Hawksworth
Emergency helicopter transport service
a time. All cases are thus brought to Stornoway even if later transfer is likely. This also allows resuscitation initiated at the accident site to be continued in hospital at the earliest opportunity. The number of patients discharged the same day, 13 (15%), is rather worrying. The majority of these cases were rather trivial injuries and many did not need helicopter transport. One of the problems seems to be poor communication between ships (especially foreign ones) and the landbased authorities. The three foreign fishermen discharged the same day had flu, a minor epistaxis and a bruised hand. All had been reported to the Coastguard as seriously ill or injured. Medical advice is usually sought by radio before the helicopter will take off and the doctors involved are understandably cautious in theirinterpretation of the description of symptoms and injuries. It is easier to send a helicopter and accompanying doctor to assess the patient. Once there, it is difficult not to uplift the patient no matter how trivial the injuries appear. The service is, of course, free of charge for the patient. This may influence some ships captains to call the helicopter rather than waste valuable fishing time making their own way to Stornoway. However, distance from port, the ships speed and prevailing weather conditions should also be considered. Feedback to captains and ships owners may be of benefit in reducing inappropriate use of the service. Despite a few cases of possibly inappropriate usage, the fact that 70 out of 85 patients were either admitted or transferred to the mainland suggests that for the majority of these cases, helicopter transport is appropriate. One surprising finding was the number of army personnel using the service. Nine of the 11 soldiers uplifted were based on St. Kilda, some 45 miles from Lewis. Two ofthese had minor injuries
which were 2-3 days old. Under normal circumstances, they would be inappropriate cases for emergency helicopter transport. However, the flights to St Kilda, with its relatively good landing site provide excellent training runs for the helicopter crews. Conclusion The helicopter has been a valuable addition to the Coastguard Service at Stornoway and its use in SAR work and evacuation of medical casualties has undoubtedly saved lives. However, it is important that the seafaring community does not take advantage of the facility. Improved communications, particularly with foreign vessels, and feedback to ships captains and owners are needed to prevent waste of an expensive but useful resource. This would also reduce unnecessary risk to the lives of the helicopter crews and doctors attending these incidents. In the severe weather conditions that are common round the Outer Hebrides, there is often no alternative means of rapid transport available and the majority of uplifts are entirely appropriate.
ACKNOWLEDGEMENTS: I would like to thank Mr John Griffiths and his staff at HM Coastguard Office, Stomoway for their help in preparing this article, and Dr J A D Goodall for his helpful comments. REFERENCES
2 3
Wilson A, Driscoll P. Transport of injured patients. BMJ 1990; 301: 658-662. Schiller WR, Knox R, Zinnecher H. et aI. Effect of helicopter transport of trauma victims on survival in an urban trauma centre. J of Trauma 1988; 28: 1127-1134. Urdenta LF, Miller BK, Ringenberg BJ. et al. Role of an emergency helicopter transport service in rural trauma. Archives of Surgery 1987; 122: 992-996.
0036-9330/92/11391/076 $2.00 in USA © 1992 Scottish Medical Journal
Scot Med J 1992; 37: 076-080
SURGICAL CORRECTION OF CONGENITAL HEART DEFECTS IN ADULTS D I Hamilton, A.K. Bozkurt University Department of Cardiac Surgery, Royal Infirmary of Edinburgh. Abstract: From April 1987 to April 1991 ,30 patients over the age of 15 years underwent surgery for congenital heart defects in the adult department of the.Professorial Unit of Cardiothoracic Surgery, Royal Infirmary of Edinburgh. Eighteen were females (60%) and 12 were males (40%). Ages rangedfrom 15 to 68 years (mean 38.1). Six patients 20% had undergone previous cardiac surgery. Operative and hospital mortality was zero. Major postoperative complications occurred in three patients. In the follow-up period between three months andfour years, there has been one late death. The spectrum ofpatients with congenital heart defects over the age of 15 was reviewed. The relatively late presentation of these defects and the indicationsfor operating in adult life are discussed. Key words: Congenital heart defect, adult patients. Introduction ost epidemiological studies have suggested an incidence of congenital heart defects in live born infants of four to 10 per 1000 (average 8).1 These defects are also associated with early spontaneous abortion. One study reported 15.4% incidence of congenital heart defects in 247 abortuses under 24 weeks of . 2 gestation,
M
76
In the last two decades, there has been a considerable expansion of technology, including the development of angiocardiography and Echo/Doppler techniques. As a result of the wide range of congenital heart defects, which vary from single holes or valve abnormalities, to obstruction within or near the heart, to complex malpositions and valve atresias, patients may present with symptoms as neonates, infants, young children, adolescents, or in
Adult congenital heart defects
Hamilton and Bozkurt
late adult life. Patients and methods We have reviewed the data of 30 consecutive patients who had a diagnosis of congenital heart defect during the period from April 1987 to April 1991. All of these adult patients were referred to the Professorial Unit of Cardiothoracic Surgery, Royal Infirmary of Edinburgh. Eighteen patients (60%) were female and 12 male (40%). The ages ranged from 15 to 68 years (mean 38.1). Previous cardiac operations had been carried out in six patients (20%). The preoperative diagnosis was made on the basis of the history, clinical, angiocardiographic and echocardiographic findings. Table I summarises diagnosis and operations in the 30 patients. Results There was no operative or hospital mortality. One patient with partial A-V canal underwent reoperation because of tricuspid valve regurgitation and pericardial patch separation from the inferior border of the atrial septal defect. Primary repair of the tricuspid valve and reattachment of the patch was carried out. Prolonged ventilatory support was necessary without any late consequences. In another patient, temporary complete heart block necessitated A-V pacing for two weeks. One patient had mild transient weakness representing the only neurological complication in this group. Longer term follow-up information was obtained by physical examination whenever possible. When this was not possible, a review of medical records and follow-up visits was performed. The average follow-up was 28 months, and the range was from 3 to 51 months. One patient, who underwent open heart surgery for closure of a ventricular septal defect with pulmonary valve stenosis at the age of 60 years, died suddenly 11 months after the operation. No obvious cause related to the cardiac operation was apparent.
