LETTERS TO THE EDITOR
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Emergency ambulance triage
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May 2002
Fusidic acid monotherapy
JRSM1)
Mr Thakore and colleagues (March 2002 conclude that 55% of calls for emergency ambulances did not merit an immediate response. As they acknowledge, the design of the study was not ideal. The initial reason for the request was determined from ambulance crew and accident and emergency (A&E) data after the patient had been seen. This will almost inevitably introduce bias when applying the triage criteria, and the assessment should have been blinded. Also, it is much easier to make such determinations in hindsight, with additional time and clinical information, than when faced with a real call when one has to consider the consequences of the decision reached. It is surprising that this paper makes no reference to priority-based dispatch systems, such as the Advanced Medical Priority Dispatch System (AMPDS), as these are currently used by most ambulance services in the UK. These systems have been shown to have a low risk of serious under-prioritization of life-threatening episodes2. However, work that we have undertaken in Nottingham suggests that they may not be very effective in predicting low-priority 999 calls3. The NHS Executive has stressed the importance of developing telephone prioritization systems that will free ambulance services from having to respond to `patients who dialled 999 but who do not need emergency care'4. We believe this may be dif®cult to achieve. Appropriate and effective telephone triage on non-emergency 999 calls requires a greater understanding of the relationship between the initial telephone assessment by ambulance control and the subsequent outcome of the individual call. Without these data we will not be able to ensure that such a system could operate safely and we endorse the authors' views that prospective studies are essential to assess the feasibility of accurately identifying lower priority calls.
Dr Biswas and colleagues (February 2002 JRSM1) present two cases of hypocalcaemia arising during fusidic acid therapy. We agree that this could represent a rare sideeffect of fusidic acid. However, we would like to focus on a different aspectÐthat of antimicrobial resistance selection. In both patients fusidic acid was used as monotherapy (for more than one month in case 2, unspeci®ed for case 1). The general view is that fusidic acid should not be used alone because natural mutants with an alteration in the elongation factor G are harboured even at low rates of 106 staphylococci2. This leads to a rapid spontaneous mutation rate, seen when the organism is grown in increasing concentrations of the drug. Therefore, combination with another antistaphylococcal antibiotic such as ¯ucloxacillin or vancomycin will decrease the risk of resistance emergence1±3, particularly if the infection is with methicillinresistant Staphylococcus aureus or chronic4. The British National Formulary (BNF) recommends `clindamycin alone or ¯ucloxacillin+fusidic acid' for the treatment of osteomyelitis5. Both patients were taking aspirin during treatment with fusidic acid. There is some evidence that this too could promote the emergence of resistance6, and one might consider replacing aspirin with a different antiplatelet agent. In case 1 the patient was concurrently taking aspirin and cipro¯oxacin. According to the BNF such a combination can increase the risk of convulsions even in patients with no previous history5 and cipro¯oxacin resistance might also increase in the presence of salicylates7. In conclusion, fusidic acid should be used only in combination with another antistaphylococcal agent, and interactions with even as `benign' a drug as aspirin should be considered.
