correspondence - Europe PMC

0 downloads 0 Views 556KB Size Report
water, safe sexual practices, and infectious diseases and could be ... immunisation handbook. Though it quotes the ... for years looked after OXFAM's fieldworkers and Oxford Univer- ... of Tropical Medicine, and that the general prac- titioners inĀ ...
CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the

BMJ.

* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.

Overprescription of cholera vaccine SIR,-Though Drs Alison Mott and Paul Kinnersley's article documents very usefully the overprescription of cholera vaccine to travellers by general practitioners, it fails to emphasise that the Department of Health itself is primarily responsible for the contradictory information that both travellers and general practitioners have received on this subject.' Its publication Before You Go,' which is widely distributed to the public, does not follow the World Health Organisation's guidelines but recommends cholera vaccination for all countries where cholera is endemic. An attempt to explain to a patient that one disagrees with the advice given in the booklet issued by the Department of Health is likely to fall on deaf ears. This situation is particularly unfortunate as the two booklets Before You Go and While You Are Away3 contain useful irnformation about drinking water, safe sexual practices, and infectious diseases and could be issued to all travellers by general practitioners in their surgeries. I would also like to disagree with the interpretation by Drs Mott and Kinnersley of the information given in Immunization Against Infectious Diseases, again published by the Department of Health.4 This is widely used by general practitioners as their immunisation handbook. Though it quotes the World Health Organisation's view and the limited use of cholera vaccine, it still persists in suggesting that vaccination may confer some personal protection, and still recommends that people travelling to countries where cholera is endemic should be vaccinated. Might I suggest that the only step necessary to reduce overprescription of cholera vaccine would be to place pressure on the Department of Health to bring its own recommendations in line with informed medical opinion concerning this subject. J SILVERMAN Health Centre, Linton, Cambridge CB I 6JS I Mott A, Kinnerslev P. Overprescription of cholera vaccine to travellers by general practitioners. Br Medj 1990;300:25-6.

(6 January.) 2 Department of Health. Before you go. London: HMSO, 1989.

(SA 40.) 3 Department of Health. While You are awaY. London: HMSO, 1989. (SA 41.) 4 Department of Health and Social Services. Immunization against infectious diseases. London: HMSO, 1988.

SIR,-Drs Alison Mott and Paul Kinnersley take upon themselves a grave responsibility when they talk about "educating general practitioners" before they are sure that their own house is in order. ' For those of us who have to deal with people who travel BMJ

VOLUME 300

27 JANUARY 1990

to tropical Africa and Asia and who have to cope with the problems when they return the position is not as simple as the reader might be led to believe by the article. My department has for years looked after OXFAM's fieldworkers and Oxford University's expeditions and many members who travel in the course of their work. The World Health Organisation's recommendation that cholera vaccine should no longer be given was based on the fact that vaccination did not prevent the spread of cholera throughout Africa. No one would claim that cholera vaccine is one of our best prophylactic preparations, but an alarming number of travellers are asked in many Third World countries if they have been vaccinated against cholera, and if they have not the immigration official has an arrangement with a local person who will vaccinate them. No doubt this is a good source of extra income, but the risk now of contracting not only hepatitis B but also HIV from non-sterile needles is great, and that alone is ample reason for giving cholera vaccine. Some countries demand a valid vaccination certificate as their official policy. In the floods of the Sudan in 1988 it became clear that people who had had two or more immunisations against cholera had a 50% lower chance of contracting cholera than those who had had one injection or none.2 When the vaccine is given intradermally in a dose of 0-2 ml side effects are very rare, even after multiple injections, and the cost negligible. BENT JUEL-JENSEN Radcliffe InfirmarN, Oxford OX2 6HE

the requirement in May 1989.) Additionally, though a certificate is not required for entry into India, "travellers proceeding to countries that impose restrictions for arrivals from India" are required to possess a certificate. Seasoned travellers will often ask for cholera certificates for travel to countries where they know from experience that they may have problems with immigration authorities if they do not possess one. This particularly applies to travellers to or between countries in Africa. For these I have heard a number of people suggest that a certificate should be supplied without the vaccine. I regard this as unethical and fraudulent. The certificate is valueless because vaccination does not prevent carriage of the vibrio across international borders. The protection is not totally valueless. General practitioners cannot be expected to be up to date with recommendations unless their sources give more uniform advice. "Special centres" have the benefit of a constantly reviewed database as well as considerable experience, making the recommendation of cholera vaccination and other procedures more rational. J M STEWART British Airways,