Discussion Congenital heart defects result from developmental aberrations in the formation of the "heart tube", and although present at birth, may not be recognised (diagnosed) until much later in life. Children who have defects with prominent signs and symptoms like transposition of the great arteries, Tetralogy ofFallot, or large ventricular septal defects, will almost invariably be discovered in infancy or early childhood. However, many children, such as those with minimal valvar pulmonary stenosis or small atrial septal defects, may not be diagnosed until adult life because of the late presentation of symptoms and signs. The layman recognises the condition of "a hole in the heart", although not all realise that this hole is situated in one of the inner partitions (septa) of the heart. Others recognise that the heart valves may be narrowed (stenosed), to a mild, moderate or severe degree. Most have heard of "blue babies", but many do not appreciate the causes of cyanosis, which results from the passage of venous blood through a defect, in either atrial or ventricular septum, into the left side of the heart and thence to the body Correspondence and reprint requests to: Professor D I Hamilton, University Department of Cardiac Surgery, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EID 9YW
(systemic) circulation. This occurs when the pressure within the right side of the heart exceeds that of the left side as a result of severe tricuspid or pulmonary valve stenosis or a major increase in pulmonary vascular resistance. Congenital cardiac defects occur in approximately 8 per 1000 live births (1: 100). Defects may be single, but frequently are multiple with as many as five or six abnormalities combining within a single heart. These form the more complex group of conditions and present to the medical profession very soon after birth. The following classification on congenital heart defects may be helpful: 1 Failures of septation Atrial Septal Defects (A.S.D.) Holes in the atrial septum of various sizes and at well recognised sites (central, high and low). Absence of the entire septum or "common atrium" is usually associated with a mitral valve abnormality which may produce regurgitation. Ventricular Septal Defects (V.S.D.) These are the commonest congenital heart defects and may occur in any of the named portions of the interventricular septum (inlet, apical, trabecular muscular, outlet). These defects vary in size from a few millimetres to absence of the entire septum (common, single, univentricular heart). V.S.D's are sometimes multiple (Swiss Cheese septum). Table I Detailed diagnosis and operations of patients. Diagnosis
No
Operation
No
1. Atrial septal defect
13
Secundum type
6
Suture closure Patch closure
4 2
Sinus venosus type
6
Redirection of pulmonary veins. Patch closure ASD
6
Coronary sinus type with deroofing of coronary sinus
1
Reconstruction of coronary sinus with closure of ASD
2. Partial A-V canal defect with mitral cleft
3 2
without mitral cleft
Patch closure of ASD with repair 2 of cleft Patch closure of ASD
3. Tetralogy of Fallot
4
Total correction
4
4. Coarctation of Aorta
3
End to end anastomosis Patch repair using GoreTex
2 1
5. Aortic regurgitation
1
Aortic valve replacement
(Previous total correction ofTOF)
6. Truncus arteriosus type II (obstructed Hancock conduit with porcine valve)
7. Ventricular septal defect and puhnonary stenosis
Replacement of valve from the conduit and insertion of 21mm aortic homograft Patch repair of VSD and relief of pulmonary stenosis
8. Tricuspid atresia
Fontan repair
9. LVOT obstruction and VSD
Modified Konno procedure
10. Aortic Stenosis
Aortic prosthetic replacement
11. Mitral regurgitation
Repair of posterior leaflet and insertion of Carpentier ring
77
Adult congenital heart defects
Aorto-pulmonary window A direct communication between the main pulmonary artery and ascending aorta due to incomplete septation of the truncus arteriosus. 2 Stenosis: May be partial or complete (atresia). Obstruction may occur within the heart or outside it. Stenosis inside the heart Valvar Any valve may be stenosed as a result of congenital deformity. Tricuspid, pulmonary, mitral, aortic. Subvalvar The right and left ventricular outflow tracts may be underdeveloped (hypoplastic) or partially obstructed by a fibro-muscular diaphragm (sub-aortic stenosis). In the Tetralogy of Fallot, thick muscle bundles encircle the right ventricular outflow tract, like calipers. At times, these muscle bundles constrict tightly, totally obstructing the flow of blood from the right ventricle into the pulmonary circuit. Stenosis outside the heart Supravalvar stenosis of the ascending aorta may be a familial disorder (Williams syndrome), and, if severe, leads to massive hypertrophy of the left ventricle and premature death. Coarctation of the aorta A tight stricture of the aorta can occur at any point along the length of the aorta. The usual site is distal to the left subclavian artery. This may be an isolated abnormality, (simple coarctation), or is often associated with one of a number ofintracardiac defects (VSD, ASD, bicuspid aortic valve stenosis, mitral valve defects, transposition of the great arteries, and univentricular heart). Coarctation of the aorta may present in the neonatal and infant age range or not until early adult life. 3 Malpositions Transposition of the great arteries The developing heart tube may "loop" in the wrong direction resulting in discordant connection between the ventricles and their outlet arteries. Thus the aorta may connect to the right ventricle and the pulmonary artery to the left ventricle. Double outlet right ventricle. Both great arteries are connected to the right ventricle. The left ventricle exits through a VSD into the right ventricle. Pulmonary valve or subpulmonary stenosis may be present, in which case the pulmonary circulation is "protected" from high pressure blood flow, which results from the left to right "shunt" through the VSD. This simplified and very incomplete classification of congenital cardiac defects should be considered in conjunction with the further sub-division of patients into three clinical categories. Group 1 Simple defects Single small or moderate sized "holes" and minor valve deformities. These produce insignificant symptoms and can be corrected relatively easily and safely, with excellent long term haemodynamic results, following open heart surgery. Operative mortality 1-2%. Group II Intermediate defects These are single or multiple septal defects (ASD and VSD), which are frequently associated with intra cardiac obstruction (stenosis). VSD with right ventricular outflow tract obstruction (RVOTO) comprises the Tetralogy of
78
Hamilton and Bozkurt
Fallot. Transposition of the great arteries without additional intracardiac defects such as VSD or pulmonary stenosis is included within this category. Total anomalous pulmonary venous connection (TAPVC) results from a failure of the pulmonary veins to connect into the posterior aspect of the left atrium. The pulmonary veins drain via an anomalous venous pathway over the top of the heart via the brachiocephalic vein to the superior vena cava and right atrium, or through the diaphragm inferiorly to enter the portal circulation and thence to the IVC and right atrium, or directly to the dilated coronary sinus and thence to the right atrium. This group of congenital abnormalities requires urgent surgical correction in the neonatal or infant period. The commonest "supracardiac" subgroup is relatively easy to correct surgically, and the operative mortality is in the region of 5%. The long term prognosis is excellent? Group III Complex congenital heart defects These defects are frequently multiple, and there may be as many as six or seven individual abnormalities, some of which compensate for each other, and permit the heart to function with varying degrees of efficiency, at least for weeks, months or a number of years. Septal defects, severe intracardiac obstructions including valve atresia in association with great vessel malposition are included in this category. Cardiac surgery for this group of patients may have to be "staged" from infancy through childhood to adult life. Initially, if the condition is not "totally correctable", palliation is performed, increasing inadequate pulmonary blood flow by systemic to pulmonary artery shunting (Blalock-Taussig shunt, Gore-Tex tube graft from systemic to pulmonary artery or Waterston anastomosis). If the haemodynamic problem results in excessive pulmonary blood flow and plethora, then bonding of the main pulmonary artery is performed, constricting the vessel to approximately 8mm diameter as a temporary expedient for several years. This protects the pulmonary vasculature from high blood flow and precludes the development ofpulmonary vascular disease and hypertension, allowing the child to grow until its size is adequate for more definitive "corrective reconstructional surgery". Comments on specific anatomical subgroups of congenital heart defects Atrial Septal Defect (A.S.D.) Atrial septal defects comprise the largest group in our series (16/30). As a result of this defect, left to right intracardiac shunting occurs. Pulmonary vascular disease is rare in childhood in this group of patients compared with patients with V.S.D., P.D.A., and aortopulmonary window. 15-20% of adults with atrial septal defects which have not been closed eventually develop increased pulmonary vascular resistance (P.V.R.).4 The remaining patients may be asymptomatic or become aware of tiredness, developing exertional dyspnoea or palpitation in middle life. Gradually, the right heart chambers dilate, and occasionally shunt reversal resulting in cyanosis occurs. Surgical closure of A.S.D. is usually advised before serious schooling starts (4-5 years), but should certainly be carried out in early or mid adult life, to arrest the natural history of this condition as outlined above. Surgical
