Biomedical subjects
Publications and source records attributed to R M Pearse.
A 72-yr-old man presented with respiratory failure secondary to Guillain-Barré syndrome. Although the criteria for mechanical ventilation were satisfied, the absence of weakness of the bulbar muscles allowed the safe use of non-invasive ventilation for 2 weeks in this patient. Invasive ventilation and tracheostomy were avoided and the patient made a good recovery.
Medical error is an important cause of morbidity and mortality. Organisational failure in the pre-operative period has been associated with catastrophic outcome. Little information is available regarding peri-operative organisational problems. The incidence and nature of organisational failure before urgent and emergency surgery in a district general hospital was studied prospectively in 159 cases over a 30-day period. Organisational failure affected more than half of the cases overall, but varied in both its incidence and its complexity between surgical disciplines. Various causative factors were identified, e.g. 8% of cases were subject to delay due to clinical emergencies. The median [range] time required to rectify the problems was 115 [5-750] min. A consultant anaesthetist and surgeon were present in 30 and 20% of cases, respectively. Difficulty with the preparation of patients for emergency surgery is an important but underevaluated cause of medical error that may put patients at risk.
BACKGROUND: Five years ago we described the acute caseload of a typical general medical senior house officer (SHO) post. This follow-up report assesses the effects of changes since then on SHOs' training. We also look at the opportunities for all medical SHOs to learn and practise the practical procedures suggested as being necessary during a six month unselected general medical take. RESULTS: In six months 752 patients presented, up by 29% in five years. They fell into 87 diagnostic categories. The ten most common categories accounted for 53% of cases seen, indicating little change over five years. The numbers of patients seen by the firm had increased from a mean of 14 to 20 on each take day, but with the appointment of a second SHO to the firm the numbers seen by each SHO fell to 10. Some techniques such as lumbar puncture were used frequently. Others listed as recommended training for all SHOs, such as vital capacity measurement, were not needed. Five procedures that our take patients did require, including Sengstaken tube insertion, are listed only under specialist training requirements. CONCLUSIONS: An SHO post in a DGH continues to offer good exposure to common medical problems but little to more rare conditions. The reduction in hours worked and other changes in the NHS have not altered this. Further thought may be required to formulate achievable recommendations for experience of practical procedures, or specific arrangements made for SHOs to be taught and allowed to practise those techniques for which there is little day-to-day patient need. Our findings support the recent changes to the Royal College of Physicians' requirements for general professional training and the use of log books to identify gaps in experience.