London WIR 5TA 1 Mott A, Kinnersley P. Overprescription of cholera vaccine to travellers by general practitioners. Br MedJ 1990;30:25-6. (6 January.) 2 World Health Organisation. International travel and health: vaccination requirements and health advice. Geneva: WHO, 1989.

1 Mott A, Kinnerslex 1P. Overprescription of cholera vaccine to travellers by general practitioiners. BrAlcdj 1990;300:25-6. (6

Januarv.) 2 Immunisationi Practices Advisory Committcc. Cholera vraccinc. AIAIWR 1988;37:617-24.

SIR,-Our immunisation service recommends cholera vaccination much less frequently than in the past and often counsels travellers not to have the vaccine. I agree that among the cases described by Drs Alison Mott and Paul Kinnersley' the traveller to Sudan is the only one to whom vaccine should have been recommended, but the decision is not always clear cut. Healthy Europeans are unlikely to contract cholera, and if they do then adequate rehydration and treatment with tetracycline or co-trimoxazole are quickly effective. For cholera, as well as other diseases with faecal-oral spread, good food hygiene and water treatment are paramount, but 60% protection is not to be totally disregarded if there is moderate or serious risk of exposure. The World Health Organisation's booklet International Travel and Health2 cites four countries where a vaccination certificate is required by travellers arriving from endemic areas-Pakistan, Pitcairn, Somalia, and Sudan. (Lesotho dropped

SIR, -Drs Alison Mott and Paul Kinnersley have shown that cholera immunisation would be recommended to travellers by general practitioners more frequently than by the Liverpool School of Tropical Medicine, and that the general practitioners in their sample varied among themselves in the advice that they offered to a series of five hypothetical patients.' They conclude that either cholera vaccine should be available only through special centres, or general practitioners should be educated about its use. Last year we showed that the prophylactic immunisations recommended by a sample of 50 general practitioners for a hypothetical traveller to Turkey varied considerably among doctors.2 Many of the recommendations were not supported by expert opinion. Thus vaccines other than that for cholera may also be prescribed inappropriately. One reason may be that general practitioners receive conflicting guidance on prophylaxis for travellers. Both Drs Mott and Kinnersley and ourselves noted multiple inconsistencies among the various sources of information quoted by the general practitioners in our respective samples. Dr John Holden has also drawn attention to this, and 257

has highlighted the medicolegal implications of these discrepancies.' There is a real need for consistency among the various sources of written and verbal guidance available to travellers and to their doctors. TIM USHERWOOD

VIKKI USHERWOOD

D)epartmtent of(iencral Plractice, University of Shcffield Niedical School, Shc-ficid S 1() 2RX

ott A, Kinnersley P. Overprescription of cholcra vaccine to travellers by general practitioners. fBrfed j 1990;300:25-6. 6

Januarv. 2 Usherwoodl V, Usherwood 'IP. Stirvy of gencral practitioners' advice for travellers to Tuirkey. 7 R Coll Geni Prac-t 1989;39: 148-50. 3 Holden JI). General practitioners aitd vaccination for foreign travel. jourttal oftic MIedical I)efcnce 'tzloti 1989 Spring:6-7.