Adult congenital heart defects
Hamilton and Bozkurt
56
mortality is less than 1% in uncomplicated cases. • Tetralogy of Fallot (T of F) Only 5-10% of patients with Tetralogy of Fallot can be ex~ected to live over 20 years of age without surgical intervention. Cerebral thrombosis and abscess, cardiac failure from hypoxia and increasing blood viscosity with gradual elevation in haematocrit are the main causes of morbidity and mortality. Infants who require augmentation of pulmonary blood supply before the age of two years (10 Kg in weight approximately) are usually palliated by establishing a systemic to pulmonary artery shunt. Total correction is then performed, as in the group of children who are symptomatic but who have not previously required palliative surgery, at three to six years of age. Surgical mortality is lowest at this time (5% approximately). Four of our patients were referred with this diagnosis, and all were over 22 years of age. Two had undergone previous open heart surgery with the resection of some obstructing muscle bundles from the right ventricular outflow tract. The V.S.D. had been left open on purpose to allow further growth of the main and branch pulmonary arteries which were underdeveloped at that time. Two patients had received systemic to pulmonary artery shunts in childhood. All of these patients complained of diminished exercise performance and tiredness. Palliative shunts may protect the patient from a serious level of cerebral hypoxia, but do not allow adequate augmentation of pulmonary blood flow during exertion. The improved quality of life experienced by these patients following "total correction" of the Tetralogy of Fallot is one of surgery's most rewarding achievements. These patients usually wish that they had had their major surgery at a much earlier age. Coarctation of the Aorta This defect is an isolated congenital defect in approximately 33% of all cases of coarctation ("simple"), but is associated with other intracardiac defects in 66% ("complex"). Coarctation of the aorta, therefore, presents in the neonatal and infant period as an emergency, or in later childhood, teenage and early adult life. If the diagnosis has not been made previously, adults usually present with hypertension in the upper body and suffer also from a degree of intermittent claudication in the lower limbs. The hallmark of the clinical diagnosis is the delay in femoral pulsation, the diminished pulse volume and the slow pulse upstroke. Well developed collateral vessels, if present, may be palpable over the back and periscapular regions, and these may cause visible rib notching on the chest X-ray. The results of surgical correction of aortic coarctation, even in the neonate, are excellent. 8.9 However, resection after childhood becomes more hazardous because of the extensive collateral circulation. These tortuous intercostal vessels become thin walled and are fragile and friable. They lie in wait for the unwary surgeon and confront him with a severe test of anatomical knowledge and technical dexterity. Patience, concentration and manual delicacy are mandatory for this type of thoracic surgery. The challenge is considerable, as post-operative paraplegia occurs in 1 in 200 cases. Improvements in peroperative intra-arterial pressure monitoring (upper and lower limbs) and the augmentation of inadequate lower segment arterial perfusion by temporary bypass techniques should minimise this tragic complication in future. Residual
post-operative hypertension and reactive hypertension (during the initial 12 hours post sur¥ery) may require careful pharmacological control in adults. 0 Carpenter et al documented abnormal left ventricular function despite satisfactory relief of coarctation of the aorta in older patients. 11 Coarctation should be treated surgically in infancy or early childhood to avoid subsequent complications as these can be lethal. Before surgery was available, few adults lived beyond 40 years of age with this condition. 12 "Spare-part" and reconstructive surgery The ideal substitute for irreparably damaged heart valves remains elusive. Experience over a 30 year period suggests that man-made prostheses such as the ball in a cage, tilting disc, or butterfly bi-leaflet valve can all function satisfactorily for many years. The main disadvantage of such implants is that these patients require anticoagulant therapy for life. Nevertheless, children can be managed on this regimen satisfactorily, and careful medical supervision during pregnancy, parturition and the postnatal period has ensured the safe arrival of a number of neonates. The prosthesis may have to be changed after a number of years as the child grows rapidly, and this has been accomplished frequently. Such prostheses do not function satisfactorily as substitutes for the pulmonary valve, as the lower pressures on the right side of the heart allow the closing mechanism of the valve to fail as a result of thrombus formation. The alternative to manufactured prostheses is a tissue valve, (homograft or heterograft), and this may be a free graft or a frame-supported bio-prosthesis. Frame-mounted porcine valves have not stood up to the test of time particularly well, as they calcify rapidly in children and degrade similarly, but at a slower rate in adults. Ten years is usually the maximal functional life of such valves. Homograft aortic and pulmonary valves have been used more successfully for aortic valve replacement in adults, and for the reconstruction of the right ventricular outflow tract in children and adults in the Tetralogy of Fallot. Such valves are utilised as part of a composite conduit in association with a length of Dacron tube, for major reconstructions to bypass the atretic pulmonary valve or artery, bridging the gap between right ventricle and the confluence of the main branch pulmonary arteries. Such conduits are also employed in the reconstruction of truncus arteriosus, initially in infancy and later replacing these small diameter conduits with larger ones. In recent years, major improvements based on a clearer understanding of functional anatomy has resulted in more successful surgical repair of the heart valves. This allows the conservation of the mitral valve in certain cases where formerly a prosthesis would have been implanted. 13 By-passing the right side of the heart, and cave-pulmonary connection During the past 20 years, significant advances in the surgical management of tricuspid valve atresia and a number of options for right heart bypass have been developed. These techniques are employed to deviate systemic venous return directly into the pulmonary arterial circulation (by gravity flow and calf pump action) in cases of univentricular heart (single ventricle cor biatrium triloculare). Such operations must be considered to be palliative, even in the long term. Nevertheless, severely disabled cyanotic patients may enjoy a surprisingly
79
Hamilton and Bozkurt
Adult congenital heart defects
active lifestyle when these procedures are successful. Careful preoperative assessment of their anatomical and haemodynamic aberrations are the basis of sound case selection. The number of patients requiring primary correction of congenital heart defects as adults will diminish in the future as diagnosis improves, as a result of increasing awareness of the possibilities and achievements of cardiac surgery for congenital and acquired lesions. However, the cohort of patients who have had their congenital cardiac defects palliated and corrected in childhood is now marching into adulthood, and the numbers increase year by year. This group of patients will continue to require expert cardiological and surgical supervision, sometimes throughout life. It is necessary now to establish clinics which are staffed by combined medical and surgical teams, who have wide experience in the management of congenital heart defects in childhood and are also expert in handling adult cardiac patients. REFERENCES Hoffman nE. Congenital heart disease: Incidence and inheritance. Ped Clin North Am 1990; 37:1 25-43 2 Gerlis LM. Cardiac malformations in spontaneous abortions. Int J Cardiol 1985; 7: 29-43.
