Correspondence also showed that even secondary skin ulceration does not necessarily require surgical intervention. Previous reports indicate that traumatic pediatric superficial palmar arch pseudoaneurysms have all been treated surgically.3-5 For the emergency medicine provider, awareness of this potential complication from penetrating trauma is important, and bedside ultrasonography can rapidly identify the diagnosis. Given the paucity of literature on this condition, we recommend that all cases be immediately referred to a specialist, who should decide the optimal management on a case-by-case basis. We agree with the sentiments of Cozzi et al that a conservative approach with compression bandages and close observation may be the best first-line therapy. J. Matthew Fields, MD Leah Orchowski, CRNP Department of Emergency Medicine Thomas Jefferson University Philadelphia, PA

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see The authors have stated that no such relationships exist. 1. Ceccanti S, Frediani S, Andreoli GM, et al. Effective compression bandage for repair of a complicated radial artery pseudoaneurysm. Ann Vasc Surg. 2014. 2. Fields JM, Chandra S, Au AK, et al. Images in emergency medicine. Child with painful palmar mass. Superficial palmar arch pseudoaneurysm. Ann Emerg Med. 2013;62:569, 577. 3. Hughes CD, Binette C, Babigian A. Pseudoaneurysm in the hand of a three-year-old boy: a case report. J Emerg Med. 2012;42:e87-e89. 4. Cozzi DA, Zani A, Pacilli M, et al. Uncomplicated iatrogenic pseudoaneurysm of the superficial palmar arch treated by excision and vascular reconstruction. J Pediatr Surg. 2004;39:1302. 5. Franck D, Christophe S, Michel P. False aneurysm of the palmar arch in a child. J Pediatr Surg. 2004;39:117-119.

Extreme Sporting Events and Transport-Mitigating Strategies: An Australian Perspective To the Editor: We read with interest your case series of patients presenting from a Tough Mudder event.1 We were particularly interested in your relatively high patienttransport-to-hospital rate (38 patients in 22,000: patient transfer rate of 1.72/1,000) and your recommendation for enhanced event medical coverage at future events. We have 10 years of experience with providing field medical teams at mass-gathering events in Australia. Our out-of-hospital medical team deployments specifically aim to reduce presentations Volume 64, no. 2 : August 2014

to emergency departments and spread the surge of presentations spatially and temporally throughout the health care system.2,3 We deploy a comprehensive field medical emergency response. This includes first aid responders (who meet the Australian First Responder Standard), in-field transport, and a medical tent staffed by volunteer experienced medical practitioners, paramedics, and nurses. We describe below our experiences providing medical services through a structured first aid and medical team model at Tough Mudder in Australia. In late March 2012, we led the on-site medical team for the first Tough Mudder event held in Australia. This event appears similar to yours, with 22,000 participants attempting an equivalent number and nature of obstacles during 2 consecutive days. Notably, 2 “10,000-volt electric shock” obstacles were also present at this event. From the 22,000 competitors, we had 441 patients present for first aid or medical attention during the 2 days: 315 first aid and 126 through the medical team at the finish line. Of the 126 patients treated in our onsite field hospital, many received treatment that avoided the need for ambulance transport to the hospital, including reduction of shoulder dislocations (12), stabilization of distal limb fractures (12), cleaning and suturing of lacerations (26), and assessment of numerous other soft tissue, eye, and ear injuries. There were no serious injuries from the electric shock obstacles (unpublished data).3 Our transport-to-hospital rate is significantly less than that described in your series (0.13 versus 1.72/1,000 event participants; P

Extreme sporting events and transport-mitigating strategies: an Australian perspective.

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