methanesulphonate (P2S)) in a dose of 30 mg/kg body weight intravenously every four to six hours until full recovery. Although the importance of supportive measures and atropine cannot be underestimated, adults severely poisoned with organophosphorus compounds are likely to need 8-12 g pralidoxime daily for as long as the features of poisoning are present. So called "treatment failures" and "clinical relapses" after initial treatment with pralidoxime may well be due to inadequate oxime regimens, such as that proposed by Dr Hodgetts of only 2 g pralidoxime daily. Sustained therapeutic oxime concentrations could never be achieved in an adult by such a dosage regimen. In contrast, Dr Hodgetts advocates that very large doses of atropine (2-4 mg every five to 10 minutes) should be given. Even in severe cases such high doses are likely to be required for only a short period if the patient is receiving adequate supportive care and effective oxime therapy. The contents of this lettcr represent the authors' views alone and in no wax commit the Department of Health. J A VALE West Alidlands l'oisons Unit, DUcdlcy Road Hospital, Birmaingham BIS 7QH T J MEREDITH Division of 'oxicology and Environmental Health, Department of Health, London 1 Hodgetts TJ. Update box for "Oxford handboo)k of clinical medicine." B.1O7 1991;302:389. (16 February. 2 Sundwall A. Minimum concentration of N-methylpyridinitum-2aldoxime tttethanesulphonate (P.S which rcverse neuromuscular block. Biochem Pharmacol 1961;8:413-7. st M NMaksimovic MNi. 3 Bokon jic D, Jovanovic D, Jokanovic Protcticve effects of oximes H1-6 and PAiM1-2 applied by osiuotic minipumps in quinalphos-polsoned rats. Archives Internationales de Pharmacodvnamet 1987;288:309-18. 4 Shiloff JD, Clement JG. Comparison of serum concentrations of the acetvlcholinesterase oxime reactivators HI-6, obidoxime, and PAMi to efficacy against Sarin tisopropl) methvlphosphonofluoridate) poisoning in rats. Toxicol Appl Pharmacol
1987;89:278-80.
SIR,-Dr T J Hodgetts points out that delayed polyneuropathy may develop after poisoning with organophosphorus compounds.' Earlier he had drawn attention to the similarities between organophosphorus insecticides and nerve agents. In fact, there are several major differences, both structural (nerve agents tend to be fluoridated organophosphonates, while pesticides are phosphates, phosphonates, and corresponding thioates) and in their clinical effects. In particular, similarities may well not extend to the likelihood of delayed polyneuropathy after recovery from poisoning, and the suggestion that they might may cause alarm among those who may have to care for casualties of chemical warfare. The fundamental reason why different organophosphates have different potential to produce delayed neuropathy at acutely equitoxic doses is that structure-activity relations for the inhibition of acetylcholinesterase (the target enzyme in acute poisoning) and neuropathy target esterase (the target enzyme in delayed polyneuropathy) are quite different. Some assessment of the likelihood of polyneuropathy occurring can be made by comparing, in vitro, the concentration of a given organophosphorus compound necessary to produce 50% inhibition of acetylcholinesterase with that required to produce a similar inhibition of neuropathy target esterase. Gordon et al used this approach and gave the following ratios-: diisopropyl phosphorofluoridate 1-13; mipafox 1 8; sarin 0 0056; soman 0 0012; tabun 0 0005; and VX 10 6. Thus the compounds diisopropyl phosphorofluoridate and mipafox, which produce delayed neuropathy, have ratios greater than 1 while the ratio for the nerve agents is much less than 1. Gordon et al pointed out that, though the use
BMJ
VOLUME
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20 APRIL 1991
of inhibition ratios may underestimate the neuropathic potency of the nerve agents, in the avian model the neuropathic dose of sarin was 30 times the median lethal dose and the estimated neurotoxic doses of soman and tabun were 100-150 times the median lethal dose. Clearly exposure to such large doses is unlikely. Dr Hodgetts states that oximes are effective only within 24-36 hours. For treatment of poisoning with organophosphorus pesticide there is a strong rational basis and supportive clinical evidence that persisting with pralidoxime treatment may be beneficial long beyond the 24-36 hours often quoted.' In severe intoxication administration of oxime should continue until the patient's clinical condition has improved irreversibly; this may take as long as five to 14 days. R I. MAYNARD T C MARRS
Toxicology and Environmental Health Division, Department of Health, London SE1 6TE M K JOHNSON MRC Toxicology Laboratories,
Carshalton, Surrey SM5 4EF I Hodgetts TJ. Update box for "Oxford handbox)k of clinical medicine." RMJ 1991;302:389. (16 February.) 2 Gordon JJ, Inns RH, Johnson MK, et al. The delayed neuropathic effects of nerve agents and some other organophosphorus compounds. Arch Toxicol 1983;51:71-82. 3 International Programme on Chemical Safety. Antidotes for patsoning bty organophosphorus compounds. Geneva: International Programme on Chemical Safety in press,i.