3 Lamb RK, Qureshi SA, Hamilton DI. Total anomalous pulmonary venous drainage: Seventeen year surgical experience. J Thorac Cardiovasc Surg 1988; 96: 368-375. 4 Spencer FC. Atrial Septal Defect, anomalous pulmonary veins, and atrioventricular septal defects (AV cancl). In: Sabiston DC and Spencer FC (eds). Surgery of the Chest 5th Ed. Philadelphia, W B Saunders Company 1990: 1250-1273. 5 Liberthson RR. Congenital heart disease in the child, adolescent and adult. In: Eagle KA, Haber E, De Sanctis RW, Austen WG (eds). The Practice of Cardiology, 2nd ed. Boston, Little Brown Co. 1989: 1091-1281. 6 Kirklin JW, Barratt-Boyes BG. Atrial Septal Defect and partial anomalous pulmonary venous connection. Cardiac Surgery. New York, John Wiley & Sons 1986; 463 -497. 7 Bertranou EG, Blackstone EH, Hazelrig JB, Turner ME. Kirklin JW. Life expectancy without surgery in Tetralogy of Fallot. Am J Cardiol1978; 42: 458-466. 8 Williams WG, Shindo G, Trusler GA, Dische MR, Alley PM. Results of repair of coatctation of the aorta during infancy. J Thoracic Cardiovasc. Surg 1980; 79: 603-608. 9 Hamilton DI, De Eusanio GD, Donnelly RJ. Early and late results of aortopla sty with left subclavian flap for coarctation of the aorta in infancy. J Thoracic Cardiovasc Surg 1978; 75: 699. 10 Liberthson RR, Pennington DG, Jacobs ML, Daggett WM. Coarctation of the aorta: Review of 234 patients and clarification of management problems. Am J Cardiol1979; 43: 835-840. II Carpenter MA, Danman JF, Watson DD. Left ventricular hyperkinesia at rest and during exercise in normotensive patients 2 to 27 years after coarctation repair. J Am ColI Cardio11985; 6: 879-886. 12 Reifenstein HG, Levine SA, Gross RE. Coarctation: Review of 104 autopsied cases of "adult type" 2 years of age or older. Am Heart J 1947; 33: 146-168 13 Carpentier A. Cardiac valve surgery - the "French correction". J Thorac Cardiovasc Surg 1983; 86: 323-337.
Scot Med J 1992; 37: 80-82
0036-9330/92/11591/080 $2.00 in USA © 1992 Scottish Medical Journal
CO-ORDINATING GERIATRIC AND GENERAL MEDICAL SERVICES; EXPERIENCE OF A GERIATRIC ASSESSMENT WARD IN THE ROYAL INFIRMARY OF EDINBURGH 1
W.1. Macl.ennan, B.1. Chapman. M. Smith, *R.J. Prescott, *IX. Wang Geriatric Medicine Unit, Department of Medicine, Royal Infirmary, Edinburgh and *Medical Statistics Unit, Department of Community Medicine, University of Edinburgh.
Abstract: The paper describes the work ofan assessment unit setup to provide a serviceforfrail elderly patients admitted to general medical units at the Royal Infirmary ofEdinburgh during the period of April 1989 to March 1990. Patients were selected on the basis ofdiagnosis. mental and physicalfunction. age and social background and transferred to the assessment ward within 24 hours ofadmission to a medical ward. Most ofthe 376 patients admitted to the ward had a high level ofmultiple pathology and physical incapacity and a third had an acute confusional state. The mean length ofstay was 19.4 days. There was a 13% mortality with 71% ofsurvivors returning to their own homes. Review of mobility and self care capacity of the group revealed a striking increase in function during their stay in the ward. Factors increasing the likelihood ofdischarge included having a spouse. receiving support at home, having a low initial dependence rating. Adverse factors included having cerebrovascular disease, having dementia and initial maintenance of urine andfaeces. Key words: Co-ordinating, geriatric, general medical services
Introduction here has been considerable debate over the relationship between geriatric and general medical services. I ,2 One approach is for geriatricians and general physicians to admit and care for all patients in a common admission area, with geriatricians having the additional responsibility of transferring patients with particular problems to second line rehabilitation beds? An
T
Correspondence to: Professor W.J. MacLennan, Geriatric Medicine Unit, The city Hospital, Greenbank Drive, Edinburgh EHIO 5SB.