Peter Marks
University College London Medical School, London WC1E 6BT, UK
V Vassiliou
Division of Public Health Sciences, University of Nottingham, Queen's Medical
e-mail:
[email protected]
Centre, Nottingham NG7 2UH, UK
A K Demetriades
Tim Daniel North Nottinghamshire Health Authority
National Hospital for Neurology and Neurosurgery, London WC1N 3BG
G Scott Department of Microbiology, UCL Hospitals NHS Trust
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REFERENCES
REFERENCES
1 Thakore S, McGugan EA, Morrison W. Emergency ambulance dispatch: is there a case for triage? J R Soc Med 2002;95:126±9 2 Nicholl J, Coleman P, Parry G, et al. Emergency priority dispatch systemsÐa new era in the provision of ambulance services in the UK. Pre-hospital Emerg Care 1999;3:71±5 3 Marks PJ, Daniel TD, Afolabi O, Spiers G, Nguyen Van-Tam JS. Emergency (999) calls to the ambulance service that do not result in the patient being transported to hospital: an epidemiological study. Emerg Med J (in press) 4 Department of Health. Reforming Emergency Care. London: Stationery Of®ce, 2001
1 Biswas M, Owen K, Jones MK. Hypocalcaemia during fusidic acid therapy. J R Soc Med 2002;95:91±3 2 Turnidge J, Collignon P. Resistance to fusidic acid. Int J Antimicrob Ag 1999;12:S35±44 3 Turnidge J, Grayson ML. Optimum treatment of staphylococcal infections. Drugs 1993;45:353±66 4 Chang SC, Hsieh SM, Chen MI, Sheng WH, Chen YC. Oral fusidic acid fails to eradicate methicillin-resistant Staphylococcus aureus colonization and results in emergence of fusidic acid strains. Diagn Microbiol Inf Dis 2000;36:131±6 5 British National Formulary. London: Pharmaceutical Press, 2001
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6 Price CT, Gustafson JE. Increases in the mutation frequency at which fusidic acid-resistant Staphylococcus aureus arise with salicylate. J Med Microbiol 2001;50:104±6 7 Gustafson JE, Candelaria PV, Fisher SA, et al. Growth in the presence of salicylate increases ¯uoroquinolone resistance in Staphylococcus aureus. Antimicrob Ag Chemother 1999;43:990±2
Authors' reply
Dr Vassiliou and colleagues agree that the severe hypocalcaemia and renal failure we described in two patients was probably related to fusidic acid therapy. We accept that fusidic acid should generally be used in conjunction with another antibiotic in the treatment of osteomyelitis. Concurrent therapies are given in diabetic foot disease where there is an increased likelihood of aerobic and anaerobic infection. In case 1 fusidic acid was initially administered with ¯ucloxacillin and subsequently with cipro¯oxacin. Potential drug interactions should be considered in patients treated with long courses of antimicrobials, and an increasing number of diabetic patients take aspirin. The risks of drug resistance and drug interactions, however, must be balanced against the risk of substituting or discontinuing other therapies. M Biswas K Owen M K Jones Department of Medicine, Singleton Hospital, Swansea SA2 8QA, UK
Attitudes to torture
We feel it necessary to reply to Dr Blachar's letter (December 2001 JRSM1) since we were responsible for quoting the statement he ®nds so offensive. We must insist at the outset that Professor Dolev did state that `a couple of broken ®ngers' are a price worth paying for information. Let us put the matter into context. For several years there has been plentiful evidence that the Israeli General Security Service (GSS), also known as Shin Bet or Shabak, has routinely used harsh techniques of interrogation, euphemistically known as `moderate physical pressure' or even `increased physical pressure', when interrogating Palestinian suspects2,3, even though Israel is a signatory of the UN Convention against Torture. The techniques are so well known that some of them have attracted nicknames. They include hooding, violent shaking, being shackled to a low, sloping chair (shabeh), being forced to crouch for extended periods (gambaz), being subjected to loud music, transient suffocation and sleep deprivation. Following a death caused by violent shaking4, these practices were condemned by the Israel Supreme Court. The Knesset then
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brought in a Bill to legalize the techniques and to give the GSS impunity but, following strong lobbying by human rights groups, the Bill fell and since then there has been no further attempt at legislation; the procedures remain in use. There is good evidence that Israeli doctors routinely monitor Palestinian detainees being interrogated by the GSS5. Dr Blachar has stated in his role as President of the Israeli Medical Association (IMA) that, if anyone would give him the names of such doctors, he would take action6. During a Medical Foundation visit to Israel in November 1999 we sought an interview with Professor Dolev, Chairman of the IMA Ethics Committee, in order to clarify the IMA's ethical stance. We asked him if he could name any doctors involved in interrogations by the GSS but he was unable to do so. During the interview it became obvious that Professor Dolev was sympathetic to the use of `moderate physical pressure', citing the argument of the `ticking bomb'. It was in that context that he made the disputed remark that `a couple of broken ®ngers' were a price worth paying for vital informationÐa remark which, as readers