, NSW documented,1 if he or she is wearing a 2112. protective helmet the chances of head injury TO THE EDITOR: The conclusion of would be reduced significantly. Holland et al that horse-related injuries in Safety in all potentially dangerous sports children account for a considerable number should be foremost in the minds of those of deaths and injury is unarguable.1 In New who administer, supervise and participate Zealand, hospitalisation rates for falls from in such games. As yet there are no hard data horses and rugby injuries are comparable.2 to support the wearing of body protectors to Despite these disconcerting facts, the data reduce the risk of ASCI, or other vertebral on horse-riding injuries need to be put in a injuries, in horse riding. balanced perspective. The frequency of 1. Holland MA, Roy GT, GOH V, et al. Horse-related injuries in injuries in adult equestrian activity, Pony children. Med J Aust 2001; 175: 609-612. Club riding, occupational riding (including 2. Buckley SM, Chalmers DJ, Langley JD. Injuries in falls from professional jockeys) and riding for leisure horses. Aust J Public Health 1993; 17: 269-271. 3. Roe JP, Edmunds IA, Taylor TKF, et al. Equestrian spinal are quite different. Collective raw data are cord injuries in New South Wales 1976–96. J Bone Joint misleading. Surg 1998; 80 Suppl 11: 153. The freak accident of actor Christopher 4. Taylor TKF, Walter WL. Screening of children with Down syndrome for atlanto-axial (C1-2) instability: another Reeve in 1995, with the resulting much- contentious health question. Med J Aust 1996; 165: 448- publicised quadriplegia, brought public 450. ❏ attention worldwide to the question of acute spinal cord injury (ASCI) in horse riding and led to widespread parental concern Andrew J A Holland,* Gerard T Roy† about “spine safety” in this sport. Spinecare Senior Lecturer in Paediatric Surgery, The Children's Foundation was subsequently involved in a Hospital at Westmead, University of Sydney, Locked Bag 4001, Westmead, NSW 2145. review of 32 patients with ASCIs from <Andrewh3@chw.edu.au>; † Paediatric Surgeon, horse riding admitted to the spinal cord John Hunter Children's Hospital, Newcastle, NSW. injury units at Royal North Shore and Prince Henry hospitals, Sydney, for the IN REPLY: One of the reasons for publishing years 1976 to 1996.3 Occupational and our data was to raise the level of awareness leisure riding accounted for 88% of injuries. of both the frequency and severity of horse- ASCIs occurred in only two riders under related trauma in Australian children.1 This the aegis of the Equestrian Federation of trauma appeared to be associated with a low Australia — one while competing and the level of compliance with basic safety other while training. There were no injuries measures, in particular the use of a in children younger than 14 years of age in Standards-approved riding helmet.1,2 any form of riding. Most importantly, in the We stated clearly in our article that the study period, there had been no ASCIs in risk of injury needed to be viewed in the 402 MJA Vol 176 15 April 2002 LETTERS context of the important social and health emergency department. After the patient 1. Nocera A, Levitin HW, Hilton JMN. Dangerous bodies: a case of fatal aluminium phosphide poisoning. Med J Aust benefits of horse-riding as a sporting and died, they sealed his body in an impervious 2000; 173: 133-135. leisure activity.1 Taylor and Roe have suit and bin. It was buried, without autopsy, 2. International Programme on Chemical Safety. Environmen- commented on the perceived benefits of tal health criteria 73: phosphine and selected metal using earth-moving equipment — it being phosphides. Geneva: World Health Organization, 1988. Riding for the Disabled, especially in considered too dangerous to do this by 3. Singh S, Dilawari JB, Vashist R, et al. Aluminium children with Down syndrome. hand. The burial was filmed for television. phosphide ingestion. BMJ 1985; 290: 1110-1111. Certainly, the available data suggest that The article sought to highlight risks to 4. Singh S, Singh D, Wig N, et al. Aluminium phosphide ingestion — a clinicopathological study. Clin Toxicol 1996; in this strictly supervised scenario horse hospital staff from poisoned patients and 34: 703-706. ❏ riding would appear to be very safe.3 indicated that phosphine gas emanating However, the evidence for therapeutic from this patient could be toxic before it benefit would appear to be relatively weak, was able to be smelt. Despite stated fears of Antony Nocera and the risks of this form of equestrianism extreme toxicity, no air samples were Emergency Physician, Unit 10, 85 Florence Street, cannot be compared with the more com- collected for analysis, and the sole symptom Williamstown, VIC 3016. firstname.lastname@example.org mon interaction that might occur between a among staff was nausea (not unexpected normal child and horse.4 IN REPLY: In our article, we clearly stated given the smell). The incidence of spinal cord injury in that the emergency department was evacu- In parts of India, where wheat is children fortunately appears low, at less ated on the instructions of officers from the commonly stored in the home before being than 2% of children admitted with all forms New South Wales Fire Brigades.1 The of traumatic injury.5 In this context, the use ground into flour, aluminium phosphide officers then placed the patient’s body of spinal cord injury