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Journal of the Royal Society of Medicine Volume 84 April 1991
All neonates should have intravenous access in situ prior to transfer. All other minimum standards applicable to helicopter transfer of paediatric and adult patients should be met in neonatal cases. Medical directors should draw up protocols for specific clinical situations such as cyanotic congenital heart disease, diaphragmatic hernia, pneumothorax. Protocols There should be a written protocol book. The headings should include the following: Introduction Definitions Personnel Daily set up mechanism Coordination and accepting missions Primary missions Secondary transfers Medical protocols Standing orders Communications Major disasters Inventories Hospital details Check lists Audit A permanent clinical record sheet should be kept for each patient, and this should be securely stored for a minimum period of 7 years. In view of the small numbers of patients transferred by helicopter, data should be freely shared between schemes subject to normal restraints of confidentiality. The following is the minimum data that should normally be recorded: Patient information (name, age, sex) Clinical information (history, investigations, examination) Indication for call Timings Pick up and disposal points Accident scene details
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Myocarditis - a controversial disease I read with interest the editorial on myocarditis by Peters and Poole-Wilson (January 1991 JRSM, p 1). It was a comprehensive review of a rather controversial subject. Unfortunately they left out sarcoid myocarditis, an important entity well described by their compatriot H A Fleming'. Sarcoid myocarditis is commoner than recognized clinically2. It is a difficult diagnosis to make even at autopsy, unless thorough sampling included the upper portion of the ventricular septum and the conduction system3. During life myocardial biopsy has been relied upon almost exclusively for making a definitive
Treatment and procedures in transit Clinical parameters every 15 minutes in transit Complications Follow up Trauma, sickness or APACHE II scores The medical data should be audited by the medical director, who should also debrief the team following a proportion of flights, either by means of individual debriefings or regular audit meetings. Any audit that is in progress elsewhere in the health authority should apply to this scheme if appropriate.
Major disasters Each helicopter scheme should be part of its region's major disaster plan. Confidentiality The importance of medical confidentiality should be recognized by everyone involved in a system. The level of medical confidentiality should be that laid down in HC (FP) (87)9. Any research should be subject to approval by the appropriate ethical committee. Appendices The following documents may be of assistance to those involved in medical helicopter systems: Guide lines for requesting HEMS (available from The London Hospital Department of Accident & Emergency Medicine) Aviation medicine handbook for patient transfer by air (available from Dr I Perry, British Helicopter Advisory Board). Careflight - information for senior medical staff (available from Department of Anaesthetics, St Bartholomew's Hospital). A Bristow Department of Anaesthetics St Bartholomew's Hospital West Smithfield, London EClA 7BE
diagnosis of sarcoid myocarditis. Its value, however, is rather limited, because of the patchy distribution of the disease. Furthermore, a deliberate attempt is usually made to avoid both the upper septum and the conduction system during myocardial biopsy2. Myocardial biopsy in the diagnosis of myocarditis is a tricky matter. Both false positives and false negatives have been reported4. Whereas sampling errors account for most false-negative diagnoses, falsepositive diagnoses may result from misinterpretation of non-inflammatory cells as lymphocytes and from clinical bias56. Whereas only positive findings are regarded as diagnostic, negative findings do not exclude the possibility that myocarditis exists elsewhere beyond the reach of the bioptome. Because of the high incidence of sudden death7, all patients with myocardial sarcoidosis should be aggressively treated with corticosteroids and closely monitored8. T 0 CHENG
Department of Medicine Division of Cardiology The George Washington University Medical Center 2150 Pennsylvania Ave, NW, Washington DC 20037, USA
Journal of the Royal Society of Medicine Volume 84 April 1991 References 1 Fleming HA. Sarcoid heart disease. BMJ 1986;292: 1095-6 2 Cheng TO. Sarcoid myocarditis. NZ Med J 1990;103:465 3 Temple-Camp CRE. Sarcoid myocarditis: a report of three cases. N Z Med J 1989;102:501-2 4 Cheng TO. Cardiac biopsy in myocarditis. Lancet 1990;336:888-9 5 Edwards WD. Myocarditis and endomyocardial biopsy. Cardiol Clin 1984;2:647-56 6 Edwards WD. Endomyocardial biopsy and cardiomyopathy. Cardiovasc Rev Rep 1990;11:26-43 7 Cheng TO. The international textbook of cardiology. Oxford: Pergamon Press, 1987:748 8 Sharma OP. Sarcoidosis. Dis Mon 1990;36:474-535