80
alternative is for the geriatrician to take responsibility for all patients over a certain age, say 75 years, and admit them direct to a geriatric assessment unit." A pattern more familiar in Scotland is for geriatricians to concentrate on the management of elderly patients presenting with needs which seem particularly appropriate to the resources and skills of the geriatric service. Examples of patients appropriate to such a service might include those with multiple pathology, significant physical incapacity, concurrent mental disorders, important confounding social factors or ex-
Emergency helicopter transport service
a time. All cases are thus brought to Stornoway even if later transfer is likely. This also allows resuscitation initiated at the accident site to be continued in hospital at the earliest opportunity. The number of patients discharged the same day, 13 (15%), is rather worrying. The majority of these cases were rather trivial injuries and many did not need helicopter transport. One of the problems seems to be poor communication between ships (especially foreign ones) and the landbased authorities. The three foreign fishermen discharged the same day had flu, a minor epistaxis and a bruised hand. All had been reported to the Coastguard as seriously ill or injured. Medical advice is usually sought by radio before the helicopter will take off and the doctors involved are understandably cautious in theirinterpretation of the description of symptoms and injuries. It is easier to send a helicopter and accompanying doctor to assess the patient. Once there, it is difficult not to uplift the patient no matter how trivial the injuries appear. The service is, of course, free of charge for the patient. This may influence some ships captains to call the helicopter rather than waste valuable fishing time making their own way to Stornoway. However, distance from port, the ships speed and prevailing weather conditions should also be considered. Feedback to captains and ships owners may be of benefit in reducing inappropriate use of the service. Despite a few cases of possibly inappropriate usage, the fact that 70 out of 85 patients were either admitted or transferred to the mainland suggests that for the majority of these cases, helicopter transport is appropriate. One surprising finding was the number of army personnel using the service. Nine of the 11 soldiers uplifted were based on St. Kilda, some 45 miles from Lewis. Two ofthese had minor injuries
which were 2-3 days old. Under normal circumstances, they would be inappropriate cases for emergency helicopter transport. However, the flights to St Kilda, with its relatively good landing site provide excellent training runs for the helicopter crews. Conclusion The helicopter has been a valuable addition to the Coastguard Service at Stornoway and its use in SAR work and evacuation of medical casualties has undoubtedly saved lives. However, it is important that the seafaring community does not take advantage of the facility. Improved communications, particularly with foreign vessels, and feedback to ships captains and owners are needed to prevent waste of an expensive but useful resource. This would also reduce unnecessary risk to the lives of the helicopter crews and doctors attending these incidents. In the severe weather conditions that are common round the Outer Hebrides, there is often no alternative means of rapid transport available and the majority of uplifts are entirely appropriate.
ACKNOWLEDGEMENTS: I would like to thank Mr John Griffiths and his staff at HM Coastguard Office, Stomoway for their help in preparing this article, and Dr J A D Goodall for his helpful comments. REFERENCES
2 3
Wilson A, Driscoll P. Transport of injured patients. BMJ 1990; 301: 658-662. Schiller WR, Knox R, Zinnecher H. et aI. Effect of helicopter transport of trauma victims on survival in an urban trauma centre. J of Trauma 1988; 28: 1127-1134. Urdenta LF, Miller BK, Ringenberg BJ. et al. Role of an emergency helicopter transport service in rural trauma. Archives of Surgery 1987; 122: 992-996.
0036-9330/92/11391/076 $2.00 in USA © 1992 Scottish Medical Journal
Scot Med J 1992; 37: 076-080
SURGICAL CORRECTION OF CONGENITAL HEART DEFECTS IN ADULTS D I Hamilton, A.K. Bozkurt University Department of Cardiac Surgery, Royal Infirmary of Edinburgh. Abstract: From April 1987 to April 1991 ,30 patients over the age of 15 years underwent surgery for congenital heart defects in the adult department of the.Professorial Unit of Cardiothoracic Surgery, Royal Infirmary of Edinburgh. Eighteen were females (60%) and 12 were males (40%). Ages rangedfrom 15 to 68 years (mean 38.1). Six patients 20% had undergone previous cardiac surgery. Operative and hospital mortality was zero. Major postoperative complications occurred in three patients. In the follow-up period between three months andfour years, there has been one late death. The spectrum ofpatients with congenital heart defects over the age of 15 was reviewed. The relatively late presentation of these defects and the indicationsfor operating in adult life are discussed. Key words: Congenital heart defect, adult patients. Introduction ost epidemiological studies have suggested an incidence of congenital heart defects in live born infants of four to 10 per 1000 (average 8).1 These defects are also associated with early spontaneous abortion. One study reported 15.4% incidence of congenital heart defects in 247 abortuses under 24 weeks of . 2 gestation,
M
76
In the last two decades, there has been a considerable expansion of technology, including the development of angiocardiography and Echo/Doppler techniques. As a result of the wide range of congenital heart defects, which vary from single holes or valve abnormalities, to obstruction within or near the heart, to complex malpositions and valve atresias, patients may present with symptoms as neonates, infants, young children, adolescents, or in
Adult congenital heart defects
Hamilton and Bozkurt
late adult life. Patients and methods We have reviewed the data of 30 consecutive patients who had a diagnosis of congenital heart defect during the period from April 1987 to April 1991. All of these adult patients were referred to the Professorial Unit of Cardiothoracic Surgery, Royal Infirmary of Edinburgh. Eighteen patients (60%) were female and 12 male (40%). The ages ranged from 15 to 68 years (mean 38.1). Previous cardiac operations had been carried out in six patients (20%). The preoperative diagnosis was made on the basis of the history, clinical, angiocardiographic and echocardiographic findings. Table I summarises diagnosis and operations in the 30 patients. Results There was no operative or hospital mortality. One patient with partial A-V canal underwent reoperation because of tricuspid valve regurgitation and pericardial patch separation from the inferior border of the atrial septal defect. Primary repair of the tricuspid valve and reattachment of the patch was carried out. Prolonged ventilatory support was necessary without any late consequences. In another patient, temporary complete heart block necessitated A-V pacing for two weeks. One patient had mild transient weakness representing the only neurological complication in this group. Longer term follow-up information was obtained by physical examination whenever possible. When this was not possible, a review of medical records and follow-up visits was performed. The average follow-up was 28 months, and the range was from 3 to 51 months. One patient, who underwent open heart surgery for closure of a ventricular septal defect with pulmonary valve stenosis at the age of 60 years, died suddenly 11 months after the operation. No obvious cause related to the cardiac operation was apparent.