AUTHORS' REPLY,--The effective plasma concentrations suggested by Drs Vale and Meredith were derived from observations in anaesthetised cats given lethal doses of sarin. Animal experimentation certainly serves as a guideline to treatment of intoxication in humans, but large doses of pralidoxime can produce neuromuscular block' and even inhibition of acetylcholinesterase. The maximum daily dose suggested for adults is 12 g.' Importantly, it is reported that intramuscular injections of only 7 5 or 10 mg/kg body weight have produced plasma concentrations exceeding the therapeutic value of 4 mg/l that experimental data indicate is necessary. We agree that pralidoxime should be continued for as long as the organophosphorus compound or its active metabolites are present in the body, and it is in these situations that caution is required to prevent pralidoxime toxicity. Management of poisoning with organophosphorus insecticide has been successful with dose regimens varying from 1 g in 24 hours to 1 g six hourly.4 When measurements of biochemical variables for assessing severity of intoxication are not available it would be dangerous to administer potentially toxic doses of pralidoxime. In patients with severe bradyvcardia, miosis, and profuse secretions 2-4 mg doses of atropine intravenously need to be repeated at five to 10 minutes initially until signs of atropinisation occur; clinically it is necessary to ensure that mild atropinisation is maintained until such time as the organophosphorus agent or its metabolites are no longer present. Many workers have observed that several hundreds of milligrams of atropine will be needed in the course of treatment."' As regards "clinical relapses" being a result of inadequate oxime regimens, this remains a theoretical supposition requiring clinical corroboration. T J HODGETTS
L. KARALLIEDDE Queen Elizabeth Military Hospital, Lonldon SE18 4Q H Reynolds J. ed. Martintdale the extra phtarmacopeia. 28th cd. London: I'harmaceutical Press, 1982:389. 2 British Medical Association and Roval Plharmaceutical Society of Great Britaitt. British natiotal forrnula-rv tzumber 20. London: BIMIA and Pharmacetttical Prcss, 1990):22.
3 Sidcil F, (iroff'\. Intramuscular and intravenous admiiistration of small doses of 2-pyridinium aldoxime methiwhloride in man.7 Pharm Sc-i 1971;60:1224. 4 Ecohichon D, Ozere R, Reid E, ei al. Acute tetiltrothion poisoning. Can led Assoc 7 1977;116:377. 5 (iolsotisidis H, Kokkas V. Use of' 19,590 mg of atropline durinig 24 days of treatment aftcr a case of unusually severe parathiott poisoning. Hum Toxicol 1985;4:339-40. 6 Warriner R, Nies A, Haves W. Severe organophosphatc p)isoning complicated by alcohol and turpentine ingcstionl. Arch Environ Health 1977;32:2(03-5.
Cold weather burns SIR,-Recently the BMJ has reported increased numbers of myocardial infarctions' and sledging injuries occurring during the recent cold weather. To an extent both of these increases could be predicted; however, during the same cold spell we experienced an unexpected cluster of injuriesnamely, burns related to snow. Heavy snow on the evening of 7 December resulted in Derby and many surrounding towns and villages being cut off by road, and over a large part of Derbyshire power cables were brought down, leaving many thousands of homes without electricity and heating. As a result people were forced to use portable gas heaters, candles, and hot water bottles to keep warm. Unfortunately, many basic safety precautions were ignored, leading to a sudden increase in the number of patients with burns presenting to the Derbyshire Royal Infirmary. During the 48 hours following the snowfall a total of 12 people attended with burns (over the previous weekends there was an average of three burns cases). Of these, four injuries were unrelated to snow (one acid burn, one burn from overindulgence on a sunbed, and two patients burned in a house fire). The other eight all cited the weather as a factor in the injury. Four patients scalded hands and arms pouring hot water into flasks and hot water bottles (in some cases, in the dark). Three injuries resulted from flashbacks from gas stoves or heaters, and one patient had a candle burn. One patient required inpatient treatment for an extensive flash burn to his face, trunk, and hands. In our view these injuries could have been avoided if patients had taken simple safety precautions and we would advise that should this situation occur again, local radio should be used to issue safety guidelines. G HINCHLEY A AHMED Accident and Emergency Department, Derbvshire Roval Infirmar, Derby DEI 2QY I Heppell R, Hawley SK, Channe KS. Snow shoveller's infarction. BI7 1991;302:469-70. (23 February. j 2 Cohen B, Shewring D, Chapman P. Sledging in jtiries. 13M7
1991;302:596. (9 March.