Uvulopalatopharyngoplasty We read with interest the experience of uvulopalatopharyngoplasty (UPPP) by Sharp et aL (September 1990 JRSM, p 569). They stress the value of this procedure in alleviating the socially destructive effects of heroic snoring. Their success rate together with minimal complications is commendable. However we feel that their paper fails to emphasize the spectrum of snoring with obstructive sleep apnoea (OSA) as its extreme. Heroic snoring is a cardinal feature of OSA, which cannot be reliably diagnosed on history or examination alonel2. Accordingly patients with mild to moderate OSA may be treated as simple snorers and their further management compromised. Therefore the severity of sleep disturbance and the level of obstruction needs to be established in all snorers before surgery. We have found that sleep screening, clinical observation of the sleeping patient together with pulse oximetry, and fibreoptic nasendoscopy is a simple and reliable strategy in this respect2. Simple snorers with obstruction at the velopharyngeal sphincter almost always do well after UPPP. Surgery may ameliorate the effects of mild to moderate OSA given velopharyngeal obstruction, whereas patients with severe OSA often have multiple segment obstruction and are rarely improved. This operation is upon an important physiological sphincter that is not without morbidity and complications. This is a painful procedure often requiring opiate infusion. Fatal complications from postoperative airway compromise have been reported3. Other severe problems include nasopharyngeal stenosis4 and permanent velopharyngeal incompetence. We would agree with Sharp et aL that in simple snorers UPPP is efficacious but we feel that an assessment of the complexities of the upper airway must be made in all snorers, otherwise inappropriate surgery upon OSA subjects or the wrong obstructing level may be performed. D GOLDING-WOOD The Royal National Throat, Nose & C B CROFT
Ear Hospital Gray's Inn Road, London WC1X 8DA
References 1 Simmons FB, Guilleminault C, Miles LE. The palatopharyngoplasty operation for snoring and sleep apnea. An interim report. Otolaryngol Head Neck Surg 1984; 92:375-80 2 Golding-Wood DG, Brockbank M, Swanston A, Croft CB. The assessment of chronic snorers. J R Soc Med 1990;83:363-7 3 Johnson JT, Sanders MH. Breathing during sleep immediately after uvulopalatopharyngoplasty. Laryngoscope
1990;96:1236-40
4 Katsantonis GP, Friedman WH, Krebs FJ, Walsh JK. Nasopharyngeal complications following uvulopalatopharyngoplasty. Laryngoscope 1987;97:309-14
Osler, Beaumont and Alexis St Martin D L Wingate's review of the Oxford edition ofWilliam Beaumont's Experiments and Observations . . . (December 1990 JRSM, p 816) laments the lack of 'a facsimile edition with a critical commentary and some biographical information'. Just such an edition was first published by Dover Books, New York, in 1959 and is available from them; though alas not at the $1.50 that I then paid. The Dover edition reprints, alongside a facsimile of Beaumont's original (1833) edition, Sir William Osler's 12 000 word essay on the life and work of 'William Beaumont: A Pioneer American Physiologist' (1902), as well as Osler's four appendices on Beaumont and his papers. Incidentally, Professor Wingate may like to know that both alvine (of or pertaining to the belly, abdominal) and muriatic acid (briny, and hence hydrochloric, acid) both remain in common, if not medical, parlance, at least among hog farmers and house painters respectively. R W I KESSEL
Shute Hill Malborough, Devon TQ7 3SF
History of the RSM's Honorary Feliowship I read with interest the articles by Dr Sakula (December 1990 JRSM, p 788) and Mr Banerjee (January 1991 JRSM, p 44). I have been compiling historical details of the recipients of the Society's Honorary Fellowship the origins of which may be traced back to the first meeting in 1805 ofthe Medical and Chirurgical Society of London, when the following resolutions were passed: 'That Gentlemen who have eminently distinguished themselves in Sciences connected with Medicine, but who are not of the Medical Profession, or do not practise therein, be admissible as Honorary Members', and; 'That the following Gentlemen be elected Honorary Members of this Society: Sir Joseph Banks Bt KB, Sir Charles Blagden, Dr Aikin, Humphry Davy Esq, Charles Hatchett Esq, Edward Howard Esq, Smithson Tennant Esq, Dr Wollaston'. It is interesting to note the names of Wollaston and Davy among the first eight men so honoured. I am not sure whether 'Aikin' is Charles Rochemond or Arthur Aikin: another candidate seems to be John Aikin, author of 'Biographical memoirs of medicine in Great Britain'. Of the others mentioned in Dr Sakula's article, Daubeny, Huxley and Owen too received this accolade, as did Samuel Wilks. There is an intriguing note among the Society's papers which records that: 'In 1905 .. . Sir Samuel Wilks (with others) was nominated for Honorary Fellowship, and the usual letter asking him whether he would accept nomination was sent to him. No answer being received, it was assumed that he accepted the nomination, and his name went forward for election. On Election, the usual notification was despatched. It then transpired that he had sent a letter refusing nomination and was very indignant that his name should have gone forward under the circumstances, but after a personal interview and explanation that the letter refusing nomination had never been received, he consented to become an Honorary Fellow.