will understand, was not likely to be forgotten by his audience. One problem appears to be that, like many defenders of Israel's methods of interrogation, neither Dr Blachar nor Professor Dolev regards `moderate physical pressure' as torture, despite repeated protests by the UN Committee against Torture. Of course, we are well aware that the security situation has deteriorated disastrously since our meeting in November 1999, and apologists for the methods will argue that their use is now even more justi®ed; but increased danger does not excuse the continued use of inhumane techniques. Indeed, it is now even more important that Israeli physicians should take steps to show the world that they respect international standards of ethical conduct. If the IMA rejects Professor Dolev's remark, then logically it should speak out against `moderate physical pressure' and take steps to identify doctors who cooperate in its practice. Helen Bamber Elizabeth Gordon Rami Heilbronn Duncan Forrest Medical Foundation for the Care of Victims of Torture, London, UK
REFERENCES
1 Blachar Y. Attitudes to torture. J R Soc Med 2001;94:658 2 B'Tselem. Torture as a Routine: the Interrogation Methods of the GSS. Jerusalem: B'Tselem, 1998 3 Human Rights Watch/Middle East. Torture and Ill-treatment. Israel's Interrogation of Palestinians from the Occupied Territories. New York: Human Rights Watch, 1994 4 Pounder DJ. Shaken adult syndrome. Am J Forens Med Pathol 1997;18:321±4
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5 Livneh N. Why are Israeli doctors forced to be present in Shin Bet torture cells? Haaretz 29 January, 1999 6 Blachar Y. Amnesty report on torture in Israel. Lancet 1996;248:1738
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practitioner normally uses. Clearly there would be no objection to retired doctors' reinstating their entitlement. E N Wardle 81 Gloucester Avenue, Grimsby DN34 5BU, UK
Revalidation of the retired
Professor Hatch (March 2002 JRSM1) says that for revalidation a retired doctor will have to provide evidence of being up-to-date. Not only do we have access to the professional journals, medical libraries and our own, often extensive, collection of materia medica but we also have access to the InternetÐPubMed and the restÐ and we can afford the time to study the subjects on which we require information. Such information is available to the patients themselves but they generally need a doctor to help them pick their way through the jungle of case-histories, etc. Thus I have recently been able to help three women with SjoÈgren's syndrome in Scotland, Sweden and South Africa. Gearin-Tosh's book Living Proof illustrates how the advice of `competent' doctors can vary by 1808, and that a person with no medical background can acquire a knowledge of multiple myelomatosis and orthomolecular oncology that I doubt any member of the General Medical Council (GMC) could match. My family and I are registered with GPs, as are all the retired doctors that I know, and it is precisely to avoid adding to their workload that as far as possible we look after our own instead of adding to the queue in the surgery. My own GP, who knows what my role is locally, says `Keep up the good work'. Finally, Hatch's remark about `an easier back-door route to a licence' is an insult to doctors who have paid the GMC's dues for 40 years and have served the public much longer than he. His letter supports the widely held impression that GMC members live in an academic fairyland, out of touch with the realities of the doctor/patient personal relationship. There has never been a case of malpraxis amongst retired doctors. What does the GMC imagine it will achieve by disbarring them? John Rawlins Little Cross, Holne, Newton Abbot, South Devon TQ13 7RS, UK
REFERENCE
1 Hatch DJ. Revalidation of the retired. J R Soc Med 2002;95:163±4
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I wrote to the British Medical Association and the General Medical Council to say that the simplest and most important form of revalidation would be to have a 3±5-yearly exam of the pharmacology and therapeutics of the drugs that a
Back painÐwhose responsibility?
In his account of the RSM's excellent conference (February 2002 JRSM1) Malcolm Morrison rightly indicates that no formal conclusions were reached nor were any resolutions passed. My chief disappointment in the meeting was the under-representation of medical educators. I entirely agree that more cases of back pain should be dealt with in primary care (or in the workplace). There is a mass of evidence on the ef®cacy and safety of musculoskeletal therapies2. But I cannot accept that it is `. . . the responsibility of all those who deal with back pain, across the disciplines, to ensure that patients do not endure prolonged suffering . . . '; at present they cannot help itÐ the great majority of them do not know how! Professor Mansell Aylward made some pertinent comments on the costs. The most important factor in improving the patient's lot is surely for those in primary care to be taught how to deal with these disorders. Contrary to some long held beliefs3, this is not timeconsuming and diminishes the primary-care clinical workload by reducing the need for multiple follow-up attendances. John K Paterson
1 rue du Castellas, 13640 la Roque D'Anthe ron, France.