Diving into the unknown SIR,-The editorial by Mr David Grundy and colleagues emphasises that diving into shallow water is hazardous and may cause serious spinal injury.' Diving accidents also occur in activities that are not related to water sports. A peculiar and dangerous new sport has appeared in recent years -namely, stage diving. This takes place at pop concerts, when spectators climb on to the stage or speaker stacks and dive into the crowd, who endeavour to catch them and thereby break their fall. A variant on this is bar diving, which is performed by customers of crowded public houses. Not surprisingly, these activities can result in serious injury to the limbs and spine. An 18 year old male shop assistant was stage diving at a pop concert but was caught inexpertly and fell, landing heavily on to his flexed neck. Initially he had pain in the neck and both arms, but he had full power and sensation. Radiographs of
963
his cervical spine suggested an extensive posterior ligament tear with instability at the level of C6-7. His injury was initially treated with a firm polythene neck collar. Subsequent flexion and extension radiographs showed instability with subluxation of C6 on C7. This was stabilised by bone grafting and fixation with Halifax hooks. Spinal injuries that result from diving accidents are underreported and not confined to water sports. As noted by Mr Grundy and colleagues, alcohol and bravado compound this problem. Pop events may provide the right ingredients for such accidents to occur. C L M H GIBBONS A D McLAIN A H R W SIMPSON Accident Service, John Radcliltfc Hospital, Oxford 0X3 9DU 1 (Grundv E, Penny P, Graham L. Diving into the unknown.
BJfj
1991;302:670-1. (23 March.)
Mental handicap and guardianship SIR,-Under the Mental Health (Scotland) Act 1984, the term "mental impairment" refers only to compulsory admission to hospital -therefore there is no requirement for a diagnosis ofmental handicap to be accompanied by "abnormally aggressive or seriously irresponsible behaviour" before an application for guardianship can be made. Certainly the conditions in the particular case described in "Any Questions"' would indeed seem to warrant an application for guardianship under the Mental Health (Scotland) Act 1984. The difficulty is that guardianship is in no way an emergency procedure. SHEILA McDONALD
lMiental Health Unit, Gogarburn Hospital, Edinburgh EH12 9BJ I Tiplady P. Any questions. BdM] 1991 ;302:517. (2 M\larch.)
practitioners themselves. The distribution of cases was extremely uneven: 41 practices had only one each, but another 40 practices had from four to eight cases each. The number in a practice seemed unrelated to the number of partners. Our statistics contain some flaws, but the general picture in the north seems similar to that near London. Long term mentally ill patients include several distinct management groups, among them manicdepressive patients with frequent illnesses possibly controlled by lithium, schizophrenic patients receiving oral drugs only or no drugs, and elderly patients with paraphrenia or depression quite apart from dementia (one quarter of the 2000 patients receiving depot neuroleptic drugs in our survey were aged 60 or more, an age group imperfectly considered by Dr Kendrick and colleagues). The uneven scatter of these varied cases, always in small numbers in a practice, makes it difficult for general practitioners to recognise their special features and handle them well, and both in South West Thames and the north general practitioners favour the community psychiatric nurse assuming responsibility for them. In my opinion the aftercare of long term mentally ill patients in the community would be much improved if community psychiatric nurses were formally recognised everywhere as the key workers. This would mean for them some increase in status as medical auxiliaries, with some more specific training, and the right to refer cases to a general practitioner, psychiatrist, or social worker and (after teaching and experience) to vary the prescription of a limited range of neuroleptic and antiparkinsonian drugs and lithium carbonate. This should be within the NHS and not under local authorities to ensure even standards, adequate staff and funds, and an ease in following cases across local authority boundaries as a proportion of the patients can be mobile. Those patients who are lost because they will not go to see their doctor may be willing to accept the visit of a nurse. Perhaps the royal colleges of nursing, general practitioners, and psychiatrists could jointly develop an acceptable national scheme to improve community care through a formal role for community psychiatric nurses. JOHN CRAMMER
GPs and long term mentally ill patients SIR,-Dr 'fony Kendrick and colleagues report the results of questioning 369 general practitioners in South West Thames region about their workload from long term mentally ill patients in their practices, and their opinions on who should be the key worker for these patients.' 'fhey note that nearly half the general practitioners replying were in group practices of three to five partners and that the patients were widely but unevenly distributed, with at most 10 in one practice and often far fewer. It was hard for general practitioners to keep in touch with them, and most general practitioners wanted the community psychiatric nurse to assume responsibility for them for regular care, and referral when necessary to specialist agencies (including general practitioners themselves for physical care). In 1987 we made a somewhat similar survev as a pilot project on behalf of the research committee of the Royal College of Psychiatrists in a different part of England far from London-the Northern region, which includes Cumbria, Cleveland, and Newcastle.` In addition to asking general practitioners for their opinions we inquired about the specific work they did for patients with chronic schizophrenia who were receiving monthly injections of a depot neuroleptic drug. Of the 686 general practitioners who replied, only 125 had such patients on their lists: there were 445 patients, a quarter of whom were actually being seen regularly by community psychiatric nurses, the rest by practice nurses, health visitors, or general
964
Steeple Aston, Oxfordshire OX5 3SE 1 Kendrick T, Sibbauld B, Burns T, Freeling P. Role of general practitioners in care of long term mentally ill patients. BMJ 1991;302:508-10. (2 March.) 2 Crammer J, Eccleston D. A sttrvey of the use of depot neuroleptics in a whole region. Psychiatric Bulletin 1989;13:517-20.
