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1740 BRITISH MEDICAL JOURNAL VOLUME 292 -28 JUNE 1986

lead to improved patient survival, but is this thecase? I know of no surveys in the UK designed toshow this, and surveys from the USA, whereparamedic training is generally more organised andmore advanced, show conflicting results. Thequestion of whether or not better paramedictraining improves patient outcome in trauma iscontroversial. 'There are two schools ofthought on the manage-

ment of major trauma: those who advocate fieldstabilisation (performed by paramedics) and thosewho advocate quick evacuation (the "load and go"or "scoop and run" philosophy). The value offieldstabilisation is in "time dependent" patients-those with extremely urgent life threatening prob-lems, those with long transport times, and thosewho are trapped. In situations such as these mostdoctors agree that the ABC of resuscitation shouldbe performed as soon as possible. However, recentsurveys in the USA have advocated the "load andgo" philosophy in urban areas, where transittimes are short,2 though some surveys have shownincreased survival in certain kinds ofurban traumawith paramedic intervention.3 In truth, however,neither school is supported by large quantities ofresearch, and the need for further research is great.

In the UK most major trauma will occur inurban areas where transit times will be short; if apolicy of "load and go" is instituted then littleopportunity will arise for the skills taught to be putinto practice. The greater skills of the highlytrained paramedic are unlikely to provide betterresults than the techniques of resuscitation used byambulance staff today.

Finally, the interval between injury and defini-tive surgical treatment is a critical factor in deter-mining the survival rate of trauma victims.4 Arecent report suggests that the delay in definitivesurgery may rest with the medical profession andthe lack of a dedicated trauma system in somehospitals.5 The future introduction of regionaltrauma centres will, I hope, relieve this stateof affairs. The increased skills of a qualifiedparamedic are a small'but important part in theoverall resuscitation of the trauma victim in certaincircumstances, but without other improvementsthe true benefits of these skills will not be known.

BRIAN J RYANRoyal Hospital,Wolverhampton

I Dailey RH, Callaham M. Controversies in trauma managent.New York: Churchill-Livingstone, 1985.

2 Gervin AS, Fischer RP. The importance of prompt transport insalvage of patients with penetrating heart wounds. J Trauma1982;22:443.

3 Baxt WG, Moody P. The impact of a rotorcraft aeromedicalemergency care service on trauma mortality.JAMA 1983;249:3047.

4 Trunkey DD. Trauma. Sciennfic Amercan 1983;249:20-7.5 Dearden CH, Rutherford WH. The resuscitation of the severely

injured in the accident and emergency department-a medicalaudit. Injury 1985;16:249-52.

Dangers of lumbar puncture

SIR,-Since reading the article by Messrs P GRichards and E Towu-Aghantse on the dangers oflumbar puncture (1 March, p 605) and the subse-quent correspondence (22 March, p 827; 26 April,p 1134) we have seen two childreh who presentedwith clinical meningitis and deteriorating levelsof consciousness; they did not undergo lumbarpuncture and subsequently recovered from theirillness.

Case 1- A 2 year old boy was admitted in asemiconscious state (responding to painful stimulionly) with marked neck stiffness, positive Kernig'ssign, left facial palsy, and a history of left otitismedia, vomiting, and fever. A lumbar puncture was

considered dangerous despite a normal computedtomogram and no papilloedema. The child was treatedwith intravenous chloramphenicol, ampicillin,- andpenicillin. Haemophilhs influenzae was subsequentlygrown from blood, at which stage penicillin wasdiscontinued. The child made a slow recovery. Hisconsciousness level improved the next day but it wasnot until the third day that he was fully conscious andalert. His temperature took 11 days to settle. Thefacial palsy resolved completely by day 14. He isprobably left -with some residual hearing defect, forwhich he is to undergo hearing tests.

Case 2-A 12 year old girl wa,s admitted with a veryshort history of fever and headache and deterioratinglevel of consciousness over two hours before ad-mission. On arrival in hospital she was moribund,unconscious, and in shock. She had marked neckstiffness and a purpuric rash overher trunk. She wastreated with intravenous chloramphenicol and peni-cillin and made an excellent and prompt recovery. Nobacteria were grown from her blood.Most children and babies with life threatening

illnesses in the UK are admitted to district generalhospitals, at least initially. Having computedtomography and a neurosurgical department in ourdistrict is an advantage. However, we wish to pointout to colleagues at Great Ormond Street that"early transfer to a paediatric intensive care unitwith facilities for intracranial monitoring" wouldhave been an option carrying some- risk. Wethought positively about local measures likely tominimise intracranial pressure: (a) careful nursingof the airway; (b) maintaining effective breathing,with regular blood gas analysis to identify earlythe need for assisted ventilation; (c) circulatoryappraisal with measurement of skin temperatureand blood pressure; (d) drug therapy with chlor-amphenicol, ampicillin, and penicillin; (e) earlydetection of neurological change-standard headinjury chart; and (f) fluid restriction, but not somuch as to cause hypoglycaemia.We do agree with our colleagues in Great

