BRITISH MEDICAL JOURNAL
20
OCTOBER
1979
1005
for intraperitoneal use and preliminary clinical or to have the solution prepared in the sterile make it a relatively simple matter for the results with them are proving to be most products division of the hospital pharmacy in responsibility for care, including admissions, to be accorded to nurses. This, however, those places where such provision exists. encouraging. should release specialists not to do vaguely M K BROWNE C F SCURR defined consultant work in the community Monklands District General Hospital, Airdrie, Lanarkshire (unless we are looking for a declining number Magill Department of Anaesthetics, of preretirement jobs) but to concentrate in School, Medical 603. Westminster 85, J. Surgery, 1979, Stephen, M, and Lowenthal, much greater depth on the psychiatric aspects 2Moynihan, B, Abdominal Operations, vol 2, p 113. London SWlP 2AP London, Saunders, 1926, 2, 113. of the care and treatment of the mentally 3Maingot, R, Abdominal Operations, 6th edn, vol 2, 'Blogg, C E, Ramsey, M A E, and Jarvis, J D, British handicapped. p 1416. New York, Appleton-Century, 1974. journal of Anaesthesia, 1974, 46, 260. 4Anne, S, and Normanne, E, Acta Chirurgia ScandiPioneering work on this has already been Scurr, C F, and Edgar, W M, Lancet, 1962, 1, 1303. navica, 1970, 136, 401. done in Dundee (and elsewhere) and there is 5 Silaev, Y S, Vestnik Khirurgii IImeni I I Grekova, 1960, 85, 38. now a chair with this title in London. Much Burnett, W E, Pennsylvania MedicalJoturnal, 1961, 64, more needs to be done in this area, however, 497. Stewart, D J, and Mathieson, N A, British 3'ournal of Unwanted journals than has been achieved in the past by lone Surgery, 1978, 65, 57. workers, often against considerable odds. 8Hau, T, Payne, W D, and Simmons, R I, Surgery, Gynaecology and Obstetrics, 1979, 148, 415. SIR, The issue Dr R E Simmons raises is by RHAs should cut out the dead wood of O'Leary, J P et al, Surgery, Gynaecology and Obstetrics, no means an OLVPS-a One Lone Voice consultant responsibility that amounts to a 1979, 148, 571. Hopkin, D A B, Lancet, 1978, 2, 1193. Protesting Subject. I would like to support charade in clinical terms, reduce their conSindelar, W F, and Mason, G R, Surgery, Gynaecology him in his criticism (6 October, p 867) of the sultant establishments, and use the money they and Obstetrics, 1979, 148, 409. Browne, M K, and Stoller, J, British J'ournal of way doctors get bombarded with unsolicited save to follow the example of authorities south Surgery, 1970, 57, 525. Browne, M K, Mackenzie, M, and Doyle, P J, Sturgery, journals. He receives World Medicine only of the Thames-that is, fund academic departGytnaecology and Obstetrics, 1978, 146, 721. because last June he signed a card asking us to ments in the psychiatry of mental handicap, '' Pfirrmann, R W, and Leslie, G B, J7ournal of Applied send it to him. We send World Medicine with senior staff having service commitments, Bacteriology, 1979, 46, 97. only to doctors who within the previous three at the local universities and medical schools. years have signed a card requesting it. And This strategy may involve sacrifices by some many moons ago we instructed our distribu- existing consultants, but if there is a conviction tors not to let our list of readers be used for that such work needs to be done a way must Barbiturate hypnotics distribution of other journals or promotional be found out of the ravages that have characterised this field since the watershed public events SIR,-Insomnia is a symptom, a complaint. literature. MICHAEL O'DONNELL of 1967. The Committee on the Review of Medicines Editor, World Medicine T L PILKINGTON concludes (22 September, p 719) that "severe, London SW1Y 4EL intractable insomnia" (presumably the persistStockton on Tees, Cleveland TS18 5DQ ently complaining patient) provides an indica' Royal College of Psychiatrists, British J7ournal of tion for the prescription of barbiturate Psychiatry, suppl News and Notes, December 1973, Deployment of mental handicap hypnotics. p 2. 