Discussion Congenital heart defects result from developmental aberrations in the formation of the "heart tube", and although present at birth, may not be recognised (diagnosed) until much later in life. Children who have defects with prominent signs and symptoms like transposition of the great arteries, Tetralogy ofFallot, or large ventricular septal defects, will almost invariably be discovered in infancy or early childhood. However, many children, such as those with minimal valvar pulmonary stenosis or small atrial septal defects, may not be diagnosed until adult life because of the late presentation of symptoms and signs. The layman recognises the condition of "a hole in the heart", although not all realise that this hole is situated in one of the inner partitions (septa) of the heart. Others recognise that the heart valves may be narrowed (stenosed), to a mild, moderate or severe degree. Most have heard of "blue babies", but many do not appreciate the causes of cyanosis, which results from the passage of venous blood through a defect, in either atrial or ventricular septum, into the left side of the heart and thence to the body Correspondence and reprint requests to: Professor D I Hamilton, University Department of Cardiac Surgery, Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh EID 9YW
(systemic) circulation. This occurs when the pressure within the right side of the heart exceeds that of the left side as a result of severe tricuspid or pulmonary valve stenosis or a major increase in pulmonary vascular resistance. Congenital cardiac defects occur in approximately 8 per 1000 live births (1: 100). Defects may be single, but frequently are multiple with as many as five or six abnormalities combining within a single heart. These form the more complex group of conditions and present to the medical profession very soon after birth. The following classification on congenital heart defects may be helpful: 1 Failures of septation Atrial Septal Defects (A.S.D.) Holes in the atrial septum of various sizes and at well recognised sites (central, high and low). Absence of the entire septum or "common atrium" is usually associated with a mitral valve abnormality which may produce regurgitation. Ventricular Septal Defects (V.S.D.) These are the commonest congenital heart defects and may occur in any of the named portions of the interventricular septum (inlet, apical, trabecular muscular, outlet). These defects vary in size from a few millimetres to absence of the entire septum (common, single, univentricular heart). V.S.D's are sometimes multiple (Swiss Cheese septum). Table I Detailed diagnosis and operations of patients. Diagnosis
No
Operation
No
1. Atrial septal defect
13
Secundum type
6
Suture closure Patch closure
4 2
Sinus venosus type
6
Redirection of pulmonary veins. Patch closure ASD
6
Coronary sinus type with deroofing of coronary sinus
1
Reconstruction of coronary sinus with closure of ASD
2. Partial A-V canal defect with mitral cleft
3 2
without mitral cleft
Patch closure of ASD with repair 2 of cleft Patch closure of ASD
3. Tetralogy of Fallot
4
Total correction
4
4. Coarctation of Aorta
3
End to end anastomosis Patch repair using GoreTex
2 1
5. Aortic regurgitation
1
Aortic valve replacement
(Previous total correction ofTOF)
6. Truncus arteriosus type II (obstructed Hancock conduit with porcine valve)
7. Ventricular septal defect and puhnonary stenosis
Replacement of valve from the conduit and insertion of 21mm aortic homograft Patch repair of VSD and relief of pulmonary stenosis
8. Tricuspid atresia
Fontan repair
9. LVOT obstruction and VSD
Modified Konno procedure
10. Aortic Stenosis
Aortic prosthetic replacement
11. Mitral regurgitation
Repair of posterior leaflet and insertion of Carpentier ring
77
Adult congenital heart defects
Aorto-pulmonary window A direct communication between the main pulmonary artery and ascending aorta due to incomplete septation of the truncus arteriosus. 2 Stenosis: May be partial or complete (atresia). Obstruction may occur within the heart or outside it. Stenosis inside the heart Valvar Any valve may be stenosed as a result of congenital deformity. Tricuspid, pulmonary, mitral, aortic. Subvalvar The right and left ventricular outflow tracts may be underdeveloped (hypoplastic) or partially obstructed by a fibro-muscular diaphragm (sub-aortic stenosis). In the Tetralogy of Fallot, thick muscle bundles encircle the right ventricular outflow tract, like calipers. At times, these muscle bundles constrict tightly, totally obstructing the flow of blood from the right ventricle into the pulmonary circuit. Stenosis outside the heart Supravalvar stenosis of the ascending aorta may be a familial disorder (Williams syndrome), and, if severe, leads to massive hypertrophy of the left ventricle and premature death. Coarctation of the aorta A tight stricture of the aorta can occur at any point along the length of the aorta. The usual site is distal to the left subclavian artery. This may be an isolated abnormality, (simple coarctation), or is often associated with one of a number ofintracardiac defects (VSD, ASD, bicuspid aortic valve stenosis, mitral valve defects, transposition of the great arteries, and univentricular heart). Coarctation of the aorta may present in the neonatal and infant age range or not until early adult life. 3 Malpositions Transposition of the great arteries The developing heart tube may "loop" in the wrong direction resulting in discordant connection between the ventricles and their outlet arteries. Thus the aorta may connect to the right ventricle and the pulmonary artery to the left ventricle. Double outlet right ventricle. Both great arteries are connected to the right ventricle. The left ventricle exits through a VSD into the right ventricle. Pulmonary valve or subpulmonary stenosis may be present, in which case the pulmonary circulation is "protected" from high pressure blood flow, which results from the left to right "shunt" through the VSD. This simplified and very incomplete classification of congenital cardiac defects should be considered in conjunction with the further sub-division of patients into three clinical categories. Group 1 Simple defects Single small or moderate sized "holes" and minor valve deformities. These produce insignificant symptoms and can be corrected relatively easily and safely, with excellent long term haemodynamic results, following open heart surgery. Operative mortality 1-2%. Group II Intermediate defects These are single or multiple septal defects (ASD and VSD), which are frequently associated with intra cardiac obstruction (stenosis). VSD with right ventricular outflow tract obstruction (RVOTO) comprises the Tetralogy of
78
Hamilton and Bozkurt
Fallot. Transposition of the great arteries without additional intracardiac defects such as VSD or pulmonary stenosis is included within this category. Total anomalous pulmonary venous connection (TAPVC) results from a failure of the pulmonary veins to connect into the posterior aspect of the left atrium. The pulmonary veins drain via an anomalous venous pathway over the top of the heart via the brachiocephalic vein to the superior vena cava and right atrium, or through the diaphragm inferiorly to enter the portal circulation and thence to the IVC and right atrium, or directly to the dilated coronary sinus and thence to the right atrium. This group of congenital abnormalities requires urgent surgical correction in the neonatal or infant period. The commonest "supracardiac" subgroup is relatively easy to correct surgically, and the operative mortality is in the region of 5%. The long term prognosis is excellent? Group III Complex congenital heart defects These defects are frequently multiple, and there may be as many as six or seven individual abnormalities, some of which compensate for each other, and permit the heart to function with varying degrees of efficiency, at least for weeks, months or a number of years. Septal defects, severe intracardiac obstructions including valve atresia in association with great vessel malposition are included in this category. Cardiac surgery for this group of patients may have to be "staged" from infancy through childhood to adult life. Initially, if the condition is not "totally correctable", palliation is performed, increasing inadequate pulmonary blood flow by systemic to pulmonary artery shunting (Blalock-Taussig shunt, Gore-Tex tube graft from systemic to pulmonary artery or Waterston anastomosis). If the haemodynamic problem results in excessive pulmonary blood flow and plethora, then bonding of the main pulmonary artery is performed, constricting the vessel to approximately 8mm diameter as a temporary expedient for several years. This protects the pulmonary vasculature from high blood flow and precludes the development ofpulmonary vascular disease and hypertension, allowing the child to grow until its size is adequate for more definitive "corrective reconstructional surgery". Comments on specific anatomical subgroups of congenital heart defects Atrial Septal Defect (A.S.D.) Atrial septal defects comprise the largest group in our series (16/30). As a result of this defect, left to right intracardiac shunting occurs. Pulmonary vascular disease is rare in childhood in this group of patients compared with patients with V.S.D., P.D.A., and aortopulmonary window. 15-20% of adults with atrial septal defects which have not been closed eventually develop increased pulmonary vascular resistance (P.V.R.).4 The remaining patients may be asymptomatic or become aware of tiredness, developing exertional dyspnoea or palpitation in middle life. Gradually, the right heart chambers dilate, and occasionally shunt reversal resulting in cyanosis occurs. Surgical closure of A.S.D. is usually advised before serious schooling starts (4-5 years), but should certainly be carried out in early or mid adult life, to arrest the natural history of this condition as outlined above. Surgical
