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Original article

and unfamiliar categories as relevant to the emergency


preparedness, and evaluate the relative importance of each
category according to their perceived influence on the emergency preparedness.
We believe that all elements of infrastructure and equipment
are important to assure preparedness to manage pandemic
influenza, and that the parameters which were validated by the
modified Delphi method should be implemented as part of the
contingency plan for pandemic influenza.

CONCLUSIONS
This study contributes to the identification of benchmarks in
the infrastructure and equipment required for managing an
outbreak of pandemic influenza and for evaluating the level of
preparedness of hospitals. It would appear that the initiative
and leadership taken by the MOH in requiring hospitals to
develop pandemic influenza preparedness programmes, in
conjunction with the ongoing evaluation process of and the
level of emergency preparedness, encourages and motivates the
maintenance of a high level of hospital preparedness. The
significant relationship between maintaining stockpiles of
antiviral medications for patients and staff and performance
in an avian flu drill emphasises the importance of procuring
effective functional stockpiles in accordance with the relevant
threats and risk assessments in order to assure emergency
preparedness.

Competing interests: None.


Provenance and peer review: Not commissioned; externally peer reviewed.

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Images in emergency medicine


Winged scapula as the presenting
symptom of GuillainBarre syndrome
An 18-year-old British girl with long-standing traumatic winging of the scapula on the right side (from a sports injury) noticed
spontaneous winging of the scapula on the left side with no
other associated symptoms. The following day she developed
left upper limb weakness, which then progressed to weakness of
her other limbs. Her weakness was more pronounced in the
upper limbs. All limbs were more weak proximally than distally.
Cerebrospinal fluid analysis showed raised protein (0.5 g/l) and
electrophysiological studies showed findings (absent F waves)
consistent with GuillainBarre syndrome. She was treated with
5 days of intravenous immunoglobulins and an extensive
physiotherapy programme. She made a full recovery in 8 weeks
with complete resolution of the winging of the scapula on the
left side. Physicians must be aware that GuillainBarre
syndrome can rarely present with winging of the scapula as
the first symptom/sign.

Figure 1 The photograph taken during the rehabilitation phase shows


the prominent traumatic winging on the right side and the resolving
winging (caused by GuillainBarre syndrome) on the left side.
Correspondence to: Dr M Sivan, Department of Rehabilitation Medicine, Chapel
Allerton Hospital, Leeds, UK; drmanojsivan@yahoo.com
Competing interests: None.
Patient consent: Obtained.

M Sivan, A Hassan

Accepted 2 October 2008

Leeds Teaching Hospitals NHS Trust, Leeds, UK

Emerg Med J 2009;26:790. doi:10.1136/emj.2008.066613

790

Emerg Med J November 2009 Vol 26 No 11

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