864
Hospital
Practice
events that occur during the course of the baby’s illness are written on the chart as they take place, so that they can be correlated with changes in PaO2. The accuracy of the in-vivo catheter recording of PaO2 is checked by periodic measurements of P 002 in vitro on samples of blood taken via the same catheter.
ADVERSE EFFECTS OF ROUTINE PROCEDURES ON PRETERM INFANTS B. D. SPEIDEL
Special-Care Baby Unit, Southmead General Hospital, Bristol BS10 5NB
Continuous monitoring of arterial oxygen tension (PaO2) in sick neonates has shown that handling the baby for any reason often causes a fall in PaO2. Although the baby usually recovers spontaneously, a series of procedures one following closely upon the other may cause a prolonged fall in PaO2 necessitating respiratory support. This survey showed that infants were being disturbed at hourly or more frequent intervals, often for routine purposes, some of which do not justify the resulting hypoxia. Even simple procedures which are part of neonatal intensive care are hazardous and their routine use should be reconsidered.
RESULTS
Any disturbance of these babies, even for the most minor of procedures, often causes a sharp fall in PaO2. Fig. 1 shows a 2½h continuous PaO2 recording of a baby
Summary
INTRODUCTION
ANYONE caring for the small or sick neonate will be of the deterioration that may occur in the baby’s clinical condition whenever he is handled for diagnostic or therapeutic procedures. If he is disturbed too often, he may be pushed from a stable state into one in which respiratory support is needed; there are al6o definite ’ cases of seriously ill neonates dying as a direct result of the routine procedures in special and intensive-care practices. A policy of minimum handling has therefore been adopted in many neonatal intensive-care units and remote monitoring techniques which do not disturb the baby are used to record heart-rate, respiration, and blood-pressure. The use of techniques which allow the continuous monitoring of either transcutaneous’ or arterial oxygen tension2 shows that the clinical deterioration seen when a baby is handled may be associated with a fall in arterial oxygen tension (P,,02);1,4 this observation has usually been made as part of an evaluation of the apparatus. But since January 1975 the continuous-reading umbilical arterial-oxygen probe has been used in Bristol where it has shown that any procedure carried out on a small or sick neonate can cause a serious fall in Peo2. aware
METHODS
1-Continuous recording of arterial oxygen tension effect of handling on a baby breathing spontaneously.
Fig.
showing
born at 33 weeks gestation (birth-weight 2.06 kg), starting when he was 1½h old. The baby who was breathing 50% inspired oxygen throughout the recording had a relatively stable PaO2 of around 80 mm Hg which fell from 93 to 58 mm Hg during routine nursing observations of his heart-rate, respiratory rate, and temperature and when a heel-stab blood-sample was taken for a ’Dextrostix’ test. From the time at which the Pao2 started to fall, it was 12 min before Pao2 returned to the original level. A similar but more prolonged fall in PaO2 occurred when the house-officer set up an intravenous drip in a vein on the dorsum of the baby’s hand. Shortly after this the baby was lifted slightly in order for an X-ray plate to be slipped under him; the undersheet in the incubator became ruffled and the nurse changed it. As a result of these two events occurring immediately one after the other, the PaO2 continued to fall to 30 mm Hg, at which point the baby had to be treated by nasal continuous positive airway pressure (C.P.A.P.) which rapidly produced an improvement in his Pao2. Even while receiving C.P.A.P. similar falls in PaO2 occurred when he was handled. In the 24 h after the insertion of the umbilical catheter, this baby was handled 32 times for routine observations of vital functions, chest X-rays, setting up an intravenous infusion, blood-sampling, pharyngeal suction, and changing of soiled nappies, and on 24 (75%) of these the Pa02 fell, the average fall being 31 mm Hg. As he recovered he tolerated handling better and the falls in Pa02became less frequent.
This report is of observations made during the routine care of infants admitted to the Special-Care Baby Unit at Southmead Hospital. After admission to this unit the baby’s clinical condition is assessed and a size S FG catheter with an oxygen electrode at its tip (G. D. Searle Ltd.) is inserted into the umbilical artery if the baby (1) has moderate or severe respiratory distress, (2) has a birth-weight of less than 1.3kg, or (3) requires more than 40% inspired oxygen to abolish cyanosis. Whenever possible the catheter is placed in the abdominal aorta with its tip at the level of the third lumbar vertebra, the position being confirmed radiographically. Catheter recordings of P 802 are made continuously on a chart recorder and all
2--Continuous recording of arterial oxygen tension showing effect of spontaneous activity and handling on a baby being treated by nasal C.P.A.P.
