did we not bring the patient into the hospital to deliver the baby? Why had we delivered the baby outside in the cold, knowing that something could have happened to the baby out there? I kept quiet, wishing only that he had been there to witness our predicament. When I returned to the ED with the nurses, all was still quiet. We looked at each other and smiled, and then I ordered coffee for everyone. The day-shift nurses ar- rived an hour later, and the night-shift nurses had a long story to tell them. My resident came in, and I told him he had missed all the action. The next day, I was off call but came in for the monthly staff meeting. I went to the labor and delivery department to see the new mother. Her room was full of flowers. “It’s a boy!” a sign proclaimed. She told me that her two other children had come out quickly, like this baby— but that they had come out onto the delivery table. A few other people also were in the room and were joking and smiling. Among them was a man holding a collection of balloons in his hand. I recognized him as the cab driver. I asked the mother if she had decided on a name for the baby. The cab driver eagerly offered his suggestion. “I think we should name him ‘Cougar—the cab baby,’ ” he said. The reason became clear as we learned that the old cab with the burned-out interior light was a Mer- cury Cougar. Everyone in the room smiled. “I wish I had told him to fix his cab light,” I thought as I walked back to the ED offices. Rajesh Gupta, MD Department of Emergency Medicine Kaiser Permanente Medical Center Fresno, California doi:10.1016/S0736-4679(02)00743-6 Acknowledgment—The Medical Editing Department, Kaiser Foundation Hospitals, provided editorial assistance. e SPONTANEOUS RUPTURE OF ARTERIOVENOUS FISTULA IN A CHRONIC DIALYSIS PATIENT Hemodialysis is one of the treatment modes in end-stage renal disease, however, various complications due to hemodialysis may be observed. Thrombosis of arterio- venous fistula, excessive flow through fistula, high-out- put cardiac failure, hypotension, carpal tunnel syndrome, ipsilateral limb hypertrophy, arm edema, and stasis der- matitis have been reported (1–5). Herein, we report spon- taneous rupture of arteriovenous fistula in a chronic dialysis patient. A 7-year-old boy was followed in our hospital with the diagnosis of chronic renal failure and underwent hemodialysis for 2 years. Recently, he was admitted to our hospital with a 1-week history of redness, swelling and pain on the left proximal forearm in the arterio- venous fistula region. The personal and family history were unremarkable. On physical examination, weight and length were 22 kg (25 th –50 th percentile) and 108 cm (below the 3 rd percentile), respectively. Body tempera- ture was 36.5°C; pulse rate 72 beats/min (rhythmic); respiration rate 24 breaths/min; and arterial blood pres- sure 120/80 mm Hg. His general condition was good. Redness, swelling, and pain were noted in the arterio- venous fistula region. A systolic murmur III/VI degree was also noted on the mesocardiac focus. He was anuric. Laboratory investigations revealed the following results: hemoglobin 6.5 g/dl, white blood cell count 6800/mm 3 , thrombocyte count 262,000/mm 3 . Blood glucose level was 85 mg/dl; serum sodium 136 mmol/L; potassium 6.4 mmol/L; chloride 96 mmol/L; blood urea nitrogen 113 mg/dl; creatinine 9.7 mg/dl; calcium 9 mg/dl; phospho- rus 7.4 mg/dl; alkaline phosphatase 807 U/L; uric acid 12.1 mg/dl; aspartate aminotransferase 57 U/L; alanine aminotransferase 373 U/L; total protein 5.7 g/dl; and albumin 2.9 g/dl. Partial thromboplastin time was 28 s, and prothrombin time was 14 s. A thorax radiograph was normal. An echocardiographic examination was unre- markable. The patient was hospitalized with the diagno- sis of soft tissue infection of the arteriovenous fistula. The fistula was not used and hemodialysis was continued by jugular catheter. In addition, an operation for a new arteriovenous fistula was planned. Aside from local ther- apy, cefazolin (100 mg/kg/day) plus metronidazole (30 mg/kg/day) were initiated in order to treat the soft tissue infection. Additionally, he continued to use amlodipin and enalapril as antihypertensive agents, which had been initiated about 1 year ago. On the 4 th day of admission, spontaneous rupture of the arteriovenous fistula occurred and abundant bleeding was noted. Just before that time the arterial pressure was very high (170/130 mm Hg). The ruptured vessels were ligated. After the operation, the patient’s general condition improved and a blood transfusion (15 cc/kg) was given. The antibiotic therapy was given for 14 days and he was then discharged from the hospital. This patient revealed that spontaneous rupture of ar- teriovenous fistula may be seen in chronic dialysis pa- tients. We think that both the severe hypertension and local soft tissue infection facilitated rupture of the arte- riovenous fistula. Therefore, we suggest that chronic dialysis patients, particularly those with soft tissue infec- 224 Letters to the Editor