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Journal of the Royal Society of Medicine Volume 84 April 1991
All neonates should have intravenous access in situ prior to transfer. All other minimum standards applicable to helicopter transfer of paediatric and adult patients should be met in neonatal cases. Medical directors should draw up protocols for specific clinical situations such as cyanotic congenital heart disease, diaphragmatic hernia, pneumothorax. Protocols There should be a written protocol book. The headings should include the following: Introduction Definitions Personnel Daily set up mechanism Coordination and accepting missions Primary missions Secondary transfers Medical protocols Standing orders Communications Major disasters Inventories Hospital details Check lists Audit A permanent clinical record sheet should be kept for each patient, and this should be securely stored for a minimum period of 7 years. In view of the small numbers of patients transferred by helicopter, data should be freely shared between schemes subject to normal restraints of confidentiality. The following is the minimum data that should normally be recorded: Patient information (name, age, sex) Clinical information (history, investigations, examination) Indication for call Timings Pick up and disposal points Accident scene details
Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double-spaced.
Myocarditis - a controversial disease I read with interest the editorial on myocarditis by Peters and Poole-Wilson (January 1991 JRSM, p 1). It was a comprehensive review of a rather controversial subject. Unfortunately they left out sarcoid myocarditis, an important entity well described by their compatriot H A Fleming'. Sarcoid myocarditis is commoner than recognized clinically2. It is a difficult diagnosis to make even at autopsy, unless thorough sampling included the upper portion of the ventricular septum and the conduction system3. During life myocardial biopsy has been relied upon almost exclusively for making a definitive
Treatment and procedures in transit Clinical parameters every 15 minutes in transit Complications Follow up Trauma, sickness or APACHE II scores The medical data should be audited by the medical director, who should also debrief the team following a proportion of flights, either by means of individual debriefings or regular audit meetings. Any audit that is in progress elsewhere in the health authority should apply to this scheme if appropriate.
Major disasters Each helicopter scheme should be part of its region's major disaster plan. Confidentiality The importance of medical confidentiality should be recognized by everyone involved in a system. The level of medical confidentiality should be that laid down in HC (FP) (87)9. Any research should be subject to approval by the appropriate ethical committee. Appendices The following documents may be of assistance to those involved in medical helicopter systems: Guide lines for requesting HEMS (available from The London Hospital Department of Accident & Emergency Medicine) Aviation medicine handbook for patient transfer by air (available from Dr I Perry, British Helicopter Advisory Board). Careflight - information for senior medical staff (available from Department of Anaesthetics, St Bartholomew's Hospital). A Bristow Department of Anaesthetics St Bartholomew's Hospital West Smithfield, London EClA 7BE
diagnosis of sarcoid myocarditis. Its value, however, is rather limited, because of the patchy distribution of the disease. Furthermore, a deliberate attempt is usually made to avoid both the upper septum and the conduction system during myocardial biopsy2. Myocardial biopsy in the diagnosis of myocarditis is a tricky matter. Both false positives and false negatives have been reported4. Whereas sampling errors account for most false-negative diagnoses, falsepositive diagnoses may result from misinterpretation of non-inflammatory cells as lymphocytes and from clinical bias56. Whereas only positive findings are regarded as diagnostic, negative findings do not exclude the possibility that myocarditis exists elsewhere beyond the reach of the bioptome. Because of the high incidence of sudden death7, all patients with myocardial sarcoidosis should be aggressively treated with corticosteroids and closely monitored8. T 0 CHENG
Department of Medicine Division of Cardiology The George Washington University Medical Center 2150 Pennsylvania Ave, NW, Washington DC 20037, USA
Journal of the Royal Society of Medicine Volume 84 April 1991 References 1 Fleming HA. Sarcoid heart disease. BMJ 1986;292: 1095-6 2 Cheng TO. Sarcoid myocarditis. NZ Med J 1990;103:465 3 Temple-Camp CRE. Sarcoid myocarditis: a report of three cases. N Z Med J 1989;102:501-2 4 Cheng TO. Cardiac biopsy in myocarditis. Lancet 1990;336:888-9 5 Edwards WD. Myocarditis and endomyocardial biopsy. Cardiol Clin 1984;2:647-56 6 Edwards WD. Endomyocardial biopsy and cardiomyopathy. Cardiovasc Rev Rep 1990;11:26-43 7 Cheng TO. The international textbook of cardiology. Oxford: Pergamon Press, 1987:748 8 Sharma OP. Sarcoidosis. Dis Mon 1990;36:474-535
