494

Medical kits

on

airliners

SIR,—Very early one November morning my wife and I joined the queue at the check-in desk for a charter flight. Our fellow passengers contained a high percentage of senior citizens. After a very long queue was waiting to go through the security screen and anxiety built up during the hour it took to come to the head of the line, there then being only about 7 minutes to take-off. As we took our seats my wife noticed one woman passenger who seemed breathless and cyanosed, and somewhere over Belgium a call for a doctor came over the passenger address system. I found a stewardess administering oxygen to a very distressed woman. her huband told me of her history of heart problems and valve replacements some twelve years previously. She was clearly in severe left heart failure. It was difficult to be sure that the patient was getting enough oxygen because there was no flow meter and attempts to listen to the gas entering the face mask were frustrated by the noise of the engines. I advised that the patient should be off the aeroplane as soon as possible, and the flight was diverted to a German airport that could be reached in the next 15 minutes. The aircraft’s medical box contained an ampoule of frusemide with two syringes and needles. After administering the frusemide intravenously I began to think that the patient might survive but 2 minutes later she regurgitated and inhaled her stomach contents. The only equipment available for clearing the airway was a small suction apparatus more suitable for a newborn baby, and suction proved ineffective. The patient’s condition deteriorated rapidly and she died. We returned to the airport of departure. On two previous occasions I had been asked for help during a flight but on those occasions the complaints were due to the effects of reduced air pressure on the sinuses and ears. While on holiday I had time to rethink the events of that tragic morning. These days many retired people can afford special off-season holidays in the winter sun, and a high proportion of travellers on such charter flights will be over 60, some having occult or treated cardiac problems. Thus the charter airlines may have a higher risk of in-flight death than the figure of 14 deaths among 22 million passengers quoted for British Airways. Furthermore airport security checks have lately become more thorough and the added delay puts additional stress on passengers of this age. Charter flights tend to be fully loaded and if there is an in-flight emergency there is nowhere for a patient to be transferred to and treated discreetly. Aircraft cannot, of course, carry a miniature intensive care unit but airways, catheters, and a portable battery driven suction apparatus should be provided. A wider range of life-saving drugs should be included in the medical box. The ability to administer dextran or saline solution could be invaluable on a long-haul flight. Emergency oxygen bottles must be light and simple but a flow meter would have helped on this occasion. All cabin staff receive some first-aid instruction but companies offering long-haul flights could consider more advanced instruction for some of their cabin crews. Such in-flight tragedies are upsetting to other passengers but cabin staff can handle that, and in this incident the captain of the aircraft on the second, successful attempt at our journey took the time to speak personally to all 200 passengers. I estimate that the company I travelled with could easily have paid for the improvements I suggest with what it cost in extra fuel as a result of this one episode.

check-in

11

Ridge Park, Bramhall, SK7 2BJ, UK 1. Kahn FS. The

curse

J. V. OCCLESHAW of Icarus. London:

Need for

change

Routledge,

1990.

in patents for

drugs

SIR.— The law with respect to patents for pharmaceutical products is becoming outdated and some changes are needed to revitalise the patent’s role as an incentive to increase and improve scientific work. There are at least two main changes that should be made. The first is quantitative: the time for which patents are in force should be

extended. In Europe patents expire 20 years after application and this time is largely used for the development of new drugs, which can take about 10 years. Obviously there are no objections to the requirement of proof of therapeutic activity and safety before drugs can be marketed, but it should be recognised that the time available for payback on successful drugs is fast becoming too short in relation to the resources needed for the development of new drugs. Therefore it seems logical that patent protection is extended to about 30 years. The second change is related to the fact that a new chemical entity can be evaluated by many tests since copious new chemical mediators, growth factors, second messengers, enzymes, and so on are available as targets for drug action. The tests that may be potentially predictive for a therapeutic effect are innumerable and their use is still justified. Unfortunately most of the millions of chemicals synthesised in the past will never be studied with these tests merely because they cannot now be patented. Many drugs that might be useful for different indications from those for which the chemicals were first developed and marketed. It is therefore proposed that a chemical should be "repatented" if a new indication for its use is found; this new patent should not only cover the new use, but also provide the same measure of protection as a first patent on a new chemical entity. Obviously such changes would require international legislation. The new European Agency for Drugs may well have an important item on its agenda. Mario Negri Institute of Pharmacological Research, 20157 Milan, Italy

Head and neck injuries conflict

SILVIO GARATTINI

during

armed

SIR,—Dr Heering and colleagues (Jan 26, p 242) report that half the injuries sustained by Israeli soldiers in the Palestinian uprising of 1987-89 affected the head. Since ophthalmologists found that eye injury caused by projectile fragmentation was surprisingly frequent (7% of all injuries) in Israeli troops in recent desert conflicts,’ we examined trends in frequency of head and neck wounds in armed conflicts after 1914.zA second objective was to assess whether incidence of wounding reflected the proportion of body surface area represented by the head and neck (about 12%). We categorised conflicts according to Eiseman3and searched for publications about the pattern of troop injury in 13 major conventional wars (such as conflicts in World War I), 15 minor conventional wars (such as the Falklands campaign), 15 "rural attacks" (such as Cambodia), and 7 terrorist conflicts (such as Northern Ireland and the Palestinian uprising). Although many of the published accounts of wound distribution were not comparable because of the variable inclusion of burns, ophthalmic injuries, wounds in those killed, and wounds sustained in accidents or sport, and because only parts of some conflicts were included, some conclusions were possible. We found no evidence of change in overall frequency of head and neck injury in any category of conflict since 1945, though some personnel, such as armoured vehicle commanders and drivers, do seem to be at increased risk in modem warfare. Mean incidence of head and neck injury in all 50 conflicts was 16%-higher than expected in terms of random injury. The mean incidence of head and neck wounding in terrorist conflicts was 21% compared with 15-16% in the other three categories. Protection of the trunk and limbs afforded by trenches, armoured vehicles, and protective clothing may explain high overall frequency of head and neck wounds. The opportunities to target the head and neck, which are exploited in terrorist activity or civil unrest, may be a reason for the higher incidence of these wounds. Wound prevention is a priority in any category of conflict. Accurate information about their character and distribution, such as that provided by the UK Ministry of Defence Hostile Action Casualty System, should be the means by which changes in protective clothing design are made. Although impact-resistant goggles and modified protective head gear were introduced promptly in Israeli tank crews to prevent eye injury, and visors and shields are routinely used in civil unrest, design changes have not

Need for change in patents for drugs.

494 Medical kits on airliners SIR,—Very early one November morning my wife and I joined the queue at the check-in desk for a charter flight...
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