Fig.
865
Fig. 3-Continuous recording
of
heart-rate, respiration, and arterial oxygen tension showing effects of handling during routine
procedures.
Fig. 2 shows 2 h of PaO2 recording of a more mature infant born at 36 weeks gestation (birth-weight 2-54 kg). During these 2 h, he was being treated for respiratory distress syndrome by C.P.A.P. given via nasal cannulae. Again the record shows the fall in P a02 when a chest X-ray was taken and during routine observations of vital functions. It also shows how the baby’s movement and struggling caused the P a02 to fall. Fig. 3 shows how the fall in Pao2 is related to the heart-rate and pattern of breathing in an infant who had been born at 30 weeks’ gestation (birth-weight 1 - 3 4 kg) and who had respiratory distress syndrome. The pattern of breathing was recorded with a transthoracic impedance pneumograph using a 4-electrode system. When he was disturbed for a chest X-ray, routine observations, fitting of a urine-collecting bag, setting-up of an intravenous infusion, or blood-samplirig by heel-stab, his Pao2 fell, his breathing showed a crying pattern, and his heart-rate rose a little. Spontaneous crying also produced a fall in Pao2. The inspired oxygen concentration remained unchanged during the three recordings.
DISCUSSION
Since the general condition of very premature those with respiratory distress often deteriorates when the baby is handled, gentle minimum hand-ling has become an important feature of their care. The examples given in this report and the work of Rolfe3 and of Dangman et al. show that even minor disturbances may cause a fall in Pa02 of as much as 30 to 40 mm Hg, and that the policy of minimum handling in Southmead Hospital does not go far enough. The mechanism by which handling of the infant causes his Pao2 to fall is not clear. If a procedure makes a baby apnoeic, then the P a02 will fall. On the other hand, fig. 3 shows that a baby’s usual reaction to handling is crying rather than apnrea, but crying, either induced or spontaneous, does cause a fall in Pao2 in the sick neonate,4 probably by right-to-left shunting of blood via the foramen ovale and ductus arteriosus. The fall in Pao2 has been observed in infants breathing spontaneously and in those being treated by C.P.A.P. In the latter group crying could produce a fall neonates or
the C.P.A.P. seal thus allowing the fall. This pressure explanation applies especially to the nasal system for administering C.P.A.P. I have, however, seen similar falls in P a02 in infants treated by C.P.A.P. given via an endotracheal tube or by a pressured head chamber and in these situations crying would not break the c.P.A.P. seal. Clearly, many clinical procedures which are regarded as an essential part of special or intensive care are not as safe as is thought and their routine practice must be reconsidered. Before handling any sick infant, medical or nursing staff must ask themselves whether the procedure justifies the risk of a fall in the baby’s Pao2, and how the risk can be minimised. An extreme example would be whether a stable PaO2 or a clean nappy was more important. A sheet fouled by urine or meconium is a potential source of infection and must be changed but with minimum disturbance and as infrequently as possible. X-rays must be taken but the infant need not be touched if the incubator were fitted with a cassette tray under the mattress. Intravenous infusions should be done by the most skilled operator in the shortest possible time and if he fails at the first or second attempt, he should stop and let the baby recover before trying again; the same applies to the insertion of umbilical arterial and venous catheters. Blood-samples for dextrostix or other laboratory tests can be obtained via the umbilical-artery catheter instead of by a heel-stab. (The risk of thrombosis from leaving the catheter in place for several days can be reduced if it is used for sampling only and never for the infusion of fluids.) No machine can replace skilled observations by a trained nurse but the routine assessment of heart-rate, respiration, temperature, and blood-pressure can best be obtained by electronic monitoring apparatus, which not only does away with repeated handling of the baby but also provides a continuous display of these variables which is considerably more valuable than hourly observations. It is not only unnecessary to disturb small or seriously ill neonates undergoing intensive care every -1h for several days, but the repeated episodes of iatroin
Pao2 by breaking to
genic hypoxia may also be dangerous. Hence, our watchword must be "hands off". References overleaf
866
Personal
Paper
GERIATRICS IS MEDICINE: BOTH SIDES OF THE FENCE
J. F. HARRISON Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD THE report of the working party of the Royal College Physicians of London on the medical care of the elderly favoured a close relationship between geriatrics and hospital general medicine.’ In June 1975, after 9 years as a full-time consultant general physician, I became a geriatrician in the same health district. Few doctors have made such a move at consultant level, so my personal impressions may have some value. The medical department’s appreciation that it depended on the geriatric service was at the root of my decision. Like most recently appointed physicians, I had had specialist training, further narrowed by research in a particular field; though useful, this had little bearing on most of my clinical work. I was particularly uncertain of my role when it came to managing the common illnesses and emergencies of old age. Partly to deal with this problem my colleagues and I set aside a medical ward for rehabilitation, where we taught ourselves what we now realise was good geriatric practice. When a crisis of consultant staffing occurred in the geriatric department, I was attracted by the opportunity of gaining access to the department’s facilities. Eventually I agreed to become fully committed, after three weeks’ orientation in well-established units elsewhere.