Adult congenital heart defects
Hamilton and Bozkurt
56
mortality is less than 1% in uncomplicated cases. • Tetralogy of Fallot (T of F) Only 5-10% of patients with Tetralogy of Fallot can be ex~ected to live over 20 years of age without surgical intervention. Cerebral thrombosis and abscess, cardiac failure from hypoxia and increasing blood viscosity with gradual elevation in haematocrit are the main causes of morbidity and mortality. Infants who require augmentation of pulmonary blood supply before the age of two years (10 Kg in weight approximately) are usually palliated by establishing a systemic to pulmonary artery shunt. Total correction is then performed, as in the group of children who are symptomatic but who have not previously required palliative surgery, at three to six years of age. Surgical mortality is lowest at this time (5% approximately). Four of our patients were referred with this diagnosis, and all were over 22 years of age. Two had undergone previous open heart surgery with the resection of some obstructing muscle bundles from the right ventricular outflow tract. The V.S.D. had been left open on purpose to allow further growth of the main and branch pulmonary arteries which were underdeveloped at that time. Two patients had received systemic to pulmonary artery shunts in childhood. All of these patients complained of diminished exercise performance and tiredness. Palliative shunts may protect the patient from a serious level of cerebral hypoxia, but do not allow adequate augmentation of pulmonary blood flow during exertion. The improved quality of life experienced by these patients following "total correction" of the Tetralogy of Fallot is one of surgery's most rewarding achievements. These patients usually wish that they had had their major surgery at a much earlier age. Coarctation of the Aorta This defect is an isolated congenital defect in approximately 33% of all cases of coarctation ("simple"), but is associated with other intracardiac defects in 66% ("complex"). Coarctation of the aorta, therefore, presents in the neonatal and infant period as an emergency, or in later childhood, teenage and early adult life. If the diagnosis has not been made previously, adults usually present with hypertension in the upper body and suffer also from a degree of intermittent claudication in the lower limbs. The hallmark of the clinical diagnosis is the delay in femoral pulsation, the diminished pulse volume and the slow pulse upstroke. Well developed collateral vessels, if present, may be palpable over the back and periscapular regions, and these may cause visible rib notching on the chest X-ray. The results of surgical correction of aortic coarctation, even in the neonate, are excellent. 8.9 However, resection after childhood becomes more hazardous because of the extensive collateral circulation. These tortuous intercostal vessels become thin walled and are fragile and friable. They lie in wait for the unwary surgeon and confront him with a severe test of anatomical knowledge and technical dexterity. Patience, concentration and manual delicacy are mandatory for this type of thoracic surgery. The challenge is considerable, as post-operative paraplegia occurs in 1 in 200 cases. Improvements in peroperative intra-arterial pressure monitoring (upper and lower limbs) and the augmentation of inadequate lower segment arterial perfusion by temporary bypass techniques should minimise this tragic complication in future. Residual
post-operative hypertension and reactive hypertension (during the initial 12 hours post sur¥ery) may require careful pharmacological control in adults. 0 Carpenter et al documented abnormal left ventricular function despite satisfactory relief of coarctation of the aorta in older patients. 11 Coarctation should be treated surgically in infancy or early childhood to avoid subsequent complications as these can be lethal. Before surgery was available, few adults lived beyond 40 years of age with this condition. 12 "Spare-part" and reconstructive surgery The ideal substitute for irreparably damaged heart valves remains elusive. Experience over a 30 year period suggests that man-made prostheses such as the ball in a cage, tilting disc, or butterfly bi-leaflet valve can all function satisfactorily for many years. The main disadvantage of such implants is that these patients require anticoagulant therapy for life. Nevertheless, children can be managed on this regimen satisfactorily, and careful medical supervision during pregnancy, parturition and the postnatal period has ensured the safe arrival of a number of neonates. The prosthesis may have to be changed after a number of years as the child grows rapidly, and this has been accomplished frequently. Such prostheses do not function satisfactorily as substitutes for the pulmonary valve, as the lower pressures on the right side of the heart allow the closing mechanism of the valve to fail as a result of thrombus formation. The alternative to manufactured prostheses is a tissue valve, (homograft or heterograft), and this may be a free graft or a frame-supported bio-prosthesis. Frame-mounted porcine valves have not stood up to the test of time particularly well, as they calcify rapidly in children and degrade similarly, but at a slower rate in adults. Ten years is usually the maximal functional life of such valves. Homograft aortic and pulmonary valves have been used more successfully for aortic valve replacement in adults, and for the reconstruction of the right ventricular outflow tract in children and adults in the Tetralogy of Fallot. Such valves are utilised as part of a composite conduit in association with a length of Dacron tube, for major reconstructions to bypass the atretic pulmonary valve or artery, bridging the gap between right ventricle and the confluence of the main branch pulmonary arteries. Such conduits are also employed in the reconstruction of truncus arteriosus, initially in infancy and later replacing these small diameter conduits with larger ones. In recent years, major improvements based on a clearer understanding of functional anatomy has resulted in more successful surgical repair of the heart valves. This allows the conservation of the mitral valve in certain cases where formerly a prosthesis would have been implanted. 13 By-passing the right side of the heart, and cave-pulmonary connection During the past 20 years, significant advances in the surgical management of tricuspid valve atresia and a number of options for right heart bypass have been developed. These techniques are employed to deviate systemic venous return directly into the pulmonary arterial circulation (by gravity flow and calf pump action) in cases of univentricular heart (single ventricle cor biatrium triloculare). Such operations must be considered to be palliative, even in the long term. Nevertheless, severely disabled cyanotic patients may enjoy a surprisingly
79
Hamilton and Bozkurt
Adult congenital heart defects
active lifestyle when these procedures are successful. Careful preoperative assessment of their anatomical and haemodynamic aberrations are the basis of sound case selection. The number of patients requiring primary correction of congenital heart defects as adults will diminish in the future as diagnosis improves, as a result of increasing awareness of the possibilities and achievements of cardiac surgery for congenital and acquired lesions. However, the cohort of patients who have had their congenital cardiac defects palliated and corrected in childhood is now marching into adulthood, and the numbers increase year by year. This group of patients will continue to require expert cardiological and surgical supervision, sometimes throughout life. It is necessary now to establish clinics which are staffed by combined medical and surgical teams, who have wide experience in the management of congenital heart defects in childhood and are also expert in handling adult cardiac patients. REFERENCES Hoffman nE. Congenital heart disease: Incidence and inheritance. Ped Clin North Am 1990; 37:1 25-43 2 Gerlis LM. Cardiac malformations in spontaneous abortions. Int J Cardiol 1985; 7: 29-43.