Uvulopalatopharyngoplasty We read with interest the experience of uvulopalatopharyngoplasty (UPPP) by Sharp et aL (September 1990 JRSM, p 569). They stress the value of this procedure in alleviating the socially destructive effects of heroic snoring. Their success rate together with minimal complications is commendable. However we feel that their paper fails to emphasize the spectrum of snoring with obstructive sleep apnoea (OSA) as its extreme. Heroic snoring is a cardinal feature of OSA, which cannot be reliably diagnosed on history or examination alonel2. Accordingly patients with mild to moderate OSA may be treated as simple snorers and their further management compromised. Therefore the severity of sleep disturbance and the level of obstruction needs to be established in all snorers before surgery. We have found that sleep screening, clinical observation of the sleeping patient together with pulse oximetry, and fibreoptic nasendoscopy is a simple and reliable strategy in this respect2. Simple snorers with obstruction at the velopharyngeal sphincter almost always do well after UPPP. Surgery may ameliorate the effects of mild to moderate OSA given velopharyngeal obstruction, whereas patients with severe OSA often have multiple segment obstruction and are rarely improved. This operation is upon an important physiological sphincter that is not without morbidity and complications. This is a painful procedure often requiring opiate infusion. Fatal complications from postoperative airway compromise have been reported3. Other severe problems include nasopharyngeal stenosis4 and permanent velopharyngeal incompetence. We would agree with Sharp et aL that in simple snorers UPPP is efficacious but we feel that an assessment of the complexities of the upper airway must be made in all snorers, otherwise inappropriate surgery upon OSA subjects or the wrong obstructing level may be performed. D GOLDING-WOOD The Royal National Throat, Nose & C B CROFT
Ear Hospital Gray's Inn Road, London WC1X 8DA
References 1 Simmons FB, Guilleminault C, Miles LE. The palatopharyngoplasty operation for snoring and sleep apnea. An interim report. Otolaryngol Head Neck Surg 1984; 92:375-80 2 Golding-Wood DG, Brockbank M, Swanston A, Croft CB. The assessment of chronic snorers. J R Soc Med 1990;83:363-7 3 Johnson JT, Sanders MH. Breathing during sleep immediately after uvulopalatopharyngoplasty. Laryngoscope
1990;96:1236-40
4 Katsantonis GP, Friedman WH, Krebs FJ, Walsh JK. Nasopharyngeal complications following uvulopalatopharyngoplasty. Laryngoscope 1987;97:309-14
Osler, Beaumont and Alexis St Martin D L Wingate's review of the Oxford edition ofWilliam Beaumont's Experiments and Observations . . . (December 1990 JRSM, p 816) laments the lack of 'a facsimile edition with a critical commentary and some biographical information'. Just such an edition was first published by Dover Books, New York, in 1959 and is available from them; though alas not at the $1.50 that I then paid. The Dover edition reprints, alongside a facsimile of Beaumont's original (1833) edition, Sir William Osler's 12 000 word essay on the life and work of 'William Beaumont: A Pioneer American Physiologist' (1902), as well as Osler's four appendices on Beaumont and his papers. Incidentally, Professor Wingate may like to know that both alvine (of or pertaining to the belly, abdominal) and muriatic acid (briny, and hence hydrochloric, acid) both remain in common, if not medical, parlance, at least among hog farmers and house painters respectively. R W I KESSEL
Shute Hill Malborough, Devon TQ7 3SF
History of the RSM's Honorary Feliowship I read with interest the articles by Dr Sakula (December 1990 JRSM, p 788) and Mr Banerjee (January 1991 JRSM, p 44). I have been compiling historical details of the recipients of the Society's Honorary Fellowship the origins of which may be traced back to the first meeting in 1805 ofthe Medical and Chirurgical Society of London, when the following resolutions were passed: 'That Gentlemen who have eminently distinguished themselves in Sciences connected with Medicine, but who are not of the Medical Profession, or do not practise therein, be admissible as Honorary Members', and; 'That the following Gentlemen be elected Honorary Members of this Society: Sir Joseph Banks Bt KB, Sir Charles Blagden, Dr Aikin, Humphry Davy Esq, Charles Hatchett Esq, Edward Howard Esq, Smithson Tennant Esq, Dr Wollaston'. It is interesting to note the names of Wollaston and Davy among the first eight men so honoured. I am not sure whether 'Aikin' is Charles Rochemond or Arthur Aikin: another candidate seems to be John Aikin, author of 'Biographical memoirs of medicine in Great Britain'. Of the others mentioned in Dr Sakula's article, Daubeny, Huxley and Owen too received this accolade, as did Samuel Wilks. There is an intriguing note among the Society's papers which records that: 'In 1905 .. . Sir Samuel Wilks (with others) was nominated for Honorary Fellowship, and the usual letter asking him whether he would accept nomination was sent to him. No answer being received, it was assumed that he accepted the nomination, and his name went forward for election. On Election, the usual notification was despatched. It then transpired that he had sent a letter refusing nomination and was very indignant that his name should have gone forward under the circumstances, but after a personal interview and explanation that the letter refusing nomination had never been received, he consented to become an Honorary Fellow.
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