Violence in general practice SIR, -Dr John Hulbert suggests that threats and verbal abuse do not form part of a continuum with physical assault.' He also proposes that assaults on doctors are not common enough to have merited their recent publicity. McNeil and Binder examined the relation between threats of violence in the two weeks before admission to an acute psychiatric ward and subsequent physical assaults.2 They found that 32% of patients making threats assaulted someone within three days of their admission. Similar findings were reported by Werner et al, who found that a third of verbally aggressive patients in their series subsequently committed assault. They also showed that 80% of assaults were preceded by verbal aggression.3 Although these studies were of psychiatric populations, there seems no reason to doubt that other client groups exhibit a similar progression. Indeed, a recent Health Services Advisory Committee report recognised the potential for threats and verbal aggression to escalate to violence and emphasised the importance of training staff to recognise warning signs.4 Dr Hulbert reports that two deputising doctors
in his service have been assaulted "with injury": such figures are often underestimates. There is evidence that assaults on staff are underreported, particularly if guidelines are not provided on which incidents to report. Staff may also be afraid that they will be held responsible for the incident having occurred.5 The Health Services Advisory Committee has recommended that each workplace should have a system for reporting any violent incident with a patient or patient's relative, whether or not it led to damage or injury.4 Adequate training significantly reduces both physical assaults and injuries to staff.6 If assaults on health care professionals are to be reduced it is necessary to accept both that they occur and that they are preventable. Every effort should be made to improve the reporting of violent incidents (including those not resulting in injury), to facilitate training in the recognition and management of aggression, and to provide support when incidents occur. This support should not take the form of victim blaming. We believe that the acceptance of violence as an inevitable part of medicine is the greatest barrier to its reduction, and we agree with Adler et al that it is important to state that physical aggression has no place in the health care system.7 CAMERON STARK
Argyll and Clyde Health Board, Paisley PA I I DU BRIAN KIDD Southern General Hospital, Glasgow G5 1 1 Hulbert J. Violence in general practice. BMJ 1991;302:658. (16 March.) 2 McNeil DE, Binder RL. Relationship between pre-admission threats and later violent behaviour by acute psychiatric patients. Hosp Community Psychiatry 1989;40:605-8. 3 Werner PD, Yesavage JA, BeckerJM, Brunsting DW, Isaacs JS. Hostile words and assaultive behaviour on an acute inpatient psychiatric unit.J Nerv Ment Dis 1983;171:385-7. 4 Health Services Advisory Committee. Violence to staff in the health ser-vices. London: Health and Safety Commission, 1987. 5 Lion JR, Snyder W, Merrill GL. Underreporting of assaults on staff in a state hospital. Hosp Community Psychiatry 198 1;32:497-8. 6 Infantino JA, Musingo S. Assaults and injuries among staff with and without training in aggression control- techniques. Hosp Community Psychiatry 1985;36:1312-4. 7 Adler WN, Kreeger C, Ziegler P. Patient violence in a private psychiatric hospital. In: Lion JR, Reid WH, eds. Assaults within psychiatric facilities. New York: Grune and Stratton, 1983.
