1025
edly clarified the task for scientists tackling these formidable problems. Moreover, since many of the causal social and environmental and therefore prereason to hope that their results will help cut the incidence of cot death in Britain and elsewhere to the low levels seen in some Scandinavian
factors
are
ventable, there is every countries.
NORTH BY DEPTH WHY have tadpoles interested anasthetists in the North Sea? Divers from oil rigs in this area work at great depth, often in conditions which make the risks of serious injury very high. Injuries apart, with saturation diving techniques,l in which divers live under pressurisation for many days, there is always the possibility that unforeseen acute illness will arise. Peptic-ulcer perforation and appendicitis, for example, will present problems in a diver who may need up to a week to decompress safely. We do not know, but can guess, that the ill or injured diver will take longer than usual time to decompress, and the solution must be to pressurise the medical attendants and lock them into the pressurised chamber with the sick diver. However, compression is a frightening experience for the uninitiated and ideally the surgical team is trained in diving. Even with experienced divers compression to great depth cannot be hurried, because of the risk of H.P.N.S. (high-pressure nervous syndrome), and at least 30 minutes is required; stoical inexperienced mortals need 3-4 hours. Add to this the time taken to fly the surgical team to the oil rig, say 3 hours, and 6 hours is the sort of delay the diver can expect before specialist help arrives. In the pressure chamber the anaesthetist may find that his drugs are unexpectedly impotent-an effect which has been predicted with the help of tadpoles and other aquatic creatures. The original work was done long ago with intoxicated tadpolesand Halsey and WardleySmith3 lately drew attention to pressure-reversal of narcosis with various general-anwsthesic agents, with tranquillisers, and with morphine. Tadpoles which have been immobilised with the test drug begin to swim again as the ambient pressure is increased. Conversely, tadpoles can be protected, to varying degrees, from the adverse effect of high ambient pressure by previous dosage with one of these agents (althesin seemed best). One effect of very high pressure in tadpoles is that they become flaccid and immobile (pressure paralysis), and under these circumstances anxsthetic agents can paradoxically get the animals swimming again. The fact that pressure reversal applies not only to inhalation general anaathetics but also to intravenous general anaesthetics and local anaesthetics lends support to the theory that all these agents act by causing expansion of the surfacemembrane of the cells of the central nervous system; and high pressures may reverse the effects of these agents by counteracting such surface expansion by an opposite effect. These considerations have important implications for anxsthetic theory and practice. Clearly the North Sea is going to be productive of more than a fossil fuel. 1 The Problem of
Hyperbaric Rescue in the North Sea and Report by Society for Underwater Technology, London SW1H 9JJ. 2. Johnson, F. H., Flagler, E. A. Science, 1950, 112, 91. 3. Halsey, H. J. Wardley-Smith, B. Nature, 1975, 257, 811. tions.
its
1
JUNIOR HOSPITAL DOCTORS THE outcome of the ballot’ of junior hospital doctors, which sought their views on proposed changes in their N.H.S. contracts and on industrial action, was made known to a meeting of the Hospital Junior Staffs Committee at B.M.A. House on Monday. An already confused situation was little clarified by the events at a long and turbulent meeting. The executive of the committee resigned after a vote of censure was passed; and the committee decided that industrial action should ensue, not later than Nov. 27, to step up the impromptu disruptions already undertaken by junior doctors to emphasise their claim to new contracts with better overtime pay. In the ballot, 7355 voted for industrial action and 5336 against. The committee asked for: a basic 40-hour-week salary; extra pay for hours over 40 (the money to be provided within the Government’s pay policy); and, for more than 80 hours, payment at clinical-assistant sessional rates (£11.50 for 31hours). The recommendation for industrial action, which would take the form of a 40-hour week, emergencies only, and no overtime, has to be approved by the Council of the B.M.A., which is due to sit next on Nov. 26. Meanwhile, the Junior Hospital Doctors Association will press its argument that more money can be provided without breaching the Government’s policy, though some of the former B.M.A. leaders of the junior doctors have cast doubt on the J.H.D.A.’s arithmetic. For her part, the Secretary of State for Social Services, Mrs Barbara Castle, continues to assert that no more money is available while the Government’s policy is in force; but she is prepared to carry out a review of the long hours worked by junior doctors. Thus, the confrontation approaches. The junior doctors may be divided, between moderates and militants and between B.M.A. and J.H.D.A., but so far Mrs Castle has not managed to rule them. The issues are complex, and conflicting statements abound, so the public is again left wondering just why its Health Service is endangered. It may be about to be put at further hazard by the actions of junior doctors, whose pay was increased by 30% after the Review Body’s report in April, and who now seem to be pursuing the lures of overtime as a means of securing another big rise. The overtime arguments are obviously attractive as a bargaining counter, but working-by-the-hour can be professionally damaging; and if the profession is damaged so will be the patients. We hope that the large minority of junior doctors who voted against industrial action will continue to urge on their colleagues that there is still room for negotiation and compromise and that the golden egg of overtime may turn out to be addled. To add to the woe, the Hospital Consultants and Specialists Association is bracing itself for another fight in anticipation of what may have been said about private-practice legislation in the Queen’s Speech on Wednesday this week. If all members of the H.C.S.A. decide to take a day’s leave on Nov. 25, as the H.C.S.A. has advised them to do, in protest at the Government’s plans to phase-out pay-beds from N.H.S. hospitals, both juniors and seniors may be industrially in action at the same time-on the N.H.S.’s blackest day.