of
QUALMS
At first I had qualms. Physicians tend to take a dim view of geriatrics, and there is no doubt that old people are commonly held in low esteem. I wondered how frustrating it would be to lose responsibility for all adult agegroups, and whether geriatrics would make intellectual demands comparable to those of general medicine. Such misgivings were reinforced by surprised and deprecatory comments from colleagues; even my supporters used words like "courageous". The department had in fact been well developed and fairly generously supplied with resources. Almost my first impression after moving was the obvious sympathy between most of the nurses and their patients, in contrast to the resentment often shown towards old people in medical or surgical wards. It was also evident that we had to ration hospital care. General physicians comparaElderly. Report of the Working Party of the Royal College of Physicians of London. Lancet, 1977, i, 1092.
1. Medical Care of the
DR SPEIDEL:—REFERENCES
1. 2.
Rooth, G. Pediatrics, 1975, 55, 232. Conway, M., Durbin, G. M., Ingram, D., McIntosh, N., Parker, D., Reynolds, E. O.R., Soutter, L. P. ibid. 1976, 57, 244. 3. Rolfe, P. J., Br. J. clin. Eqpt. 1976, 1, 189. 4. Dangman, B. C., Indyk, L., Hegyi, T., Hiatt, I. M., Caceres, F., James, L. S. in Proceedings of the 5th European Congress of Perinatal Medicine (edited by G. Rooth and L. Bratteby); p. 137. Stockholm, 1976.
tively rarely need to limit their services, but geriatric departments are expected to provide relief for chronic dependency, for which the potential demand vastly exceeds what can be supplied. Then there was the workload : I had a scattered holding of five times as many beds, plus the same number of clinics as before, and a flow of referrals for assessment at home and in several hospitals. Although the turnover is slower and the clinic lists shorter with geriatric patients, no general physicians are nowadays appointed with a clinical responsibility like that. Geriatrics also brought an altered perspective. In general medicine elderly patients seem less important than the others, but in a geriatric department to be 70 is still young. One learns to see things through the eyes of the ill and disabled old people themselves ; life for them is often hard, expectations are low, support is not necessarily friendly, and what is going on
steady
is by no means always clear.
INTELLECTUAL CHALLENGE
I find the
commitment
genuinely rewarding. The geriatric department deliberately rations its help to permanently disabled people and other specialties and institutions, while doing its best to help in every case. The organisation allows patients assessed outside to be followed through by the assessing doctor and his team. Treatment programmes are multidisciplinary: members of all disciplines know what is expected of them and look forward to the weekly exchange of ideas in each clinic or ward. Junior medical posts give the widest possible experience with a fair degree of delegated responsibility, and general practitioners are involved with inpatient work. Cooperation extends outside to area social workers, community nurses, family doctors, health visitors, staff in the residential homes and housing department, and many others besides. I have gradually developed a new expertise, needing to know less about new
many aspects of internal medicine but
more
about orth-
opaedics, ophthalmology, neurology, psychiatry, rehabilitation, and social medicine. Preoccupation with research must never jeopardise a first-class service and there are too few geriatricians, but there is enormous scope for original work. Add to this the considerable opportunities for innovation, and the intellectual chal-
lenge is obvious. But satisfaction with the work also depends on recognition of the large contribution that geriatric departments must make to the so-called acute work-load of their district hospitals. Since so much clinical interest would otherwise be lost, ability to meet this obligation is vital for recruitment and the specialty’s future health. The need for interdepartmental transfers is also reduced, helping to preserve continuity of care. In our district the medical and geriatric departments share responsibility for all patients aged 65 and over; each may take any type of case, despite a bias in the geriatric referrals towards the over-75s and patients with locomotor and neurological problems, and in the medical referrals towards the internal-medicine cases.