Health check ups in middle age SIR,-I am puzzled as to how Professor Kozo Tatara and colleagues are able to conclude from their data that the use of health checks has caused the lower morbidity in the elderly population-it seems almost trite to point out that all they have shown is an association. To begin with, the Health Services Act was passed only in 1982, so it is difficult to see how the population who were screened (aged 40 or over) relates to the population who required less inpatient care (aged 70 or over). What is more, the paper does not provide any information about the social class structure of the cities, smoking habit, intake of alcohol, etc. Given what we already know about the use of screening services (that they are used most by those in higher social classes with healthier lifestyles and least by those who really need them), is it not equally likely that the rate of attendance for health screening is simply a marker of compliance with "healthy" behaviour? Until we are given more data I feel that it would be extremely unwise to suppose that elderly people are going to be healthier because they are offered more health screening in middle life. ROGER A FISKEN Royal Liverpool Hospital, Liverpool L7 8XP 1 Tatara K, Sinsho F, Suzuki M, et al. Relation between use of health checkups starting in middle age and demand for inpatient care by elderly people in Japan. BMJ7 1991;302: 615-8. (16 March.)
BMJ
VOLUME 302
20 APRIL 1991
1987;89:278-80.
SIR,-Dr T J Hodgetts points out that delayed polyneuropathy may develop after poisoning with organophosphorus compounds.' Earlier he had drawn attention to the similarities between organophosphorus insecticides and nerve agents. In fact, there are several major differences, both structural (nerve agents tend to be fluoridated organophosphonates, while pesticides are phosphates, phosphonates, and corresponding thioates) and in their clinical effects. In particular, similarities may well not extend to the likelihood of delayed polyneuropathy after recovery from poisoning, and the suggestion that they might may cause alarm among those who may have to care for casualties of chemical warfare. The fundamental reason why different organophosphates have different potential to produce delayed neuropathy at acutely equitoxic doses is that structure-activity relations for the inhibition of acetylcholinesterase (the target enzyme in acute poisoning) and neuropathy target esterase (the target enzyme in delayed polyneuropathy) are quite different. Some assessment of the likelihood of polyneuropathy occurring can be made by comparing, in vitro, the concentration of a given organophosphorus compound necessary to produce 50% inhibition of acetylcholinesterase with that required to produce a similar inhibition of neuropathy target esterase. Gordon et al used this approach and gave the following ratios-: diisopropyl phosphorofluoridate 1-13; mipafox 1 8; sarin 0 0056; soman 0 0012; tabun 0 0005; and VX 10 6. Thus the compounds diisopropyl phosphorofluoridate and mipafox, which produce delayed neuropathy, have ratios greater than 1 while the ratio for the nerve agents is much less than 1. Gordon et al pointed out that, though the use
BMJ
VOLUME
302
20 APRIL 1991
of inhibition ratios may underestimate the neuropathic potency of the nerve agents, in the avian model the neuropathic dose of sarin was 30 times the median lethal dose and the estimated neurotoxic doses of soman and tabun were 100-150 times the median lethal dose. Clearly exposure to such large doses is unlikely. Dr Hodgetts states that oximes are effective only within 24-36 hours. For treatment of poisoning with organophosphorus pesticide there is a strong rational basis and supportive clinical evidence that persisting with pralidoxime treatment may be beneficial long beyond the 24-36 hours often quoted.' In severe intoxication administration of oxime should continue until the patient's clinical condition has improved irreversibly; this may take as long as five to 14 days. R I. MAYNARD T C MARRS
Toxicology and Environmental Health Division, Department of Health, London SE1 6TE M K JOHNSON MRC Toxicology Laboratories,
Carshalton, Surrey SM5 4EF I Hodgetts TJ. Update box for "Oxford handbox)k of clinical medicine." RMJ 1991;302:389. (16 February.) 2 Gordon JJ, Inns RH, Johnson MK, et al. The delayed neuropathic effects of nerve agents and some other organophosphorus compounds. Arch Toxicol 1983;51:71-82. 3 International Programme on Chemical Safety. Antidotes for patsoning bty organophosphorus compounds. Geneva: International Programme on Chemical Safety in press,i.