as a measure of the tablets are widely available for household within a fire brigade hazardous materials safety of a sport for children is flawed. use to stem insect attack on the grain.3,4 encapsulated suit and, when that began to While children may be at greater risk of Ingestion of these tablets is a common way distend with phosphine gas emissions from injury when inappropriately restrained in a to attempt suicide, with perhaps as many as the body, into a hazardous materials motor-vehicle accident, this fact in itself 15 000 cases per year, two-thirds of which recovery bin. does not make horse-riding, or indeed any are fatal. The hospital in the city of In contrast, Christophers and colleagues other high-risk sporting activity, safe. The Chandigarh, in northern India, treats about state that staff at the hospital in Chandi- use of appropriate safety devices and 50 cases per year. garh, India, take no special precautions in responsible adult supervision does. The breath of patients who have ingested antemortem or postmortem care of patients aluminium phosphide has a characteristic 1. Holland AJA, Roy GT, Goh V, et al. Horse-related injuries in who have taken aluminium phosphide garlic-like odour. Diagnosis is based on children. Med J Aust 2001; 175: 609-612. tablets. I am disappointed that they provide 2. Bixby-Hammett DM. Pediatric equestrian injuries. Pediat- history and a positive result (blackening) on rics 1992; 89: 1173-1176. no data on air sampling for phosphine gas tests of the patient’s breath with paper 3. Taylor TKF, Walter WL. Screening of children with Down during this care to justify this practice. syndrome for atlanto-axial (C1-2) instability: another moistened with fresh silver nitrate solution. contentious health question. Med J Aust 1996; 165: 448- Our case highlights the problems con- Hospital staff take no special precautions 450. fronting emergency department staff with a 4. Biery MJ, Kauffman. The effects of therapeutic horseback during resuscitation, and surviving patients critically ill patient and an unknown riding on balance. Adapted Physical Activity Quarterly are managed with routine supportive care. 1989; 6: 221-229. chemical hazard. In this case, the chemical Autopsies are routine. No threat is per- 5. Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in hazard was not correctly identified for over children: a review of 103 patients treated consecutively at ceived by hospital staff. a level 1 pediatric trauma centre. J Pediatr Surg 2001; 36: 30 minutes. The risk cannot be estimated, 1107-1114. ❏ Metal phosphides have been safely used as suggested by Christophers and col- by trained people in Australia for decades. leagues, until the chemical agent and its They are Schedule 7 poisons and so require vapour concentration are correctly identi- an expensive permit for purchase. Conse- fied. Retrospective determinations cannot Dangerous bodies: a case of quently, their use for suicide is rare. Nocera fatal aluminium phosphide be used to guide the immediate emergency and colleagues understandably reacted with department response, or to determine what poisoning caution to an unusual situation. However, personal protective equipment is needed by we consider that, in documenting their staff during the initial confusion of a Allen J Christophers,* Surjit Singh,† David G Goddard‡ experience, they overstated the risk. hazardous materials incident. *Formerly Chief Industrial Hygiene Officer, Victorian Because of the legal and ethical issues In addition to organophosphates, over 30 Health Department, 2/21 Violet Crescent, East involved in patient care in a situation of chemical agents have the potential to be Brighton, VIC 3187; †Additional Professor, alleged risk, we consider that risk estimates Department of Internal Medicine, Postgraduate used as chemical weapons. Furthermore, should, when possible, be based on availa- the toxicity profiles of many industrial Institute of Medical Education and Research, Chandigarh-160012, India; ‡Occupational Physician ble evidence rather than theoretical possi- chemicals are unknown or incomplete. We and Senior Lecturer, Department of Epidemiology and bilities. In general, apart from a few highly do not believe that any hospital or Preventive Medicine, Monash University, Melbourne, toxic, mainly anticholinesterase compounds VIC. emergency department staff should be that can be absorbed through the skin (eg, exposed to avoidable danger during ante- TO THE EDITOR : In their case report sarin and tabun), there are no known mortem or postmortem care of patients, or entitled “Dangerous bodies”, Nocera and poisons that will seriously endanger hospital that healthcare institutions should be colleagues described a case of poisoning staff routinely caring for patients in an exempt from their statutory obligations with aluminium phosphide tablets,1 which emergency department. under occupational health and safety legis- generate the fumigant gas phosphine when lation. Competing interests: The authors have no association exposed to moisture.2 The foul odour with companies that manufacture or market aluminium 1. Nocera A, Levitin HW, Hilton JMN. Dangerous bodies: a emanating from the patient alarmed hospi- phosphide, and had no financial support for case of fatal aluminium phosphide poisoning. Med J Aust tal staff, leading to evacuation of the preparation of this letter. 2000; 173: 133-135. ❏ MJA Vol 176 15 April 2002 403