1
1740 BRITISH MEDICAL JOURNAL VOLUME 292 -28 JUNE 1986 lead to improved patient survival, but is this the case? I know of no surveys in the UK designed to show this, and surveys from the USA, where paramedic training is generally more organised and more advanced, show conflicting results. The question of whether or not better paramedic training improves patient outcome in trauma is controversial. ' There are two schools of thought on the manage- ment of major trauma: those who advocate field stabilisation (performed by paramedics) and those who advocate quick evacuation (the "load and go" or "scoop and run" philosophy). The value of field stabilisation is in "time dependent" patients- those with extremely urgent life threatening prob- lems, those with long transport times, and those who are trapped. In situations such as these most doctors agree that the ABC of resuscitation should be performed as soon as possible. However, recent surveys in the USA have advocated the "load and go" philosophy in urban areas, where transit times are short,2 though some surveys have shown increased survival in certain kinds of urban trauma with paramedic intervention.3 In truth, however, neither school is supported by large quantities of research, and the need for further research is great. In the UK most major trauma will occur in urban areas where transit times will be short; if a policy of "load and go" is instituted then little opportunity will arise for the skills taught to be put into practice. The greater skills of the highly trained paramedic are unlikely to provide better results than the techniques of resuscitation used by ambulance 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 A recent report suggests that the delay in definitive surgery may rest with the medical profession and the lack of a dedicated trauma system in some hospitals.5 The future introduction of regional trauma centres will, I hope, relieve this state of affairs. The increased skills of a qualified paramedic are a small'but important part in the overall resuscitation of the trauma victim in certain circumstances, but without other improvements the true benefits of these skills will not be known. BRIAN J RYAN Royal 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 in salvage of patients with penetrating heart wounds. J Trauma 1982;22:443. 3 Baxt WG, Moody P. The impact of a rotorcraft aeromedical emergency 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 medical audit. Injury 1985;16:249-52. Dangers of lumbar puncture SIR,-Since reading the article by Messrs P G Richards and E Towu-Aghantse on the dangers of lumbar puncture (1 March, p 605) and the subse- quent correspondence (22 March, p 827; 26 April, p 1134) we have seen two childreh who presented with clinical meningitis and deteriorating levels of consciousness; they did not undergo lumbar puncture and subsequently recovered from their illness. Case 1- A 2 year old boy was admitted in a semiconscious state (responding to painful stimuli only) with marked neck stiffness, positive Kernig's sign, left facial palsy, and a history of left otitis media, vomiting, and fever. A lumbar puncture was considered dangerous despite a normal computed tomogram and no papilloedema. The child was treated with intravenous chloramphenicol, ampicillin,- and penicillin. Haemophilhs influenzae was subsequently grown from blood, at which stage penicillin was discontinued. The child made a slow recovery. His consciousness level improved the next day but it was not until the third day that he was fully conscious and alert. His temperature took 11 days to settle. The facial palsy resolved completely by day 14. He is probably left -with some residual hearing defect, for which he is to undergo hearing tests. Case 2-A 12 year old girl wa,s admitted with a very short history of fever and headache and deteriorating level of consciousness over two hours before ad- mission. On arrival in hospital she was moribund, unconscious, and in shock. She had marked neck stiffness and a purpuric rash overher trunk. She was treated with intravenous chloramphenicol and peni- cillin and made an excellent and prompt recovery. No bacteria were grown from her blood. Most children and babies with life threatening illnesses in the UK are admitted to district general hospitals, at least initially. Having computed tomography and a neurosurgical department in our district is an advantage. However, we wish to point out to colleagues at Great Ormond Street that "early transfer to a paediatric intensive care unit with facilities for intracranial monitoring" would have been an option carrying some- risk. We thought positively about local measures likely to minimise intracranial pressure: (a) careful nursing of the airway; (b) maintaining effective breathing, with regular blood gas analysis to identify early the need for assisted ventilation; (c) circulatory appraisal with measurement of skin temperature and blood pressure; (d) drug therapy with chlor- amphenicol, ampicillin, and penicillin; (e) early detection of neurological change-standard head injury chart; and (f) fluid restriction, but not so much as to cause hypoglycaemia. We do agree with our colleagues in Great Ormond Street that if these children had received a lumbar puncture then subsequent respiratory arrest would not have surprised us. Interhospital transfer of premature babies has been fashionable recently, though whether transfer for very- ill children can be achieved as easily remains to be seen. Certainly a typical ambulance journey for these children without readily available life support systems would seem to carry additional risk by eroding treatment of the factors to which intracranial pressure is most sensitive-ventila- tory failure, circulatory changes, and continuing inflammation. We would thus recommend risking diagnostic purity by avoiding lumbar puncture in children with advancing coma and "treating the treatable." M SAEED G 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) is misleadingly high. Many couples who are accepted on to in vitro fertilisation programmes and who start treatment fail even to reach the stage of embryo transfer: there may be an inadequate response to ovarian- stimulation; the attempt to harvest ova may be mistimed or thwarted due to inaccessibility of the ovary or the ripe follicles; the ovum (ova) may not be successfully fertilised; or a fertilised 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 to have one embryo, let alone three, made available for transfer. Couples who, for whatever reason, are seen to have a poor chance of success-in in vitro fertilisation are advised not to undergo further attempts. It is therefore not surprising that the women who were offered a high number of cycles of in vitro fertilisation treatment had a high success rate. My own collation of statistics from in vitro fertilisation units published ;since 1984 in the Journal ofIn VitroFertilisation and Embryo Transfer suggests that the more successful units can claim that about 200/o of their patients will have the hoped foroutcome-that is, a clinically diagnosed- pregnancy.' The cost of in vitro fertilisation is stated as being about £400 per patient- treated. At a success rate of 20% this would mean a cost per pregnancy of £2000. This-seems a small price to pay for initiating the life of a baby compared with money spent to preserve neonatal life in special care baby units. The crucial question in estimating the value of in vitro fertilisation is whether the Jife of a yet to be conceived child can be regarded as of benefit to society (of which that child is not a- member) or whether society would benefit only by the improved quality of life of the parents and by the good of knowing that this treatment was available for those who need it. HILARY PAGE Department of Community 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 and embryo -transfer at the University of Calgary/Foothills Hos- pital: Journal of In Vitro Fertilisation and Embtyo Transfer 1985;2 112-3. Manpower: compendium of deliberate mistakes SIR,-It so happens that at a time when Professor James Parkhouse (10 May, p 1286), among others, has been reappraising manpower problems Pro- fessor John Swales has drawn our attention, even though many of us are already sadly aware of it, to the state of academic medicine.' There is no career structure for clinical re- searchers. There never has been, but formerly those who could deliver results did manage to get by. Unfortunately grant giving bodies support the demise of academic medicine by restricting their considerations to applicants under the age of 35 years, whereas we all know that such people are not likely to make the headlines. Clinical research is not like research in physics or biochemistry. One's background in clinical medicine is relevant to one's ability 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 based on such a record. Thus I might have done x endoscopies andy bronchoscopies and have put in z pacemaker wires. In other words, I am not a one tune Johnny but acompetent physician. Secondly, careers in clinical research could be constructed by creating an accessory consultant grade of clinical investigator. Such persons would not require full consultant status, as do independent operators. in peripheral hospitals, but they would do specialist clinics and have time for laboratory investigations. Thirdly, I think the record proves that submis- sions by investigators for grants should not be dependent on grace and favour by an overlord but rather they should be submitted directly and

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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