AUTHORS' REPLY,--The effective plasma concentrations suggested by Drs Vale and Meredith were derived from observations in anaesthetised cats given lethal doses of sarin. Animal experimentation certainly serves as a guideline to treatment of intoxication in humans, but large doses of pralidoxime can produce neuromuscular block' and even inhibition of acetylcholinesterase. The maximum daily dose suggested for adults is 12 g.' Importantly, it is reported that intramuscular injections of only 7 5 or 10 mg/kg body weight have produced plasma concentrations exceeding the therapeutic value of 4 mg/l that experimental data indicate is necessary. We agree that pralidoxime should be continued for as long as the organophosphorus compound or its active metabolites are present in the body, and it is in these situations that caution is required to prevent pralidoxime toxicity. Management of poisoning with organophosphorus insecticide has been successful with dose regimens varying from 1 g in 24 hours to 1 g six hourly.4 When measurements of biochemical variables for assessing severity of intoxication are not available it would be dangerous to administer potentially toxic doses of pralidoxime. In patients with severe bradyvcardia, miosis, and profuse secretions 2-4 mg doses of atropine intravenously need to be repeated at five to 10 minutes initially until signs of atropinisation occur; clinically it is necessary to ensure that mild atropinisation is maintained until such time as the organophosphorus agent or its metabolites are no longer present. Many workers have observed that several hundreds of milligrams of atropine will be needed in the course of treatment."' As regards "clinical relapses" being a result of inadequate oxime regimens, this remains a theoretical supposition requiring clinical corroboration. T J HODGETTS
L. KARALLIEDDE Queen Elizabeth Military Hospital, Lonldon SE18 4Q H Reynolds J. ed. Martintdale the extra phtarmacopeia. 28th cd. London: I'harmaceutical Press, 1982:389. 2 British Medical Association and Roval Plharmaceutical Society of Great Britaitt. British natiotal forrnula-rv tzumber 20. London: BIMIA and Pharmacetttical Prcss, 1990):22.
3 Sidcil F, (iroff'\. Intramuscular and intravenous admiiistration of small doses of 2-pyridinium aldoxime methiwhloride in man.7 Pharm Sc-i 1971;60:1224. 4 Ecohichon D, Ozere R, Reid E, ei al. Acute tetiltrothion poisoning. Can led Assoc 7 1977;116:377. 5 (iolsotisidis H, Kokkas V. Use of' 19,590 mg of atropline durinig 24 days of treatment aftcr a case of unusually severe parathiott poisoning. Hum Toxicol 1985;4:339-40. 6 Warriner R, Nies A, Haves W. Severe organophosphatc p)isoning complicated by alcohol and turpentine ingcstionl. Arch Environ Health 1977;32:2(03-5.
Cold weather burns SIR,-Recently the BMJ has reported increased numbers of myocardial infarctions' and sledging injuries occurring during the recent cold weather. To an extent both of these increases could be predicted; however, during the same cold spell we experienced an unexpected cluster of injuriesnamely, burns related to snow. Heavy snow on the evening of 7 December resulted in Derby and many surrounding towns and villages being cut off by road, and over a large part of Derbyshire power cables were brought down, leaving many thousands of homes without electricity and heating. As a result people were forced to use portable gas heaters, candles, and hot water bottles to keep warm. Unfortunately, many basic safety precautions were ignored, leading to a sudden increase in the number of patients with burns presenting to the Derbyshire Royal Infirmary. During the 48 hours following the snowfall a total of 12 people attended with burns (over the previous weekends there was an average of three burns cases). Of these, four injuries were unrelated to snow (one acid burn, one burn from overindulgence on a sunbed, and two patients burned in a house fire). The other eight all cited the weather as a factor in the injury. Four patients scalded hands and arms pouring hot water into flasks and hot water bottles (in some cases, in the dark). Three injuries resulted from flashbacks from gas stoves or heaters, and one patient had a candle burn. One patient required inpatient treatment for an extensive flash burn to his face, trunk, and hands. In our view these injuries could have been avoided if patients had taken simple safety precautions and we would advise that should this situation occur again, local radio should be used to issue safety guidelines. G HINCHLEY A AHMED Accident and Emergency Department, Derbvshire Roval Infirmar, Derby DEI 2QY I Heppell R, Hawley SK, Channe KS. Snow shoveller's infarction. BI7 1991;302:469-70. (23 February. j 2 Cohen B, Shewring D, Chapman P. Sledging in jtiries. 13M7
1991;302:596. (9 March.