3 Lamb RK, Qureshi SA, Hamilton DI. Total anomalous pulmonary venous drainage: Seventeen year surgical experience. J Thorac Cardiovasc Surg 1988; 96: 368-375. 4 Spencer FC. Atrial Septal Defect, anomalous pulmonary veins, and atrioventricular septal defects (AV cancl). In: Sabiston DC and Spencer FC (eds). Surgery of the Chest 5th Ed. Philadelphia, W B Saunders Company 1990: 1250-1273. 5 Liberthson RR. Congenital heart disease in the child, adolescent and adult. In: Eagle KA, Haber E, De Sanctis RW, Austen WG (eds). The Practice of Cardiology, 2nd ed. Boston, Little Brown Co. 1989: 1091-1281. 6 Kirklin JW, Barratt-Boyes BG. Atrial Septal Defect and partial anomalous pulmonary venous connection. Cardiac Surgery. New York, John Wiley & Sons 1986; 463 -497. 7 Bertranou EG, Blackstone EH, Hazelrig JB, Turner ME. Kirklin JW. Life expectancy without surgery in Tetralogy of Fallot. Am J Cardiol1978; 42: 458-466. 8 Williams WG, Shindo G, Trusler GA, Dische MR, Alley PM. Results of repair of coatctation of the aorta during infancy. J Thoracic Cardiovasc. Surg 1980; 79: 603-608. 9 Hamilton DI, De Eusanio GD, Donnelly RJ. Early and late results of aortopla sty with left subclavian flap for coarctation of the aorta in infancy. J Thoracic Cardiovasc Surg 1978; 75: 699. 10 Liberthson RR, Pennington DG, Jacobs ML, Daggett WM. Coarctation of the aorta: Review of 234 patients and clarification of management problems. Am J Cardiol1979; 43: 835-840. II Carpenter MA, Danman JF, Watson DD. Left ventricular hyperkinesia at rest and during exercise in normotensive patients 2 to 27 years after coarctation repair. J Am ColI Cardio11985; 6: 879-886. 12 Reifenstein HG, Levine SA, Gross RE. Coarctation: Review of 104 autopsied cases of "adult type" 2 years of age or older. Am Heart J 1947; 33: 146-168 13 Carpentier A. Cardiac valve surgery - the "French correction". J Thorac Cardiovasc Surg 1983; 86: 323-337.
Scot Med J 1992; 37: 80-82
0036-9330/92/11591/080 $2.00 in USA © 1992 Scottish Medical Journal
CO-ORDINATING GERIATRIC AND GENERAL MEDICAL SERVICES; EXPERIENCE OF A GERIATRIC ASSESSMENT WARD IN THE ROYAL INFIRMARY OF EDINBURGH 1
W.1. Macl.ennan, B.1. Chapman. M. Smith, *R.J. Prescott, *IX. Wang Geriatric Medicine Unit, Department of Medicine, Royal Infirmary, Edinburgh and *Medical Statistics Unit, Department of Community Medicine, University of Edinburgh.
Abstract: The paper describes the work ofan assessment unit setup to provide a serviceforfrail elderly patients admitted to general medical units at the Royal Infirmary ofEdinburgh during the period of April 1989 to March 1990. Patients were selected on the basis ofdiagnosis. mental and physicalfunction. age and social background and transferred to the assessment ward within 24 hours ofadmission to a medical ward. Most ofthe 376 patients admitted to the ward had a high level ofmultiple pathology and physical incapacity and a third had an acute confusional state. The mean length ofstay was 19.4 days. There was a 13% mortality with 71% ofsurvivors returning to their own homes. Review of mobility and self care capacity of the group revealed a striking increase in function during their stay in the ward. Factors increasing the likelihood ofdischarge included having a spouse. receiving support at home, having a low initial dependence rating. Adverse factors included having cerebrovascular disease, having dementia and initial maintenance of urine andfaeces. Key words: Co-ordinating, geriatric, general medical services
Introduction here has been considerable debate over the relationship between geriatric and general medical services. I ,2 One approach is for geriatricians and general physicians to admit and care for all patients in a common admission area, with geriatricians having the additional responsibility of transferring patients with particular problems to second line rehabilitation beds? An
T
Correspondence to: Professor W.J. MacLennan, Geriatric Medicine Unit, The city Hospital, Greenbank Drive, Edinburgh EHIO 5SB.
80
alternative is for the geriatrician to take responsibility for all patients over a certain age, say 75 years, and admit them direct to a geriatric assessment unit." A pattern more familiar in Scotland is for geriatricians to concentrate on the management of elderly patients presenting with needs which seem particularly appropriate to the resources and skills of the geriatric service. Examples of patients appropriate to such a service might include those with multiple pathology, significant physical incapacity, concurrent mental disorders, important confounding social factors or ex-
