and unfamiliar categories as relevant to the emergencypreparedness, and evaluate the relative importance of eachcategory according to their perceived influence on the emer-gency preparedness.

We believe that all elements of infrastructure and equipmentare important to assure preparedness to manage pandemicinfluenza, and that the parameters which were validated by themodified Delphi method should be implemented as part of thecontingency plan for pandemic influenza.

CONCLUSIONSThis study contributes to the identification of benchmarks inthe infrastructure and equipment required for managing anoutbreak of pandemic influenza and for evaluating the level ofpreparedness of hospitals. It would appear that the initiativeand leadership taken by the MOH in requiring hospitals todevelop pandemic influenza preparedness programmes, inconjunction with the ongoing evaluation process of and thelevel of emergency preparedness, encourages and motivates themaintenance of a high level of hospital preparedness. Thesignificant relationship between maintaining stockpiles ofantiviral medications for patients and staff and performancein an avian flu drill emphasises the importance of procuringeffective functional stockpiles in accordance with the relevantthreats and risk assessments in order to assure emergencypreparedness.

Competing interests: None.

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

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Winged scapula as the presentingsymptom of GuillainBarre syndrome

An 18-year-old British girl with long-standing traumatic wing-ing of the scapula on the right side (from a sports injury) noticedspontaneous winging of the scapula on the left side with noother associated symptoms. The following day she developedleft upper limb weakness, which then progressed to weakness ofher other limbs. Her weakness was more pronounced in theupper limbs. All limbs were more weak proximally than distally.Cerebrospinal fluid analysis showed raised protein (0.5 g/l) andelectrophysiological studies showed findings (absent F waves)consistent with GuillainBarre syndrome. She was treated with5 days of intravenous immunoglobulins and an extensivephysiotherapy programme. She made a full recovery in 8 weekswith complete resolution of the winging of the scapula on theleft side. Physicians must be aware that GuillainBarresyndrome can rarely present with winging of the scapula asthe first symptom/sign.

M Sivan, A Hassan

Leeds Teaching Hospitals NHS Trust, Leeds, UK

Correspondence to: Dr M Sivan, Department of Rehabilitation Medicine, ChapelAllerton Hospital, Leeds, UK; drmanojsivan@yahoo.com

Competing interests: None.

Patient consent: Obtained.

Accepted 2 October 2008

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

Figure 1 The photograph taken during the rehabilitation phase showsthe prominent traumatic winging on the right side and the resolvingwinging (caused by GuillainBarre syndrome) on the left side.

Images in emergency medicine

Original article

790 Emerg Med J November 2009 Vol 26 No 11

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