Diving into the unknown SIR,-The editorial by Mr David Grundy and colleagues emphasises that diving into shallow water is hazardous and may cause serious spinal injury.' Diving accidents also occur in activities that are not related to water sports. A peculiar and dangerous new sport has appeared in recent years -namely, stage diving. This takes place at pop concerts, when spectators climb on to the stage or speaker stacks and dive into the crowd, who endeavour to catch them and thereby break their fall. A variant on this is bar diving, which is performed by customers of crowded public houses. Not surprisingly, these activities can result in serious injury to the limbs and spine. An 18 year old male shop assistant was stage diving at a pop concert but was caught inexpertly and fell, landing heavily on to his flexed neck. Initially he had pain in the neck and both arms, but he had full power and sensation. Radiographs of
963
his cervical spine suggested an extensive posterior ligament tear with instability at the level of C6-7. His injury was initially treated with a firm polythene neck collar. Subsequent flexion and extension radiographs showed instability with subluxation of C6 on C7. This was stabilised by bone grafting and fixation with Halifax hooks. Spinal injuries that result from diving accidents are underreported and not confined to water sports. As noted by Mr Grundy and colleagues, alcohol and bravado compound this problem. Pop events may provide the right ingredients for such accidents to occur. C L M H GIBBONS A D McLAIN A H R W SIMPSON Accident Service, John Radcliltfc Hospital, Oxford 0X3 9DU 1 (Grundv E, Penny P, Graham L. Diving into the unknown.
BJfj
1991;302:670-1. (23 March.)
Mental handicap and guardianship SIR,-Under the Mental Health (Scotland) Act 1984, the term "mental impairment" refers only to compulsory admission to hospital -therefore there is no requirement for a diagnosis ofmental handicap to be accompanied by "abnormally aggressive or seriously irresponsible behaviour" before an application for guardianship can be made. Certainly the conditions in the particular case described in "Any Questions"' would indeed seem to warrant an application for guardianship under the Mental Health (Scotland) Act 1984. The difficulty is that guardianship is in no way an emergency procedure. SHEILA McDONALD
lMiental Health Unit, Gogarburn Hospital, Edinburgh EH12 9BJ I Tiplady P. Any questions. BdM] 1991 ;302:517. (2 M\larch.)
practitioners themselves. The distribution of cases was extremely uneven: 41 practices had only one each, but another 40 practices had from four to eight cases each. The number in a practice seemed unrelated to the number of partners. Our statistics contain some flaws, but the general picture in the north seems similar to that near London. Long term mentally ill patients include several distinct management groups, among them manicdepressive patients with frequent illnesses possibly controlled by lithium, schizophrenic patients receiving oral drugs only or no drugs, and elderly patients with paraphrenia or depression quite apart from dementia (one quarter of the 2000 patients receiving depot neuroleptic drugs in our survey were aged 60 or more, an age group imperfectly considered by Dr Kendrick and colleagues). The uneven scatter of these varied cases, always in small numbers in a practice, makes it difficult for general practitioners to recognise their special features and handle them well, and both in South West Thames and the north general practitioners favour the community psychiatric nurse assuming responsibility for them. In my opinion the aftercare of long term mentally ill patients in the community would be much improved if community psychiatric nurses were formally recognised everywhere as the key workers. This would mean for them some increase in status as medical auxiliaries, with some more specific training, and the right to refer cases to a general practitioner, psychiatrist, or social worker and (after teaching and experience) to vary the prescription of a limited range of neuroleptic and antiparkinsonian drugs and lithium carbonate. This should be within the NHS and not under local authorities to ensure even standards, adequate staff and funds, and an ease in following cases across local authority boundaries as a proportion of the patients can be mobile. Those patients who are lost because they will not go to see their doctor may be willing to accept the visit of a nurse. Perhaps the royal colleges of nursing, general practitioners, and psychiatrists could jointly develop an acceptable national scheme to improve community care through a formal role for community psychiatric nurses. JOHN CRAMMER
GPs and long term mentally ill patients SIR,-Dr 'fony Kendrick and colleagues report the results of questioning 369 general practitioners in South West Thames region about their workload from long term mentally ill patients in their practices, and their opinions on who should be the key worker for these patients.' 'fhey note that nearly half the general practitioners replying were in group practices of three to five partners and that the patients were widely but unevenly distributed, with at most 10 in one practice and often far fewer. It was hard for general practitioners to keep in touch with them, and most general practitioners wanted the community psychiatric nurse to assume responsibility for them for regular care, and referral when necessary to specialist agencies (including general practitioners themselves for physical care). In 1987 we made a somewhat similar survev as a pilot project on behalf of the research committee of the Royal College of Psychiatrists in a different part of England far from London-the Northern region, which includes Cumbria, Cleveland, and Newcastle.` In addition to asking general practitioners for their opinions we inquired about the specific work they did for patients with chronic schizophrenia who were receiving monthly injections of a depot neuroleptic drug. Of the 686 general practitioners who replied, only 125 had such patients on their lists: there were 445 patients, a quarter of whom were actually being seen regularly by community psychiatric nurses, the rest by practice nurses, health visitors, or general
964
Steeple Aston, Oxfordshire OX5 3SE 1 Kendrick T, Sibbauld B, Burns T, Freeling P. Role of general practitioners in care of long term mentally ill patients. BMJ 1991;302:508-10. (2 March.) 2 Crammer J, Eccleston D. A sttrvey of the use of depot neuroleptics in a whole region. Psychiatric Bulletin 1989;13:517-20.
