Apr 26, 1975 - Viruses and the Heart. J. H. Mitchell, M.D ....................... 192 .... to cries of racial discrimination, trade unionism, protectionism, the closed shop, ...
190
BRITISH MEDICAL JOURNAL
26 APRIL 1975
CORRES PONDENCE Emigration of Doctors N. R. E. Fendall, M.D.; A. J. R. Waterston, D.C.H.
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190
Complications of Laparoscopy J. W. Crawford, M.R.C.O.G ............... 191 Injudicious First-aid D. A. Chamberlain, M.D., and others; V. W. M. Drury, F.R.C.G.P ............... 191 Hormonal Pregnancy Tests and Congenital Malformations Gillian Greenberg, M.B., and others ........ 191 Viruses and the Heart J. H. Mitchell, M.D ....................... 192 Diagnosis of "Reflux Oesophagitis" M. Yunus, M.R.C.P., and J. R. Bennett, M.D.. . 192
Essential Fatty Acid Deficiency Due to Poisoned Children Artificial Diet in Cystic Fibrosis A. W. Craft, M.R.C.P., and others.. ...... 195 J. A. Dodge, F.R.C.P.ED., and others ........ 192 Adverse Effects of Publicity Beta-blockade and Myocardial Infarction Michael Hart .......................... 195 K. M. Fox, M.R.C.P., and others .......... 193 Battered Babies Treatment of Eye Injuries R. A. Evans ........................... 195 R. F. N. Duke, F.R.C.S ................... 194 Impaired Colour Vision in Diagnosis of Dust Mites in Hospitals Digitalis Intoxication M. E. Blythe, a.sc....................... 196 W. 0. G. Taylor, F.R.C.P.GLAS ............. 194 A Mortgage Problem Better Medical Writing R. Lefever,M.R.c.G.P ..................... 196 J. S. Bradshaw, M.B.; A. I. Klopper, F.R.C.O.G. 194 Fees for Insurance Reports Drug Combinations for Anaesthesia H. D. Young .......................... 196 M. W. P. Hudson, F.F.A.R.C.S............. 194 Cerebral Vasodilators Economies in the B.M.A. H. G. Easton, M.D.; R. A. Wood, M.R.C.P.ED. 195 G. C. Mathers, M.a ..................... 196
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are now being received that the omission of some is inevitable. Letters should be signed personally by all their authors.
Emigration of Doctors SIR, -The article by Dr. B. Senewiratne (15 March, p. 618, and 22 March, p. 669) makes interesting reading but does not present the whole picture. The subject of migration wats placed on the agenda at 'the request of the Sri Lanka delegation at the Fourth Commonwealth Medical Conference, held in Sri Lanka last November. The Sri Lankan delegaition were most concerned at the attrition rate. Tihere is a "push and pull" impetus for migration. The "push" is the imbalance between the expectations engendered by the medical educational thrust and fthe reality of the working and social environment of practice-particularly in the rural areas. The "pull" is the thirst for further postgraduate education and experience-also engendered by medical undergraduate education-and for higher economic reward and the opportunity to practise the high technological medicine the student has been taught. Medical education should conform to ithe needs and aspirations of the society within which it is situated. It may be different without necessarily being of a lesser standard; conformity of standards is possible without rigidity of curriculum content. Some of these difference's are patently a need in the underdeveloped countries for a greater emphasis on child health, fertility and infertility, nutrition and agronomy, the communicable diseases, community healtth aspects, functional skills in relation to emergencies, obstetrical, surgical, and medical, and, last 'but not least, managerial medicine, particularly in a service setting. Rural medicine need's are different from urban needs in their calls upon a doctor's skills. The implication in the article that medical aux:ilaries constitute a danger to the delivery of healith care does a discredit to a deserving buit largely unrecognized cadre of front-line health workers who 'have contributed significantly to the extension of modern care to
multitudes of people who otherwise would have been deprived of such care. Sri Lanka itself has a worthy record of such cadres: and it would do well to consider their reintroduction if the doctor is an economic and social misfit in the community setting. Next comes the argument about who shall put up the barriers-donor or recipient country. Barriers at the recipient country will inevitably lead to cries of racial discrimination, trade unionism, protectionism, the closed shop, etc., however well conceived and motivated. One could devise an international system whereby the donor country could request from the recipient country an entry visa of specific duration in relation to the additional skills and knowledge to be acquired. Nonrestriction of human freedom is a much-toted commodity, but in truth we are all limited and our behavioural patterns conditioned by law and order. The balance between the liberty of the individual and the freedom of society is a delicately balanced phenomenon which varies from country to country; and surely it is the country of citizenship which must decide the balance between the doctor's liberty and the country's needs. The recipient country can perhaps, for its part, limit the inflow as above and devise a scheme for education and qualification without the necessity of admitting the individuals to the register of licensed physicians. Other supporting criteria such as U.K. citizenship or permanent residence could be added to the requirements. Perhaps an "au pair" system could be devised for the duration of the educational process. The inflow of foreign doctors to the U.K. (and the outflow of U.K. doctors) would also be restricted if the internal system of medical education and career opportunities were to be more realistically adjusted. Much is made of the outflow from under-developed to developed countries, but in truth there is a pattern of migration from lesser to more developed countries whereby any given country may be both a donor and a recipient country. There is, for example, migration from India to East Africa, from Pakistan to Arab countries and West Africa. Britain receives physicians from less-developed countries and also donates them to North America. There is also an outflow from Western society to the less-developed countries from Government, technical assistance, and voluntary agencies of no inconsiderable extent.