2 Brook, P, Bulletin of the Royal College of Psychiatrists, Pain too is a symptom. Another four years specialists January 1979, p 7. of deliberations may enable the committee to conclude that the complaint of severe, intract- SIR,-Dr D A Spencer (6 October, p 863) able abdominal pain is an indication for the rightly draws attention to the crisis in the number of psychiatrists specialising in mental Clinical practice and community prescription of daily enemas. In the resurgence of Edwardian medicine handicap, but his suggestion that consultants mediclne should be appointed to districts rather than prescriptions shall be written in Latin. hospitals was put forward by Mrs Barbara SIR,-With reference to Professor E D IAN OSWALD Castle in February 1974. She then promoted a Acheson's "Clinical practice and community package that also contained the National medicine" (6 October, p 880), when are University Department of Psychiatry, Royal Edinburgh Hospital, Development Group for the Mentally Handi- community physicians going to realise that Edinburgh EH10 5HF capped and the Jay Inquiry into mental credibility has to be earned by the effective handicap nursing; this predictably caused practice of their own specialty rather than by disruptions, not least among the consultant aping their clinical colleagues ? force. The role of the community physician is Contamination of injections In 1973 the total number of consultants in complex,' and requires a wide knowledge base SIR,-The inconvenient report of Blogg et al,1 mental handicap in England and Wales was and traverses a number of disciplines. A synwhich confirms my own previous findings2 that 183.1 At that time the Royal College of thesis of medical knowledge and understanding at least 501" of syringes have their contents Psychiatrists said that a realistic minimum was together with knowledge in the field of the contaminated by the second refill, implies that 375 and the ideal 500. Five years later, behavioural sciences, economics, epidemiology, present methods of preparing thiopentone according to the Medical Directory, the statistics, etc, enables the community physician injections are unsatisfactory. Even when a number has fallen to 162. Over 200% of these to take the broad approach to health that is his single dose is prepared from an ampoule of are from overseas and, on the basis of a repre- brief. It is essential for the community water drawn up, transferred to the thiopentone sentative sample, it seems that 48 % are over physician to view the total picture if he is to powder for solution, and aspirated again into 50 and only 400 under 40. During 1974-7 no make an impact on health, and assuming any the syringe ready for use, this danger is appointments were made in 42 % of the clinical responsibilities will diminish his ability registrar posts advertised in mental sub- to practise community medicine. It is his job present. Obsessed by theoretical dangers of decanting normality and reservations were expressed to see the forest rather than to deal with the in the preparation of solutions in multidose about a further 18 ,/ of the successful appli- individual trees. If it is medical knowledge he (100 ml) containers, the manufacturers-en- cants.2 The assessors of the college reported is seeking, this is more effectively gained by couraged by the DHSS-now supply the that "the calibre of those interviewed seemed reading the journals and attending postwater in narrow-necked bottles and advise that particularly low in subnormality." The graduate meetings. Trainees in community medicine hankering the solution should be prepared by syringe national development team devoted less aspiration of the water and its injection into the than 1 / of its first report to the role of con- after clinical work should question their thiopentone container. Clearly one cannot use sultants and there is no evidence that its motives for choosing the specialty and ask one 20-ml syringe five times because of the "community units" attract "new consultant themselves whether they are actually commitdangers mentioned above. Should we use five blood" to their associated multidisciplinary ted to the underlying concepts. It may be that in seeking a clinical role they are opting out of fresh syringes and further syringes when the teams. As Dr Spencer points out, it is an impossible the more difficult task that constitutes the solution is injected into patients ? This seems wasteful-so would the use of a disposable and task for a consultant to be responsible for prime function of the community physician. hundreds of inpatients, and neither is this As a community physician I respect my cumbersome 100-ml syringe. The alternatives seem to be to use a special necessary. Whether or not the patients require clinical colleagues for the clinical expertise transfer needle to couple the two bottles (such nursing care (and most do not), the present that they exhibit. I am delighted when 'they needles are not currently available in the UK), arrangements for nursing accountability would take an interest in the wider aspects of health "
