Feb 23, 1985 - Throughout hospital life radio and tele- ... their own television sets or radio sets they must .... 17 years of doing domiciliary family planning,.
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Students feel he uses the authority of his position to support his message "be like me." That Dr Older should make such a bold declaration of his tactics must indicate he feels well protected by the structure in which he works or else he is about to change. At least a few appear to hope he will be
BRITISH MEDICAL JOURNAL
-much nearer the mark. Learning by personal experience is a privilege fortunately denied to most doctors, but perhaps if some of the huge volume of current medical research could be directed to the most basic symptoms and experiences and requirements of patients that might prove more profitable, not only for the patients but also for those doctors training for specialist careers in district general hospitals, for whom the present vogue for prolonged "academic" training seems largely irrelevant.
more tolerant toward "fundamentalists." Until then, to avoid embarrassing his colleagues, it might be wise to stop attributing to "fundamentalists" the reasons why he dislikes them. PHILIP NEY Hypercarotenaemia Department of Psychological Medicine, Christchurch, New Zealand
Points Is the flow rate used to drive a jet nebuliser clinically important? Drs R L PAGE and A G WARDMAN (Department of Respiratory Medicine, St James's University Hospital, Leeds) write: While appreciating the scientific merit of the study by Dr J Graham Douglas and colleagues (5 January, p 29) we fear its practical implications. Dr Grant has previously approved of the cautious and restricted use of home nebulisers in the United Kingdom and has eloquently discussed the possibility of their widespread use being associated with an epidemic of asthma deaths in New Zealand.' By implying that nebulisers may be driven by oxygen cylinders the authors have, at a single stroke, opened the doors for widespread domiciliary use of these devices. At present, because of the restricted availability of air compressors, most chest physicians can monitor nebuliser therapy carefully. We hope that the possibility of this close supervision continues, but unfortunately it may not be long before the many patients who unnecessarily have domiciliary oxygen will also have a jet nebuliser to deliver bronchodilators.
23 FEBRUARY 1985
making; but there is no good evidence to show that the death in this case was caused by anything other than unexpected sensitivity to the intravenous dose of an antiarrhythmic drug which the volunteer had never previously had.
Talking points in child abuse
Dr E CHRISTOPHER (Community Health Unit, Haringey Health Authority) writes: In his leading article (26 January, p 259) Dr D P Addy made no mention of the importance of family planning and possible prevention or delay of further pregnancies in those families where child abuse occurs. In Dr PETER SMAIL (Royal Aberdeen Children's 17 years of doing domiciliary family planning, Hospital, Aberdeen AB9 2ZG) writes: One point working with families with many problems omitted in Dr I M Sharman's excellent review of including child abuse, I have found that it is hypercarotenaemia (12 January, p 95) is that this possible to motivate couples to persevere in using benign condition is now common in infancy be- contraception and in some cases prevent further cause of the high carrot content of many propriet- pregnancies.1 However, success depends heavily ary infant foods and the availability of efficient high on the quality of the relationship-that is, conspeed home food mixers.' sistency, reliability, care, and interest-between the domiciliary team (doctor and nurses) and mother 1 Lascari AD. Hypercarotenemia. Clin Pediatr 1981 or parents. It is also true that professionals 20 :25-8. caught up in crises with these families all too easily forget the family planning.