Cardiopulmonary resuscitation and the MRCGP examination SIR,-May we offer a solution to the problem raised by Mr D H Wilson and Dr Jamie Bahrami?' We agree entirely with their views on the dilemma of having ambulance officers assess competence to perform cardiopulmonary resuscitation. We find it totally unacceptable that lay people should examine doctors in basic medical skills. General practitioners are expected to perform cardiopulmonary resuscitation in the pre-hospital or immediate care environment. The diploma of immediate care was instituted by the Royal College of Surgeons of Edinburgh to examine doctors in pre-hospital skills. There is a section on "care skills" consisting of basic life support, defibrillation, and endotracheal intubation. Failing in this section automatically means failing in the whole examination. Each pair of examiners for the section on care skills consists of a consultant anaesthetist and a general practitioner who is an experienced member of the British Association for Immediate Care. The cardiopulmonary resuscitation module of the MRCGP examination should be conducted by a consultant anaesthetist, a consultant in accident and emergency medicine, or a general practitioner who is a member of the British Association for Immediate Care and has passed the diploma of immediate care. There must not be a loss of professional status and respect.

aware of the vital role of resuscitation skills. Around 5%M of victims of myocardial infarction experience a cardiac arrest in the presence of their general practitioner,' and a substantial number (possibly half) may be saved if the general practitioner has a defibrillator.- The increasing availability of defibrillators in front line ambulances demands that a general practitioner at least be able to keep a patient alive while awaiting defibrillation. Resuscitation outside hospital, often performed alone in adverse conditions, is very different from that practised in hospital, and the royal college is correct in demanding that its potential members have retained their skills. M\r Wilson and Dr Bahrami say that it is inappropriate for doctors to be examined by ambulance officers because they have "far less educational standing, training, and experience." The test, however, is not academic but of a basic skill. The ambulance officers in this country have proved expertise and, we suggest, considerably more training and experience in resuscitation than most practising. doctors. Until the medical profession in Great Britain-casualty surgeons included-has proved its ability to perform and examine in resuscitation we should accept that the ambulance service is the group with sufficient expertise and equipment to examine nationally. Our own experience of teaching resuscitation to doctors often reveals inadequate and outdated skills associated with considerable anxietv. Most doctors recognise their inadequacies, and our most grateful pupils are often general practitioners, particularly those preparing for the MRCGP. M C COLQUHOUN

Malvern WR 14 4BE R S JOB

Worcester WR2 4SS 1 Wilson l)H, Bahrami J. CardiopuLlmonary resuscitation and the MRCGI' examination. BrMed_J 1990;300:44. (6 January. 2 Casey W'F. Cardiopulmonary resuscitation: a survey of standards among junior hospital doctors. ] R Soc Med 1984;77:921-4. 3 Skinner D)V, Camm AJ, Miles S. Cardiopulmonary resuscitation skills ol preregistration house officers. Br Med J 1985;290: 1549-50. 4 Marsdcn AK. Guidelines for cardiopulmonary resuscitation.

Br.Medj 1989;299:442-5. 5 Royal College of Physicians. Resuscitation from cardiopulmonarv arrcst. Training and organisation.7 R Coll Phvs'sicians Lond 1987;21: 1-8. 6 Rawlins DC. Study of the management of suspected cardiac infarction bv British immediate care doctors. Br Med J 1981;282:1677-9. 7 Pai GR, Haites NE, Rawles JM. One thousand heart attacks in Grampian: the place of cardiopulmonary resuscitation in

XV F DE MELLO J RESTALL

general practice. BrMfedj 1987;294:352-4. X Colqtihoun MC. Use of defibrillators by general practitioners. Br.lIed7 1988;297:336.

Wilson DH, lBahrami J. Cardiopulmonary resuscitation anid the MiRCGI' xamination. Br M1ed7 1990;300:44. 6 Jantiary.

