Email has transformed communication in the National Health Service. Handling a torrent of unfocused communication is a potential burden on the clinician's time and a source of stress at work. A prospective study of the number of emails, links and attachments received during a 14-day period by four doctors of an emergency department has revealed the large number of emails received, with consultants receiving more emails than registrars. The time required to merely read this mass communication is substantial. It is suggested that time needs to be allocated to handle emails and that doctors may benefit from training on how to handle them.

Flecainide can "organise" atrial fibrillation into atrial flutter with 1:1 conduction, leading to cardiovascular compromise. The treatment of atrial fibrillation in the emergency department is often complex and depends on several factors, including time of onset of atrial fibrillation and previously known cardiac disease. Current guidelines include flecainide as a possible treatment for chemical cardioversion and maintaining sinus rhythm in paroxysmal atrial fibrillation.1 2 an important, under-recognised complication of flecainide is the transformation of rhythm from atrial fibrillation to atrial flutter. We present four such cases.

OBJECTIVE: to determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury. DESIGN: Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care. SETTING: Five emergency departments in southwest England. PARTICIPANTS: 2127 adults and children presenting to the emergency department with acute elbow injury. INTERVENTION: Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children. MAIN OUTCOME MEASURES: Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days. RESULTS: of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children. CONCLUSION: the elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.