Violence in general practice SIR, -Dr John Hulbert suggests that threats and verbal abuse do not form part of a continuum with physical assault.' He also proposes that assaults on doctors are not common enough to have merited their recent publicity. McNeil and Binder examined the relation between threats of violence in the two weeks before admission to an acute psychiatric ward and subsequent physical assaults.2 They found that 32% of patients making threats assaulted someone within three days of their admission. Similar findings were reported by Werner et al, who found that a third of verbally aggressive patients in their series subsequently committed assault. They also showed that 80% of assaults were preceded by verbal aggression.3 Although these studies were of psychiatric populations, there seems no reason to doubt that other client groups exhibit a similar progression. Indeed, a recent Health Services Advisory Committee report recognised the potential for threats and verbal aggression to escalate to violence and emphasised the importance of training staff to recognise warning signs.4 Dr Hulbert reports that two deputising doctors
in his service have been assaulted "with injury": such figures are often underestimates. There is evidence that assaults on staff are underreported, particularly if guidelines are not provided on which incidents to report. Staff may also be afraid that they will be held responsible for the incident having occurred.5 The Health Services Advisory Committee has recommended that each workplace should have a system for reporting any violent incident with a patient or patient's relative, whether or not it led to damage or injury.4 Adequate training significantly reduces both physical assaults and injuries to staff.6 If assaults on health care professionals are to be reduced it is necessary to accept both that they occur and that they are preventable. Every effort should be made to improve the reporting of violent incidents (including those not resulting in injury), to facilitate training in the recognition and management of aggression, and to provide support when incidents occur. This support should not take the form of victim blaming. We believe that the acceptance of violence as an inevitable part of medicine is the greatest barrier to its reduction, and we agree with Adler et al that it is important to state that physical aggression has no place in the health care system.7 CAMERON STARK
Argyll and Clyde Health Board, Paisley PA I I DU BRIAN KIDD Southern General Hospital, Glasgow G5 1 1 Hulbert J. Violence in general practice. BMJ 1991;302:658. (16 March.) 2 McNeil DE, Binder RL. Relationship between pre-admission threats and later violent behaviour by acute psychiatric patients. Hosp Community Psychiatry 1989;40:605-8. 3 Werner PD, Yesavage JA, BeckerJM, Brunsting DW, Isaacs JS. Hostile words and assaultive behaviour on an acute inpatient psychiatric unit.J Nerv Ment Dis 1983;171:385-7. 4 Health Services Advisory Committee. Violence to staff in the health ser-vices. London: Health and Safety Commission, 1987. 5 Lion JR, Snyder W, Merrill GL. Underreporting of assaults on staff in a state hospital. Hosp Community Psychiatry 198 1;32:497-8. 6 Infantino JA, Musingo S. Assaults and injuries among staff with and without training in aggression control- techniques. Hosp Community Psychiatry 1985;36:1312-4. 7 Adler WN, Kreeger C, Ziegler P. Patient violence in a private psychiatric hospital. In: Lion JR, Reid WH, eds. Assaults within psychiatric facilities. New York: Grune and Stratton, 1983.
Health check ups in middle age SIR,-I am puzzled as to how Professor Kozo Tatara and colleagues are able to conclude from their data that the use of health checks has caused the lower morbidity in the elderly population-it seems almost trite to point out that all they have shown is an association. To begin with, the Health Services Act was passed only in 1982, so it is difficult to see how the population who were screened (aged 40 or over) relates to the population who required less inpatient care (aged 70 or over). What is more, the paper does not provide any information about the social class structure of the cities, smoking habit, intake of alcohol, etc. Given what we already know about the use of screening services (that they are used most by those in higher social classes with healthier lifestyles and least by those who really need them), is it not equally likely that the rate of attendance for health screening is simply a marker of compliance with "healthy" behaviour? Until we are given more data I feel that it would be extremely unwise to suppose that elderly people are going to be healthier because they are offered more health screening in middle life. ROGER A FISKEN Royal Liverpool Hospital, Liverpool L7 8XP 1 Tatara K, Sinsho F, Suzuki M, et al. Relation between use of health checkups starting in middle age and demand for inpatient care by elderly people in Japan. BMJ7 1991;302: 615-8. (16 March.)
BMJ
VOLUME 302
20 APRIL 1991