There is a considerable exchange through international organizations that should not be discounted as it attracts out of the country mature and experienced persons. More could be accomplished if the career structure in Western society recognized and rewarded service overseas. The picture is not all
one-sided; the contribution of personnel from the industrialized societies is not inconsiderable, particularly if physician-years of experience is brought into the equation. A further balancing factor is the number of overseas students who receive a heavily subsidized medical education in the recipient country.
The answer must lie not in any single action but in a multiplicity; migration barriers, improved working and social environments for doctors, a reassessment of primary healith care versus referral health care needs, a rationalization of ratios of health personnel within the health team, a reallocation of functions and responsibilities, a readjustment of medical education programmes to narrow the schism beitween the educational and service requirements, a readjustment of the balance between professional, paraprofessional, and auxiliary education programmes-different but not inferior. It is the maleducation, maldistribution, and malutilization of high-level manpower that is the root cause of the situation. In developed countries high-level manpower 'is involved in both primary health care and refersral care. Most developing countrieis cannot yet afford this, and the restriction of highlevel health manpower to referral health care while delivering primary care through auxiliary personnel would lead to a mo-re sensible deployment of resources and better job satisfaction and thus to a diminution of the outflow.-I am, etc., REX FENDALL Department of Trovical Community Health, Liverpool School of Tropical Medicine, Liverpool
SIR,-Dr. B. Senewiratne's article (15 March, p. 618 and 22 March, p. 669) pinpoints the many problems facing those organizing health services in developing countries. However, I feel he is wrong in condemning attempts to alter the medical course or train more auxiliaries in the effort to improve the nation's health. Aside from the problem of medical migration, there is the one of the doctors in the country contributing little towards its real needs, eiither (through taking up privaite practice or through working in the big city hospitals rather than the rural areas wh&ere the scarcity of doctors is most felt. This situation may be eased by alter-
BRITISH MEDICAL JOURNAL
ing the emphasis of the medical course away from the technically minded, curatively oriented Western style towards the preventive approach based on simple techniques in which the rural worker is regarded as being at the itop of the pyramid of care rather than at the bottom. The disparaging remarks which Dr. Senewiratne makes about medical auxiliaries do not accord well with experience in China' and Africa, where it is being found that a simply trained medical worker in close contact with the people and under the direction of doctors can improve basic health more effectively and much more cheaply than under a conventional Western-type system -as well as making the doctor's work, in organizing a team approach, more rewarding. It is inevitable that medical training in a developing country patterned on Western methods will encourage migration, as will postgraduate courses in Europe and America. As Dr. Senewiratne points out, much insidious harm is done by such courses, which could be avoided if the teachers were instead seconded to the country concerned for a period. Tfhis would also have the valuable effect of widening the participant's viewpoint immneasurably.-I am, etc., TONY WATERSTON Royal Hospital for Sick Children, Yorkhill, Glasgow
Health Care in China. Geneva, Christian Medical Commission, 1974.
Complications of Laparoscopy SIR,--Though a straightforward laparosopic sterilization is probably a shorter procedure than a tubal ligation after laiparotomy, the advantage is marginal and if there is an increased incidence of complications laparoscopy would be unjustifiable. However, the ishorter time taken for laparoscopic sterilization is not the c,hief justification for its use and Mr. E. E. Rawlings and Mr. B. Balgobin (29 March, p. 727), by keeping,such patients in hospital for three to four days, nullify the main advantage. Several consultants in this unit consider this procedure to be suitable for day cases, though the patients always have the option to choose to be kept in overnight or to change their mind after recovering from the anaesthetic. The table shows ithe number of patients admitted for laparoscopic sterilization as day cases and the number who were transferred for overnight recovery during the past year, since the day area in this hosDay Cases
1974
March/April May June July Total August September October November December 1975 January February March Total
191
26 APRIL 1975
16
Overnight Stay 10*
27 19 18
10 6
80
35
23
9t
it it
11 5 6
0
8
2 1
10 9 11
2 1 1
83
8
*Laparotomy and sterilization carried out in two cases. tLaparotomy and sterilization carried out in one case.