A BETTER BALANCE
So
why
is
geriatric
medicine
unpopular? One
reason
Hospital
Practice
events that occur during the course of the baby’s illness are written on the chart as they take place, so that they can be correlated with changes in PaO2. The accuracy of the in-vivo catheter recording of PaO2 is checked by periodic measurements of P 002 in vitro on samples of blood taken via the same catheter.
ADVERSE EFFECTS OF ROUTINE PROCEDURES ON PRETERM INFANTS B. D. SPEIDEL
Special-Care Baby Unit, Southmead General Hospital, Bristol BS10 5NB
Continuous monitoring of arterial oxygen tension (PaO2) in sick neonates has shown that handling the baby for any reason often causes a fall in PaO2. Although the baby usually recovers spontaneously, a series of procedures one following closely upon the other may cause a prolonged fall in PaO2 necessitating respiratory support. This survey showed that infants were being disturbed at hourly or more frequent intervals, often for routine purposes, some of which do not justify the resulting hypoxia. Even simple procedures which are part of neonatal intensive care are hazardous and their routine use should be reconsidered.
RESULTS
Any disturbance of these babies, even for the most minor of procedures, often causes a sharp fall in PaO2. Fig. 1 shows a 2½h continuous PaO2 recording of a baby
Summary
INTRODUCTION
ANYONE caring for the small or sick neonate will be of the deterioration that may occur in the baby’s clinical condition whenever he is handled for diagnostic or therapeutic procedures. If he is disturbed too often, he may be pushed from a stable state into one in which respiratory support is needed; there are al6o definite ’ cases of seriously ill neonates dying as a direct result of the routine procedures in special and intensive-care practices. A policy of minimum handling has therefore been adopted in many neonatal intensive-care units and remote monitoring techniques which do not disturb the baby are used to record heart-rate, respiration, and blood-pressure. The use of techniques which allow the continuous monitoring of either transcutaneous’ or arterial oxygen tension2 shows that the clinical deterioration seen when a baby is handled may be associated with a fall in arterial oxygen tension (P,,02);1,4 this observation has usually been made as part of an evaluation of the apparatus. But since January 1975 the continuous-reading umbilical arterial-oxygen probe has been used in Bristol where it has shown that any procedure carried out on a small or sick neonate can cause a serious fall in Peo2. aware
METHODS
1-Continuous recording of arterial oxygen tension effect of handling on a baby breathing spontaneously.
Fig.
showing
born at 33 weeks gestation (birth-weight 2.06 kg), starting when he was 1½h old. The baby who was breathing 50% inspired oxygen throughout the recording had a relatively stable PaO2 of around 80 mm Hg which fell from 93 to 58 mm Hg during routine nursing observations of his heart-rate, respiratory rate, and temperature and when a heel-stab blood-sample was taken for a ’Dextrostix’ test. From the time at which the Pao2 started to fall, it was 12 min before Pao2 returned to the original level. A similar but more prolonged fall in PaO2 occurred when the house-officer set up an intravenous drip in a vein on the dorsum of the baby’s hand. Shortly after this the baby was lifted slightly in order for an X-ray plate to be slipped under him; the undersheet in the incubator became ruffled and the nurse changed it. As a result of these two events occurring immediately one after the other, the PaO2 continued to fall to 30 mm Hg, at which point the baby had to be treated by nasal continuous positive airway pressure (C.P.A.P.) which rapidly produced an improvement in his Pao2. Even while receiving C.P.A.P. similar falls in PaO2 occurred when he was handled. In the 24 h after the insertion of the umbilical catheter, this baby was handled 32 times for routine observations of vital functions, chest X-rays, setting up an intravenous infusion, blood-sampling, pharyngeal suction, and changing of soiled nappies, and on 24 (75%) of these the Pa02 fell, the average fall being 31 mm Hg. As he recovered he tolerated handling better and the falls in Pa02became less frequent.
This report is of observations made during the routine care of infants admitted to the Special-Care Baby Unit at Southmead Hospital. After admission to this unit the baby’s clinical condition is assessed and a size S FG catheter with an oxygen electrode at its tip (G. D. Searle Ltd.) is inserted into the umbilical artery if the baby (1) has moderate or severe respiratory distress, (2) has a birth-weight of less than 1.3kg, or (3) requires more than 40% inspired oxygen to abolish cyanosis. Whenever possible the catheter is placed in the abdominal aorta with its tip at the level of the third lumbar vertebra, the position being confirmed radiographically. Catheter recordings of P 802 are made continuously on a chart recorder and all
2--Continuous recording of arterial oxygen tension showing effect of spontaneous activity and handling on a baby being treated by nasal C.P.A.P.