Ormond Street that if these children had receiveda lumbar puncture then subsequent respiratoryarrest would not have surprised us. Interhospitaltransfer of premature babies has been fashionablerecently, though whether transfer for very- illchildren can be achieved as easily remains to beseen. Certainly a typical ambulance journeyfor these children without readily available lifesupport systems would seem to carry additionalrisk by eroding treatment of the factors to whichintracranial pressure is most sensitive-ventila-tory failure, circulatory changes, and continuinginflammation.We would thus recommend risking diagnostic

purity by avoiding lumbar puncture in childrenwith advancing coma and "treating the treatable."

M SAEEDG P WYATT

Middlesbrough General Hospital,Middlesbrough,Cleveland TS5 5AZ

IVF update

SIR,-The success rate claimed for in vitro ferti-lisation by Dr M E Setchell (31 May, p 1462) ismisleadingly high. Many couples who are acceptedon to in vitro fertilisation programmes and whostart treatment fail even to reach the stage ofembryo transfer: there may be an inadequateresponse to ovarian- stimulation; the attempt toharvest ova may be mistimed or thwarted due toinaccessibility of the ovary or the ripe follicles; theovum (ova) may not be successfully fertilised; or afertilised ovum may fail to develop into a normal-embryo.

The success rates quoted by Dr Tessa Richards(3 May, p 1156) were measured per 100 women

receiving embryo transfer. Many couples fail tohave one embryo, let alone three, made availablefor transfer. Couples who, for whatever reason, areseen to have a poor chance of success-in in vitrofertilisation are advised not to undergo furtherattempts. It is therefore not surprising that thewomen who were offered a high number of cyclesofin vitro fertilisation treatment had a high successrate.My own collation of statistics from in vitro

fertilisation units published ;since 1984 in theJournal ofIn VitroFertilisation andEmbryo Transfersuggests that the more successful units can claimthat about 200/o of their patients will have thehoped foroutcome-that is, a clinically diagnosed-pregnancy.'The cost ofin vitro fertilisation is stated as being

about 400 per patient- treated. At a success rate of20% this would mean a cost per pregnancy of2000. This-seems a small price topay for initiatingthe life of a baby compared with money spent topreserve neonatal life in special care baby units.The crucial question in estimating the value of invitro fertilisation is whether the Jife of a yet to beconceived child can be regarded as of benefit tosociety (of which that child is not a- member)or whether society would benefit only by theimproved quality of life of the parents and by thegood of knowing that this treatment was availablefor those who need it.

HILARY PAGEDepartment ofCommunity Medicine,University of Sheffield,Sheffield SIO 2RX

1 Taylor PJ, Mahaderan M, Leader A, Wiseman D, Lorsheider F,Servis. S. Initial experience with in vitro fertilisation andembryo -transfer at the University of Calgary/Foothills Hos-pital: Journal of In Vitro Fertilisation and Embtyo Transfer1985;2 112-3.

Manpower: compendium of deliberatemistakes

SIR,-It so happens that at a time when ProfessorJames Parkhouse (10 May, p 1286), among others,has been reappraising manpower problems Pro-fessor John Swales has drawn our attention, eventhough many of us are already sadly aware of it, tothe state of academic medicine.'There is no career structure for clinical re-

searchers. There never has been, but formerlythose who could deliver results did manage to getby. Unfortunately grant giving bodies support thedemise of academic medicine by restricting theirconsiderations to applicants under the age of 35years, whereas we all know that such people are notlikely to make the headlines. Clinical research isnot like research in physics or biochemistry. One'sbackground in clinical medicine is relevant to one'sability to perceive crucial problems.

I can suggest three measures. Firstly, accredita-tion could be discarded in favour of a "grey book"record of witnessed clinical skills, or at least basedon such a record. Thus I might have done xendoscopies andy bronchoscopies and have put inz pacemaker wires. In other words, I am not a onetune Johnny but acompetent physician. Secondly,careers in clinical research could be constructed bycreating an accessory consultant grade of clinicalinvestigator. Such persons would not require fullconsultant status, as do independent operators. inperipheral hospitals, but they would do specialistclinics and have time for laboratory investigations.Thirdly, I think the record proves that submis-sions by investigators for grants should not bedependent on grace and favour by an overlord butrather they should be submitted directly and