pital opened. Tihe dramatic change in August reflected the increasing confidence of the sister in charge of the unit, who was not previously experienced in looking after such cases. Since August 1974 83 patients have been operated on in this way and, excluding the two laparotoinies, have required 89 bed days. The same number of patients treated by Mr. Rawlings and Mr. Balgobin would have required 283 bed days. The saving is even greater since the day area is staffed by nurses working only between 8 a.m. and 5 p.m. No complications of any consequence have occurred in this small number of cases. The calibre of anaesthesia is obviously of great importance. Most of the patients have been given follow-up appointments and there is no doubt that fthis approach is popular with patients, who so often have young children.-I am, etc., J. W. CRAWFORD University Department of Obstetrics and Gynaecology, Ninewells Hospital, Dundee
Injudicious First-aid SIR,-We are deeply concerned by the implications of your leading article (5 April, p. 5). We wonder if the State-registered nurse who gave external cardiac massage to a shopper who had collapsed was criticized unjustly after the pathologist found internal laceration ibut "no underlying disealse . . . which would have caused her collapse." Every experienced pathologist is well aware that no definite cause of death can be found in a proportion of patients who die suddenly. If widespread coronary atheroma is present this may reasonably be presumed to be the cause of death; a very recent infarct will not be evident unless special stains are used, and many patients die of ventricular fibrillation in the absence of any fresh ischaemic event. Units providing resuscitation facilities outside hospital can testify to the frequency of primary ventricular fibrillation without apparent cause. The data from Seattle' are of special interest. Of 143 patients who survived out-of-hospital fibrillation, 48 had no previous history of cardiovascular disease and no fewer than 97 had no evidence of infarction on serial electrocardiograms. Moreover, we know of many conditions that can cause ventricular fibrillation, such as Wolff-Parkinson-White syndrome complicated by atrial fibrillation and the syndromes of prolonged Q-T interval, which would show no abnormality at necropsy. Thus it would be wrong to assume that the collapse of the patient mentioned in your leading article could not have been due to cardiac arrest simply because the pathologist found no evidence of underlying disease. We believe that tissues whidh have become engorged and relatively stiff after circulatory arrest are more susceptible to damage by trauma. We wonder if the injuries described by the pathologist could ihave occurred because -the patient was already dead when the massage was given, rather than the patient having died because of the injuries. External cardiac massage is not free from risks even in experienced hans. We strongly support the notion that only skilled first-aid workers should be instructed in its use. However, the risks are small compared with the successes that can be achieved. We might
mention that 16 patients survived in our area in 1974 afiter resuiscitation outside hospital by paramedical personnel. We very much hope that nurses, ambulancemen, and other first-aid workers are not exposing themselves to risk of censure by attempting resuscitation, for if they were to -be discouraged in this way many lives might be lost unnecessarily.-We are, etc.,
Royal Sussex County Hospital, Brighton
D. A. CHAMBERLAIN R. I. K. ELLIOTT D. H. MELCHER
Baum, R. S., Alvarez, H., and Cobb, L. A., Circulation, 1974, 50, 1231.
SIR,-Death due to injudicious first-aid, as described in your leading article (5 April, p. 5), must be a rare event. I am not sure that injury due to first-aid is uncommon. I have certainly seen in the past two years two patients to whom this happened. Mhe first was a man Who was on holiday in Easrt Anglia with his wife. He is a man subject to attacks of hypoglycaemia and on this occasion 'he left his hotel before breakfasit to post a letter. He felt faint vhile waiting to cross the road. A passer-by was a nurse from an intensive care unit. She assumed carcliac arrest and immediately apolied heart compression, as a result of which the patient was in hospital with a fractured sternum and several fractured ribis for several weeks. Recently a patient of mine, subject to faints, had an attack in church. On this occasion artificial respiration fractured several riibs. The warnings in your article should be heeded by all.-I am, etc., M. DRURY Department of Medicine, Queen Elizabeth Hospital, Edgbaston, Birmingham
Hormonal Pregnancy Tests and Congenital Malformations SIR,-Your leading article (30 November, p. 485) reviewed the evidence for and against a teratogenic effect of horimones administered to women during early pregnancy and concluded that the findings of associations between sex steroid's and congenital anomalies "require confirmation or refutation from elsewhere." The Committee on Safety of Medicines has received through its spontaneous reporting scheme only a small number of reports alleging a possible causal association between 'the use of drugs during pregnancy and the subsequent delivery of a malformed child. However, in order to detect possible associations the committee has collaborated with the medical division of the Office of Population Censuses and Surveys (O.P.C.S.) in an investigation of pregnancies which resulted in the birth of a malformed hild in England and Wales during 1971 and 1972. This investigation has been based on notifications to the O.P.C.S. of babies 'born with a malformation. General practitioners who had cared for the mothers during pregnancy were identified with the help of family practitioner oommnittees. Detail's of the maternal "drug histories" were obtained from the general practitioners' records during interviews with doctors employed by the Committee on Safety of Medicines. Each case history was paired with that of a no,rmal