Fig.
865
Fig. 3-Continuous recording
of
heart-rate, respiration, and arterial oxygen tension showing effects of handling during routine
procedures.
Fig. 2 shows 2 h of PaO2 recording of a more mature infant born at 36 weeks gestation (birth-weight 2-54 kg). During these 2 h, he was being treated for respiratory distress syndrome by C.P.A.P. given via nasal cannulae. Again the record shows the fall in P a02 when a chest X-ray was taken and during routine observations of vital functions. It also shows how the baby’s movement and struggling caused the P a02 to fall. Fig. 3 shows how the fall in Pao2 is related to the heart-rate and pattern of breathing in an infant who had been born at 30 weeks’ gestation (birth-weight 1 - 3 4 kg) and who had respiratory distress syndrome. The pattern of breathing was recorded with a transthoracic impedance pneumograph using a 4-electrode system. When he was disturbed for a chest X-ray, routine observations, fitting of a urine-collecting bag, setting-up of an intravenous infusion, or blood-samplirig by heel-stab, his Pao2 fell, his breathing showed a crying pattern, and his heart-rate rose a little. Spontaneous crying also produced a fall in Pao2. The inspired oxygen concentration remained unchanged during the three recordings.
DISCUSSION
Since the general condition of very premature those with respiratory distress often deteriorates when the baby is handled, gentle minimum hand-ling has become an important feature of their care. The examples given in this report and the work of Rolfe3 and of Dangman et al. show that even minor disturbances may cause a fall in Pa02 of as much as 30 to 40 mm Hg, and that the policy of minimum handling in Southmead Hospital does not go far enough. The mechanism by which handling of the infant causes his Pao2 to fall is not clear. If a procedure makes a baby apnoeic, then the P a02 will fall. On the other hand, fig. 3 shows that a baby’s usual reaction to handling is crying rather than apnrea, but crying, either induced or spontaneous, does cause a fall in Pao2 in the sick neonate,4 probably by right-to-left shunting of blood via the foramen ovale and ductus arteriosus. The fall in Pao2 has been observed in infants breathing spontaneously and in those being treated by C.P.A.P. In the latter group crying could produce a fall neonates or
the C.P.A.P. seal thus allowing the fall. This pressure explanation applies especially to the nasal system for administering C.P.A.P. I have, however, seen similar falls in P a02 in infants treated by C.P.A.P. given via an endotracheal tube or by a pressured head chamber and in these situations crying would not break the c.P.A.P. seal. Clearly, many clinical procedures which are regarded as an essential part of special or intensive care are not as safe as is thought and their routine practice must be reconsidered. Before handling any sick infant, medical or nursing staff must ask themselves whether the procedure justifies the risk of a fall in the baby’s Pao2, and how the risk can be minimised. An extreme example would be whether a stable PaO2 or a clean nappy was more important. A sheet fouled by urine or meconium is a potential source of infection and must be changed but with minimum disturbance and as infrequently as possible. X-rays must be taken but the infant need not be touched if the incubator were fitted with a cassette tray under the mattress. Intravenous infusions should be done by the most skilled operator in the shortest possible time and if he fails at the first or second attempt, he should stop and let the baby recover before trying again; the same applies to the insertion of umbilical arterial and venous catheters. Blood-samples for dextrostix or other laboratory tests can be obtained via the umbilical-artery catheter instead of by a heel-stab. (The risk of thrombosis from leaving the catheter in place for several days can be reduced if it is used for sampling only and never for the infusion of fluids.) No machine can replace skilled observations by a trained nurse but the routine assessment of heart-rate, respiration, temperature, and blood-pressure can best be obtained by electronic monitoring apparatus, which not only does away with repeated handling of the baby but also provides a continuous display of these variables which is considerably more valuable than hourly observations. It is not only unnecessary to disturb small or seriously ill neonates undergoing intensive care every -1h for several days, but the repeated episodes of iatroin
Pao2 by breaking to
genic hypoxia may also be dangerous. Hence, our watchword must be "hands off". References overleaf
866
Personal
Paper
GERIATRICS IS MEDICINE: BOTH SIDES OF THE FENCE
J. F. HARRISON Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD THE report of the working party of the Royal College Physicians of London on the medical care of the elderly favoured a close relationship between geriatrics and hospital general medicine.’ In June 1975, after 9 years as a full-time consultant general physician, I became a geriatrician in the same health district. Few doctors have made such a move at consultant level, so my personal impressions may have some value. The medical department’s appreciation that it depended on the geriatric service was at the root of my decision. Like most recently appointed physicians, I had had specialist training, further narrowed by research in a particular field; though useful, this had little bearing on most of my clinical work. I was particularly uncertain of my role when it came to managing the common illnesses and emergencies of old age. Partly to deal with this problem my colleagues and I set aside a medical ward for rehabilitation, where we taught ourselves what we now realise was good geriatric practice. When a crisis of consultant staffing occurred in the geriatric department, I was attracted by the opportunity of gaining access to the department’s facilities. Eventually I agreed to become fully committed, after three weeks’ orientation in well-established units elsewhere.