SIR,-Mr D H Wilson and Dr Jamie Bahrami raise the twin objections of the postregistration testing of a skill acquired by registration and of the skill being tested by ambulance officers.' These arguments are cogent, but there is the additional issue of a particular skill being singled out as a qualifying condition for entrance to the examination at all. It is true that the skill being tested is a potentially lifesaving one. The same could be said for the ability to examine and assess a baby or young child for the likelihood of meningitis. To miss this early diagnosis often results in a fatal outcome or in permanent damage to the child. By the same token the Royal College of General Practitioners should demand a certificate from a consultant paediatrician that the MRCGP candidate has the skills of examination and assessment so that the lifesaving action of prompt referral of the child by the candidate is reasonably ensured. But with what does the process of certifying papers stop-appendicitis in children? subarachnoid haemorrhage? suicide and depression? spinal compression and carcinoma? The need for this certifying process leaves a serious doubt about the evaluation of learning that has been carried out by those responsible for teach-

Cambridge Military Hospital, Aldershot GU Il 2AN

SIR,-Mr D H Wilson and Dr Jamie Bahrami state that "proficiency in cardiopulmonary resuscitation is so basic and essential that the safety of the public demands that every practising doctor should be well versed with the technique."' They imply, however, that because resuscitation is taught to undergraduates most doctors are proficient in the techniques on qualification and become more expert with postgraduate experience. This statement must be severely challenged in view of the considerable evidence to the contrary.: Skill in basic and advanced life support needs to be adequately taught and regularlv practised in a simulated situation; skills decline with time and need to be reinforced.' The Royal College of Physicians' report on resuscitation has stressed the importance of examination in this subject in diploma examinations,' and the Roval College of General Practitioners is to be congratulated for taking the lead by introducing a test of basic life support into the MRCGP examination. General practitioners are of course

258

ing acute aspects of general practice. Obviously the college must have concluded that little reliance can be put on the evaluation of the learning of skills. We are also left wondering what it is that the Joint Committee for Postgraduate Training in General Practice is certifying with its certificates. JOHN I) SINSON

Lceds L.S 17 6HF I W'ilson DH, Bahrami J. Cardiopulmonary rcsoiscitation and thc MNiRCGP examination. Br Med 7 1990;300:44. 6 Januars.

SIR,-Mr D G Wilson and Dr Jamie Bahrami' voiced anxieties on examining cardiopulmonary resuscitation skills that have been expressed by several members of the medical profession. Although I understand these anxieties, some are based on misunderstanding and I would like to clarify one or two points. The practice of cardiopulmonary resuscitation is a vital skill for general practitioners. Unfortunately, unlike riding a bicycle, this skill decays rapidly and has begun to decay after three to six months. It is therefore appropriate to test this skill in a postgraduate examination taking place four years after graduation. At this stage doctors who have not been able to practise cardiopulmonary resuscitation will have definite skill decay and will be motivated to improve this skill. I do not think that this sets a dangerous precedent for other facets of knowledge that have traditionally been considered part of the undergraduate medical curriculum, as they do not deteriorate so rapidly. These doctors should not be embarrassed by the fact that a general practitioner's competence is to be examined by an ambulance worker. It is not any ambulance worker but an officer who is a skilled teacher with specialist knowledge of teaching and examining in basic life support. We are short of such teachers in our own profession, and to do such teaching within the accident and emergency department would put an enormous burden on already overworked departments. In many hospitals the resuscitation training officer works closely with this department in devising courses for hospital staff from the cleaner to the senior consultants. This does not take account of the fact that a quarter of candidates for the MRCGP examination do not qualify in this country. Advances in the technology of teaching mannikins means that the trace produced is an accurate record of the candidate's skills. Such mannikins are expensive and are held by the ambulance training schools. With the increasing development of practice teams and care in the community the time has come for doctors and other team members to recognise the ambulance officer as a colleague in pre-hospital care and to respect the skills of the training officers in the regional training schools. JUDITH M FISHER London E4 9SY I

WYilson F, Bahrami J. Cardiopulmonary resuscitation and thc l\lR(,(iP examinatioti. Br Med 7 1 990;300:44. 6 Januar\.

Radiography in women of childbearing ability SIR,-Regrettably, we have to agree with Dr Nicholas Wilson' that the guidelines issued jointly by the College of Radiographers and the Royal College of Radiologists2 on the implementation of advice from the National Radiological Protection Board' have introduced "a new order of uncertainty and confusion." This arises, we believe, from the nature of the recommended pregnancy question, "Are you, or might you be, pregnant?" (our italics).

BMJ VOLUME 300

27 JANUARY 1990