20
OCTOBER
1979
1005
for intraperitoneal use and preliminary clinical or to have the solution prepared in the sterile make it a relatively simple matter for the results with them are proving to be most products division of the hospital pharmacy in responsibility for care, including admissions, to be accorded to nurses. This, however, those places where such provision exists. encouraging. should release specialists not to do vaguely M K BROWNE C F SCURR defined consultant work in the community Monklands District General Hospital, Airdrie, Lanarkshire (unless we are looking for a declining number Magill Department of Anaesthetics, of preretirement jobs) but to concentrate in School, Medical 603. Westminster 85, J. Surgery, 1979, Stephen, M, and Lowenthal, much greater depth on the psychiatric aspects 2Moynihan, B, Abdominal Operations, vol 2, p 113. London SWlP 2AP London, Saunders, 1926, 2, 113. of the care and treatment of the mentally 3Maingot, R, Abdominal Operations, 6th edn, vol 2, 'Blogg, C E, Ramsey, M A E, and Jarvis, J D, British handicapped. p 1416. New York, Appleton-Century, 1974. journal of Anaesthesia, 1974, 46, 260. 4Anne, S, and Normanne, E, Acta Chirurgia ScandiPioneering work on this has already been Scurr, C F, and Edgar, W M, Lancet, 1962, 1, 1303. navica, 1970, 136, 401. done in Dundee (and elsewhere) and there is 5 Silaev, Y S, Vestnik Khirurgii IImeni I I Grekova, 1960, 85, 38. now a chair with this title in London. Much Burnett, W E, Pennsylvania MedicalJoturnal, 1961, 64, more needs to be done in this area, however, 497. Stewart, D J, and Mathieson, N A, British 3'ournal of Unwanted journals than has been achieved in the past by lone Surgery, 1978, 65, 57. workers, often against considerable odds. 8Hau, T, Payne, W D, and Simmons, R I, Surgery, Gynaecology and Obstetrics, 1979, 148, 415. SIR, The issue Dr R E Simmons raises is by RHAs should cut out the dead wood of O'Leary, J P et al, Surgery, Gynaecology and Obstetrics, no means an OLVPS-a One Lone Voice consultant responsibility that amounts to a 1979, 148, 571. Hopkin, D A B, Lancet, 1978, 2, 1193. Protesting Subject. I would like to support charade in clinical terms, reduce their conSindelar, W F, and Mason, G R, Surgery, Gynaecology him in his criticism (6 October, p 867) of the sultant establishments, and use the money they and Obstetrics, 1979, 148, 409. Browne, M K, and Stoller, J, British J'ournal of way doctors get bombarded with unsolicited save to follow the example of authorities south Surgery, 1970, 57, 525. Browne, M K, Mackenzie, M, and Doyle, P J, Sturgery, journals. He receives World Medicine only of the Thames-that is, fund academic departGytnaecology and Obstetrics, 1978, 146, 721. because last June he signed a card asking us to ments in the psychiatry of mental handicap, '' Pfirrmann, R W, and Leslie, G B, J7ournal of Applied send it to him. We send World Medicine with senior staff having service commitments, Bacteriology, 1979, 46, 97. only to doctors who within the previous three at the local universities and medical schools. years have signed a card requesting it. And This strategy may involve sacrifices by some many moons ago we instructed our distribu- existing consultants, but if there is a conviction tors not to let our list of readers be used for that such work needs to be done a way must Barbiturate hypnotics distribution of other journals or promotional be found out of the ravages that have characterised this field since the watershed public events SIR,-Insomnia is a symptom, a complaint. literature. MICHAEL O'DONNELL of 1967. The Committee on the Review of Medicines Editor, World Medicine T L PILKINGTON concludes (22 September, p 719) that "severe, London SW1Y 4EL intractable insomnia" (presumably the persistStockton on Tees, Cleveland TS18 5DQ ently complaining patient) provides an indica' Royal College of Psychiatrists, British J7ournal of tion for the prescription of barbiturate Psychiatry, suppl News and Notes, December 1973, Deployment of mental handicap hypnotics. p 2. 