Teenagers, sex, and risk taking.

ED1TOR,-A C Miller and J E Harvey's guidelines on the management of spontaneous pneumothorax are sensible, well presented, and much needed.' They are relevant to doctors working in accident and emergency as well as general physicians. We wish to make the following points. Firstly, the authors say that the guidelines could be incorporated into "casualty handbooks." Most accident and emergency departments are now adopting and teaching the firmly established guidelines on advanced trauma life support.2 "Inexperienced junior doctors," who have to insert intercostal tubes, will be confused to find another method of inserting tubes advocated. Although there are minor variations in positioning between the guidelines (guidelines for advanced trauma life support recommend the fourth or fifth interspace anterior to the mid-axillary line rather than the fourth, fifth, or sixth interspace in the mid-axillary line), the main difference is that the British Thoracic Society's guidelines recommend use of a trocar. The protocols for advanced trauma life support embody the maxim "do no further harm" and are intended to be safe and life saving, even when followed by inexperienced people. Secondly, even for uncomplicated spontaneous pneumothorax, a size 20-24 French gauge tube is more likely to block or kink than a wider one. To avoid the discomfort of reinsertion, the largest possible tube (at least size 28 French gauge) should be inserted. This is easier with the more anterior approach (favoured in the protocol for advanced trauma life support), where the intercostal space is wider. Perhaps the standards of care committee of the British Thoracic Society should consider the method of inserting an intercostal tube recommended for advanced trauma life support when it next reviews its guidelines. AJ IRELAND