of
QUALMS
At first I had qualms. Physicians tend to take a dim view of geriatrics, and there is no doubt that old people are commonly held in low esteem. I wondered how frustrating it would be to lose responsibility for all adult agegroups, and whether geriatrics would make intellectual demands comparable to those of general medicine. Such misgivings were reinforced by surprised and deprecatory comments from colleagues; even my supporters used words like "courageous". The department had in fact been well developed and fairly generously supplied with resources. Almost my first impression after moving was the obvious sympathy between most of the nurses and their patients, in contrast to the resentment often shown towards old people in medical or surgical wards. It was also evident that we had to ration hospital care. General physicians comparaElderly. Report of the Working Party of the Royal College of Physicians of London. Lancet, 1977, i, 1092.
1. Medical Care of the
DR SPEIDEL:—REFERENCES
1. 2.
Rooth, G. Pediatrics, 1975, 55, 232. Conway, M., Durbin, G. M., Ingram, D., McIntosh, N., Parker, D., Reynolds, E. O.R., Soutter, L. P. ibid. 1976, 57, 244. 3. Rolfe, P. J., Br. J. clin. Eqpt. 1976, 1, 189. 4. Dangman, B. C., Indyk, L., Hegyi, T., Hiatt, I. M., Caceres, F., James, L. S. in Proceedings of the 5th European Congress of Perinatal Medicine (edited by G. Rooth and L. Bratteby); p. 137. Stockholm, 1976.
tively rarely need to limit their services, but geriatric departments are expected to provide relief for chronic dependency, for which the potential demand vastly exceeds what can be supplied. Then there was the workload : I had a scattered holding of five times as many beds, plus the same number of clinics as before, and a flow of referrals for assessment at home and in several hospitals. Although the turnover is slower and the clinic lists shorter with geriatric patients, no general physicians are nowadays appointed with a clinical responsibility like that. Geriatrics also brought an altered perspective. In general medicine elderly patients seem less important than the others, but in a geriatric department to be 70 is still young. One learns to see things through the eyes of the ill and disabled old people themselves ; life for them is often hard, expectations are low, support is not necessarily friendly, and what is going on
steady
is by no means always clear.
INTELLECTUAL CHALLENGE
I find the
commitment
genuinely rewarding. The geriatric department deliberately rations its help to permanently disabled people and other specialties and institutions, while doing its best to help in every case. The organisation allows patients assessed outside to be followed through by the assessing doctor and his team. Treatment programmes are multidisciplinary: members of all disciplines know what is expected of them and look forward to the weekly exchange of ideas in each clinic or ward. Junior medical posts give the widest possible experience with a fair degree of delegated responsibility, and general practitioners are involved with inpatient work. Cooperation extends outside to area social workers, community nurses, family doctors, health visitors, staff in the residential homes and housing department, and many others besides. I have gradually developed a new expertise, needing to know less about new
many aspects of internal medicine but
more
about orth-
opaedics, ophthalmology, neurology, psychiatry, rehabilitation, and social medicine. Preoccupation with research must never jeopardise a first-class service and there are too few geriatricians, but there is enormous scope for original work. Add to this the considerable opportunities for innovation, and the intellectual chal-
lenge is obvious. But satisfaction with the work also depends on recognition of the large contribution that geriatric departments must make to the so-called acute work-load of their district hospitals. Since so much clinical interest would otherwise be lost, ability to meet this obligation is vital for recruitment and the specialty’s future health. The need for interdepartmental transfers is also reduced, helping to preserve continuity of care. In our district the medical and geriatric departments share responsibility for all patients aged 65 and over; each may take any type of case, despite a bias in the geriatric referrals towards the over-75s and patients with locomotor and neurological problems, and in the medical referrals towards the internal-medicine cases.
A BETTER BALANCE
So
why
is
geriatric
medicine
unpopular? One
reason