2 Brook, P, Bulletin of the Royal College of Psychiatrists, Pain too is a symptom. Another four years specialists January 1979, p 7. of deliberations may enable the committee to conclude that the complaint of severe, intract- SIR,-Dr D A Spencer (6 October, p 863) able abdominal pain is an indication for the rightly draws attention to the crisis in the number of psychiatrists specialising in mental Clinical practice and community prescription of daily enemas. In the resurgence of Edwardian medicine handicap, but his suggestion that consultants mediclne should be appointed to districts rather than prescriptions shall be written in Latin. hospitals was put forward by Mrs Barbara SIR,-With reference to Professor E D IAN OSWALD Castle in February 1974. She then promoted a Acheson's "Clinical practice and community package that also contained the National medicine" (6 October, p 880), when are University Department of Psychiatry, Royal Edinburgh Hospital, Development Group for the Mentally Handi- community physicians going to realise that Edinburgh EH10 5HF capped and the Jay Inquiry into mental credibility has to be earned by the effective handicap nursing; this predictably caused practice of their own specialty rather than by disruptions, not least among the consultant aping their clinical colleagues ? force. The role of the community physician is Contamination of injections In 1973 the total number of consultants in complex,' and requires a wide knowledge base SIR,-The inconvenient report of Blogg et al,1 mental handicap in England and Wales was and traverses a number of disciplines. A synwhich confirms my own previous findings2 that 183.1 At that time the Royal College of thesis of medical knowledge and understanding at least 501" of syringes have their contents Psychiatrists said that a realistic minimum was together with knowledge in the field of the contaminated by the second refill, implies that 375 and the ideal 500. Five years later, behavioural sciences, economics, epidemiology, present methods of preparing thiopentone according to the Medical Directory, the statistics, etc, enables the community physician injections are unsatisfactory. Even when a number has fallen to 162. Over 200% of these to take the broad approach to health that is his single dose is prepared from an ampoule of are from overseas and, on the basis of a repre- brief. It is essential for the community water drawn up, transferred to the thiopentone sentative sample, it seems that 48 % are over physician to view the total picture if he is to powder for solution, and aspirated again into 50 and only 400 under 40. During 1974-7 no make an impact on health, and assuming any the syringe ready for use, this danger is appointments were made in 42 % of the clinical responsibilities will diminish his ability registrar posts advertised in mental sub- to practise community medicine. It is his job present. Obsessed by theoretical dangers of decanting normality and reservations were expressed to see the forest rather than to deal with the in the preparation of solutions in multidose about a further 18 ,/ of the successful appli- individual trees. If it is medical knowledge he (100 ml) containers, the manufacturers-en- cants.2 The assessors of the college reported is seeking, this is more effectively gained by couraged by the DHSS-now supply the that "the calibre of those interviewed seemed reading the journals and attending postwater in narrow-necked bottles and advise that particularly low in subnormality." The graduate meetings. Trainees in community medicine hankering the solution should be prepared by syringe national development team devoted less aspiration of the water and its injection into the than 1 / of its first report to the role of con- after clinical work should question their thiopentone container. Clearly one cannot use sultants and there is no evidence that its motives for choosing the specialty and ask one 20-ml syringe five times because of the "community units" attract "new consultant themselves whether they are actually commitdangers mentioned above. Should we use five blood" to their associated multidisciplinary ted to the underlying concepts. It may be that in seeking a clinical role they are opting out of fresh syringes and further syringes when the teams. As Dr Spencer points out, it is an impossible the more difficult task that constitutes the solution is injected into patients ? This seems wasteful-so would the use of a disposable and task for a consultant to be responsible for prime function of the community physician. hundreds of inpatients, and neither is this As a community physician I respect my cumbersome 100-ml syringe. The alternatives seem to be to use a special necessary. Whether or not the patients require clinical colleagues for the clinical expertise transfer needle to couple the two bottles (such nursing care (and most do not), the present that they exhibit. I am delighted when 'they needles are not currently available in the UK), arrangements for nursing accountability would take an interest in the wider aspects of health "