REFERENCES
1 Morrison M. Back painÐwhose responsibility? J R Soc Med 2002;95: 98±9 2 Burn L, Paterson JK. Musculoskeletal Medicine, the Spine. London: Kluwer Academic, 1990 3 British Medical Association. Report of the Board of Science and Education. Alternative Therapy. London: BMA, 1986
Decline in rehabilitation services
Professor Grahame is right to deplore the decline in rehabilitation services (March 2002 JRSM1). An associated and far worse loss is that of convalescence. When I was in practice it was usual for anyone who had had a major operation or a severe illness to have a couple of bracing weeks on the south or east coast. There they had the bene®t of graded exercises, a nurse on hand to deal with any complications as well as board and lodging. They returned ®t to deal with ordinary life and were rarely readmitted. Recently I attended a meeting of the College of Health convened to discuss patients' experiences following joint
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replacement, and there was universal agreement that being discharged with a list of exercises, little in the way of advice about possible complications and a card to attend the clinic in six weeks was not nearly enough. I ascribe the failure of my hip replacement, which left me with a recurring dislocation and a revision operation a year later, to the inadequate follow-up I received, even when there was agreed to be an infected haematoma overlying the wound. On my last hospital admission two patients came back after a few days at home with complications that could have been dealt with by a nurse. Yes, they had had a `care package' arranged. It just didn't turn up. This cursory attitude leads to irritation and resentment as well as readmissions, surely not a good use of resources. Anne Savage 7 Akenside Road, London NW3 5RA, UK E-mail:
[email protected]
REFERENCE
1 Grahame R. The decline of rehabilitation services and its impact on disability bene®ts. J R Soc Med 2002;95:114±17
Professor Grahame (March 2002 JRSM1) suggests that an escalation in the cost of disability bene®ts may be due to the decline in rehabilitation services. I was fortunate to gain experience in medical rehabilitation in the 1960s, while registrar in Dr Frank Cooksey's department at King's College Hospital. There, short but intensive courses of rehabilitation were offered with the purpose of a return to employment in suitable work or, in the case of housewives, independence in the home and kitchen. It became clear to me, at that time, that without motivation this exercise was not as fruitful as one would wish. This impression is supported by the extremely good outcome from rehabilitation reported in airmen in the Second World War, a highly motivated group of people. The sharp rise in non-means-tested bene®ts in the past ten years could in part be due to lack of rehabilitation shortly after the incident causing the disability. However, my experience as a medical member on bene®t appeals tribunals suggests that the main problem is often a lack of motivation for improvement. This is at times due to cultural differences in coping with disability. It is also due to the intervention of certain welfare rights organizations that urge clients to claim greater disability than can be objectively demonstrated, with a hope of obtaining the highest bene®ts. It therefore appears to me that the present system and criteria for obtaining ®nancial bene®ts does not encourage or motivate claimants to improve, and expensive
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rehabilitation, unfortunately, would yield only a marginal improvement. Marita R Brown New Victoria Hospital, 184 Coombe Lane West, Kingston-upon-Thames KT2 7EG, UK
REFERENCE
1 Grahame R. The decline of rehabilitation services and its impact on disability bene®ts. J R Soc Med 2002;95:114±17
The man who walks backwards
We entirely agree with Dr Brown and Professor Peet (March 2002 JRSM1) that the backward walking by their dystonic patient who subsequently developed psychosis was unrelated to his psychosis per se. Walking backwards in preference to forwards can be a feature of dystonia, whether primary (their patient initially had torticollis and later truncal torsion) or secondary (he was treated with neuroleptics, which may have caused superadded tardive dystonia). It is one of the many manifestations of `taskspeci®city' that in the past caused dystonia and other movement disorders to be mislabelled psychogenic. Unfortunately this can still happen. The list includes not only patients with dystonia but also patients with Parkinson's disease who may be able to run up and down stairs but not walk on the ¯at, and patients with orthostatic tremor who are unable to stand still but have to keep moving like the white rabbit. The precise reasons for these disparities are not understood, but they are very strong pointers to organic extrapyramidal disease. Niall Quinn Kailash Bhatia Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, Queen Square, London WC1N 3BG, UK