Possible Solu-
Birdcage Walk, 1. See Lancet, Nov. 8, 1975, p. 913. 2. Morris, N., and others Times, Nov
1, 1975.
edly clarified the task for scientists tackling these formidable problems. Moreover, since many of the causal social and environmental and therefore prereason to hope that their results will help cut the incidence of cot death in Britain and elsewhere to the low levels seen in some Scandinavian
factors
are
ventable, there is every countries.
NORTH BY DEPTH WHY have tadpoles interested anasthetists in the North Sea? Divers from oil rigs in this area work at great depth, often in conditions which make the risks of serious injury very high. Injuries apart, with saturation diving techniques,l in which divers live under pressurisation for many days, there is always the possibility that unforeseen acute illness will arise. Peptic-ulcer perforation and appendicitis, for example, will present problems in a diver who may need up to a week to decompress safely. We do not know, but can guess, that the ill or injured diver will take longer than usual time to decompress, and the solution must be to pressurise the medical attendants and lock them into the pressurised chamber with the sick diver. However, compression is a frightening experience for the uninitiated and ideally the surgical team is trained in diving. Even with experienced divers compression to great depth cannot be hurried, because of the risk of H.P.N.S. (high-pressure nervous syndrome), and at least 30 minutes is required; stoical inexperienced mortals need 3-4 hours. Add to this the time taken to fly the surgical team to the oil rig, say 3 hours, and 6 hours is the sort of delay the diver can expect before specialist help arrives. In the pressure chamber the anaesthetist may find that his drugs are unexpectedly impotent-an effect which has been predicted with the help of tadpoles and other aquatic creatures. The original work was done long ago with intoxicated tadpolesand Halsey and WardleySmith3 lately drew attention to pressure-reversal of narcosis with various general-anwsthesic agents, with tranquillisers, and with morphine. Tadpoles which have been immobilised with the test drug begin to swim again as the ambient pressure is increased. Conversely, tadpoles can be protected, to varying degrees, from the adverse effect of high ambient pressure by previous dosage with one of these agents (althesin seemed best). One effect of very high pressure in tadpoles is that they become flaccid and immobile (pressure paralysis), and under these circumstances anxsthetic agents can paradoxically get the animals swimming again. The fact that pressure reversal applies not only to inhalation general anaathetics but also to intravenous general anaesthetics and local anaesthetics lends support to the theory that all these agents act by causing expansion of the surfacemembrane of the cells of the central nervous system; and high pressures may reverse the effects of these agents by counteracting such surface expansion by an opposite effect. These considerations have important implications for anxsthetic theory and practice. Clearly the North Sea is going to be productive of more than a fossil fuel. 1 The Problem of
Hyperbaric Rescue in the North Sea and Report by Society for Underwater Technology, London SW1H 9JJ. 2. Johnson, F. H., Flagler, E. A. Science, 1950, 112, 91. 3. Halsey, H. J. Wardley-Smith, B. Nature, 1975, 257, 811. tions.
its
1
JUNIOR HOSPITAL DOCTORS THE outcome of the ballot’ of junior hospital doctors, which sought their views on proposed changes in their N.H.S. contracts and on industrial action, was made known to a meeting of the Hospital Junior Staffs Committee at B.M.A. House on Monday. An already confused situation was little clarified by the events at a long and turbulent meeting. The executive of the committee resigned after a vote of censure was passed; and the committee decided that industrial action should ensue, not later than Nov. 27, to step up the impromptu disruptions already undertaken by junior doctors to emphasise their claim to new contracts with better overtime pay. In the ballot, 7355 voted for industrial action and 5336 against. The committee asked for: a basic 40-hour-week salary; extra pay for hours over 40 (the money to be provided within the Government’s pay policy); and, for more than 80 hours, payment at clinical-assistant sessional rates (£11.50 for 31hours). The recommendation for industrial action, which would take the form of a 40-hour week, emergencies only, and no overtime, has to be approved by the Council of the B.M.A., which is due to sit next on Nov. 26. Meanwhile, the Junior Hospital Doctors Association will press its argument that more money can be provided without breaching the Government’s policy, though some of the former B.M.A. leaders of the junior doctors have cast doubt on the J.H.D.A.’s arithmetic. For her part, the Secretary of State for Social Services, Mrs Barbara Castle, continues to assert that no more money is available while the Government’s policy is in force; but she is prepared to carry out a review of the long hours worked by junior doctors. Thus, the confrontation approaches. The junior doctors may be divided, between moderates and militants and between B.M.A. and J.H.D.A., but so far Mrs Castle has not managed to rule them. The issues are complex, and conflicting statements abound, so the public is again left wondering just why its Health Service is endangered. It may be about to be put at further hazard by the actions of junior doctors, whose pay was increased by 30% after the Review Body’s report in April, and who now seem to be pursuing the lures of overtime as a means of securing another big rise. The overtime arguments are obviously attractive as a bargaining counter, but working-by-the-hour can be professionally damaging; and if the profession is damaged so will be the patients. We hope that the large minority of junior doctors who voted against industrial action will continue to urge on their colleagues that there is still room for negotiation and compromise and that the golden egg of overtime may turn out to be addled. To add to the woe, the Hospital Consultants and Specialists Association is bracing itself for another fight in anticipation of what may have been said about private-practice legislation in the Queen’s Speech on Wednesday this week. If all members of the H.C.S.A. decide to take a day’s leave on Nov. 25, as the H.C.S.A. has advised them to do, in protest at the Government’s plans to phase-out pay-beds from N.H.S. hospitals, both juniors and seniors may be industrially in action at the same time-on the N.H.S.’s blackest day.
Possible Solu-
Birdcage Walk, 1. See Lancet, Nov. 8, 1975, p. 913. 2. Morris, N., and others Times, Nov
1, 1975.