Long term effects of cryosurgery on cutaneous sensation
Dr PHILIP HOPKINS (London NW3 4PS) writes: I was glad to see the report by Dr T S Sonnex and others (19 January, p 188) on the effects of freezing the skin with liquid nitrogen. ... While it may be true that a freeze time of 30 seconds for each of two repeated periods may be used in current practice, since I stopped using nitrous oxide as the cryogen and changed to liquid nitrogen, my experience has led me to reserve the longer freeze times for premalignant or malignant lesions, as benign ones can be treated successfully with much shorter freeze times, provided that liquid nitrogen is the cryogen and that it is used in the proper equipment.' I have treated over 17 000 skin lesions, including premalignant and malignant conditions, in almost 2000 patients. Most of them required only one freeze-thaw cycle of 10 to 25 seconds, with liquid nitrogen as the cryogen. 1 Grant IWB. Asthma in New Zealand. Br Med J This probably accounts for the fact that during 1983 ;286 :374-7. nearly 13 years of using liquid nitrogen cryosurgical techniques I have had only five patients mention, not actually complain of, some loss of sensation Being a patient around or near the treated area. In no case was this of any consequence to the patient. This Dr I I J M GIBSON (Geriatric Unit, Southern clinical experience not only supports the conclusion General Hospital, Glasgow) writes: May I con- that patients may be reassured that any sensory gratulate J A McCool on learning, through his loss after cryosurgery for up to two periods of own anguish, lessons which most doctors and 30 seconds will almost certainly recover, but it also nurses do not seem to understand (26 January, suggests that only a very small number of patients p 296). Throughout hospital life radio and tele- are likely to suffer any sensory loss at all. This, vision are misused. Patients die to the intolerable added to the other advantages of this highly noise. I do not know whether it is worse to go in- effective method of treatment for so many common to a bad geriatric unit and see patients placed in troublesome skin lesions, makes it all the more front of a television blaring out children's pro- attractive and acceptable for patient and doctor grammes while the patients are asleep or into an alike. This, in turn, makes it all the more puzzling orthopaedic unit where rather aggressive and why liquid nitrogen cryosurgery has not become relatively fit young men play various pop stations more widely available for the many patients who on radios despite the illness of many others in the could benefit from it, particularly when its cost ward. I have endeavoured over a number of years effectiveness is considered. to teach nurses the problems of such noise in hospital and I find they are quite bewildered by 1 Hopkins P. Cryosurgery by the general practitioner. Practitioner 1983;227:1861-73. my complaints. . . If patients are going to have their own television sets or radio sets they must have headphones.
Volunteer studies Dr STEVE HAWKINS (Truro TR1 2LS) writes: It is an indictment of our inattention to basic details that a patient should be sent home after a thoracotomy without being warned about the dangers of a "frozen shoulder" developing (12 January, p 142). To be told, as I was, to expect to be back to normal six weeks after a fairly major operation is heartening at the time, but depressing when you are still feeling ill three months later. I drew constant reassurance from a colleague's remark after a back operation that "It takes a year to feel well again and two years to feel absolutely normal"
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Dr J M SIMISTER (Lundbeck Ltd, Luton, Bedfordshire LU 1 5BE) writes: Minerva's exercise of journalistic licence in her note (26 January, p 327) about the young man who died after an intravenous dose of eproxindine gives the reader the impression that a drug interaction was the undisputed cause of cardiac arrest. The authors admit that their hypothesis of displacement by eproxindine of flupenthixol from protein binding sites is speculative. Their main contention of the importance of having full knowledge of medical history and drug treatment of volunteers in drug trials is well worth
1 Christopher E. Sexuality and birth control in social and community work. London: Maurice Temple Smith, 1980.
Neurology services to the district general hospital Dr PETER HUMPHREY (Walton Hospital, Liverpool, and War Memorial Hospital, Wexham) and Dr DAVID JONES (Clwyd Health Authority, Mold) write: Last year you published a considerable correspondence about the lack of neurological cover in district general hospitals.' 2 Clwyd Health Authority has sought to solve this problem by appointing a full time clinical neurologist (and paying his full salary) who spends two days a week in Clwyd and three days a week at the regional neurological centre at Walton. This post is thus satisfactory to the neurologist, who is based at Walton, where he spends most of the week, and has the same facilities and beds as his colleagues there. He is thus a full time neurologist and not a physician with an interest in neurology. Clwyd gets a better neurological service, with any neurological inpatient being seen within two to three days or sooner if urgent. As neurology forms a considerable part of any general medical department this situation may help to solve the problem of deficient neurological services in district general hospitals as well as ease the present career prospects for junior doctors in training. Clearly a similar arrangement could be considered for other regional specialties. 1 Hopkins AP. Different types of neurologists. Br MedJ
1984;288:1733-6.
2 Marshall J; Garfield J; Padget KI; Ashworth B; Perry IJ et al. Different types of neurologist. Br
MedJ7 1984;288:1994-5.
The old in the cold Dr LESLEY MORRISON (Community Health Services, City and Hackney Health Authority, London E9 6LG) writes: Elderly people may feel embarrassed about applying for heating benefits, they may not know how to apply, and they may be conditioned to regard cold not as a risk to life and health but merely as an arduous discomfort. Such attitudes and lack of knowledge can be addressed by sensitive counselling and health education. But awareness of the dangers of being cold may not be enough without the money to avoid them. Health workers should document instances where inadequate heating allowances have been directly responsible for morbidity and mortality among the elderly. The DHSS might then be pressed into implementing its stated commitment to the principles of prevention by introducing heating allowances sufficient to prevent hypothermia.