REFERENCE
1 Brown AR, Peet M. The man who walks backwards. J R Soc Med 2002;95:137
Clinical skills in ®nal year medical students
Dr Tucker (February 2002 JRSM1) suggests that medical schools have lost enthusiasm for competency as an aim in itself, describing the value of his experience as a `shadow' house of®cer when a ®nal year student at St George's in the 1970s. Competency has not been forgotten by the present generation of clinical tutors at St George's. As a ®nal year student I am currently partaking in my shadows as Dr Tucker once didÐassisting an already quali®ed house of®cer in completion of forms, running errands, taking blood, learning other practical procedures and interacting
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with many members of the multidisciplinary team. During this time I have had ample opportunity to gain experience of the eight core clinical skills identi®ed by Goodfellow and Claydon in their initial study2. The medical school has always made clear that, while it may facilitate my clinical learning, it cannot provide the same experiences and exposure for each student; I am ultimately responsible for my own learning, and have been well directed to this aim. St George's provides written learning objectives and offers access to a clinical skills laboratory, to supplement teaching by senior clinicians. We also record our experience in logbooks. Whilst I cannot claim total con®dence in all clinical skills, the grounding has been good; and the `Introduction to the PRHO year' lecture course held by St George's shortly after ®nals is said to be informative and useful. Although satis®ed by my training so far, two developments are cause for concern. The ®rst is the introduction of shift-systems for junior doctors, preventing continuity in education with patients throughout their training; and the second is the negative in¯uence of medicolegal issues, limiting the activities of students. These factors might prevent my generation from gaining all the experience that our seniors enjoyed at the same level. Kristel Longman 3 Gilbey Rd, London, SW17 0QQ, UK
REFERENCES
1 Tucker B. Clinical skills in ®nal year medical students. J R Soc Med 2002;95:110 2 Goodfellow PB, Claydon P. Students sitting ®nals: ready to be house of®cers? J R Soc Med 2001;94:516±20
Mystery syndromes
Dr Le Fanu's collection of `mystery syndromes' (March 2002 JRSM1) contains a case that is no mystery. The `walker's ankle rash', though surprising to those affected, is friction dermatitisÐa form of irritant contact dermatitis. The eruption, which I have experienced, can be ¯orid in appearance and unpleasantly symptomatic with troublesome itching on a background of tender skin. It responds rapidly to treatment with an emollient such as Nivea,
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E45 or whatever is available in the nearest village shop. No topical corticosteroid is needed. There is no need to interrupt the walking holiday. The skin just above the tops of the walking boots is unaccustomed to the friction of boots through socks, applied for several hours in a day, possibly in wet and cold weather conditions. A further factor is that the skin becomes drier and more susceptible with age; friction that caused no trouble last year may be too much this year and subsequently. M F Corbett 102 Chesterton Road, Cambridge CB4 1ER, UK
REFERENCE
1 Le Fanu J. A clutch of new syndromes? J R Soc Med 2002;95:118±25
Earth-eating
I was sorry that the interesting article by Woywodt and Kiss (March 2002 JRSM1) did not include the association with zinc de®ciency. One of the ®rst descriptions of zinc de®ciency in man was made by Prasad, Halsted and Nadimi in 1961 in adolescent boys in Iran who had been clay-eaters since childhood2. It was a syndrome of dwar®sm, sexual retardation and iron-de®ciency anaemia and the ®rst two of these responded to zinc therapy. Later a similar syndrome was reported in Egypt but schistosomiasis was a factor (which it was not in Iran) and clay-eating was not found; the dwar®sm and sexual retardation responded to zinc therapy. Clay contains anions such as phosphate which bind zinc, making it unavailable for absorption. In regions where the diet is high in phytate, which also binds zinc, de®ciency of this essential element is found. Margaret Elmes Dawros House, St Andrews Road, Dinas Powys CF64 4HB, UK
REFERENCES
1 Woywodt A, Kiss A. Geophagia: the history of earth-eating. J R Soc Med 2002;95:143±6 2 Prasad AS, Halsted JA, Namibi M. The syndrome of iron de®ciency anemia, hepatosplenomegaly, hypogonadism dwar®sm and geophagia. Am J Med 1961;61:532
