- Email: [email protected]
Abuse of disabled children
553
THE LANCET
Landmine
injuries
What it takes to be
a
doctor
Landmines, the legacy of countless regional conflicts, continue to kill and mutilate. In 1990 mines killed 12 000 Cambodians and caused 6000 amputations. 1 in every 236 Cambodians, 1 in every 470 Angolans, and 1 in every 650 Somalis is an amputee. The scale of the problem was reiterated at a seminar on landmine injuries held by MEDACT (Medical Action for Global Security) last week in London. MEDACT’s is the latest in a growing number of campaigns to reduce and ultimately eliminate the human and environmental damage from mines. It highlighted the need for resources to treat existing and potential victims of landmines-up to 200 million mines are still lying in the ground around the world. Mr Robin Coupland, a surgeon with the International Committee of the Red Cross, said that many war wounds such as mine injuries were badly managed. Often, operations have to be repeated and complications ensue when surgeons do not recognise the extent of limb injuries or when they attempt to close wounds immediately. Coupland said that following amputation the stump should be treated by delayed primary closure after five days. Repeated dressings cause unnecessary suffering in areas where no anaesthetic is available. The ICRC publishes a booklet on amputation for war wounds and is working on a video for medical personnel working in areas where mine injuries occur. There is a spectrum of opinion as to how far campaigns against mines can effectively go. Physicians for Human Rights have called for a total ban, whereas the ICRC wants tighter legislation, with use of only detectable and self-destructing mines with a finite shelf life. Whatever the chosen end-point there was agreement that ratification of the 1981 UN Weapons Convention prohibiting the indiscriminate use of mines would be a helpful first step. Many major arms suppliers, including the United Kingdom, Belgium, and Spain, have not ratified the convention.
Following review of its undergraduate courses, the Faculty of Medicine, London University, has issued a statement on the minimum skills expected of doctors on their first day as house officers. Newly qualified doctors must be able to take and record a history from all patients (or parents of infants and children), and must be able to perform the appropriate clinical examination, including rectal and pelvic examination. They must know how to use a stethoscope, ophthalmoscope, otoscope, and vaginal speculum. They will be competent to prescribe most drugs for inpatients, but will need additional training to prescribe or administer highly toxic agents such as those used in the treatment of cancer. House officers are not expected to be competent at giving intravenous drugs or fluids without formal training. All other procedures, including the insertion of peripheral lines, and cardiopulmonary resuscitation, require instruction after qualification. Newly qualified doctors are not expected to be able to break bad news to patients, but should be present, if possible, when such news is given. Commenting on these minimum requirements, Prof Sir Colin Dollery, Pro Vice-Chancellor for Medicine and Dentistry, London University, and co-author of the statement, pointed out that they provide the basis for a structured educational programme for pre-registration doctors. Such a programme is being devised by the Faculty of Medicine, London University, and is likely to recommend formal teaching of pre-registration doctors for 5 hours per week. Professor Dollery hoped that an improved educational programme for house officers would be in place within 2-3 years.
Cathy Read
The recent vote by the Dutch Government ensures that euthanasia remains illegal in the Netherlands (see Lancet Feb 13, p 426), although criteria being drawn up by the Dutch Medical Association are likely to protect some doctors from prosecution. This failure of the Government to decriminalise euthanasia contrasts with public opinion-a recent survey showed that 71 % of 1100 Dutch people over the age of 18 years were in favour of euthanasia legalisation. The Dutch Government’s decision comes in the wake of results of an investigation into medical decisions concerning the end of life. Readers may remember the first results of this investigation,l which revealed that medical decisions that might hasten death were common practice in the Netherlands: doctors were found to have made such a decision in 38% of all deaths studied; and euthanasia (the administration of lethal drugs at the patient’s request) was involved in 1 ’8% of these deaths. The full report of this investigation, first published in Dutchis now available in English.3 This report, in addition to the results already published,l gives full details of the 3 studies that contributed to this investigation: a retrospective study involving interviews with doctors, a death certificate study, and a prospective questionnairebased study.
European laboratory for study of integrins With the official opening in Luxembourg last week of a French-Luxembourg biomedical research laboratory, the two countries hope to boost the Grand-Duchy’s virtually non-existent research facilities. France, through its National Centre for Scientific Research (CNRS), will provide about a third of the approximately 200 000 annual budget of the new laboratory and the Grand Duchy and Recherche Cancer et Sang, a private Luxembourg foundation, the rest. The Luxembourg Government is also providing 300m2 of floor space for the laboratory in the capital’s
recently created university. The laboratory, the first CNRS-funded "bilateral" research facility to be set up outside France, will, like any of the 300
or so
CNRS research groups, focus
on a
research
topic-in this case, integrins, the family of cell-membrane receptors that mediate cell adhesion. Discovered only 6 years ago, integrins-about 20 have been identified-play a key role in a range of biological processes, including cell differentiation and proliferation, embryo development, platelet aggregation, immunity, tissue repair, and cancer metastasis. Scientific interest in these proteins is great,
particularly among pharmaceutical industry researchers, who see the potential for developing antithrombotic, and-inflammatory, and anti-cancer drugs. A San Francisco firm, COR Therapeutics, has a head start in this process with an integrin-based antithrombotic agent (Integrelin), which is about to enter phase II clinical trials. Dr Nelly Kieffer, director of the Luxembourg laboratory, who is native of Luxembourg who has spent much of her research career with CNRS in Paris, plans to form working relationships with other European groups. Luxembourg students have traditionally gone abroad, particularly to France, to complete their studies and establish research careers. The laboratory, Kieffer hopes, "will be a first step in encouraging many of these graduates to come back and embark on scientific careers in their home country".
Astrid James
Dutch euthanasia survey revisited
Astrid James
der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-74. 2. van der Maas PJ, van Delden JJM, Pijnenborg L. Medische Beslissingen Rond Het Levenseinde. Netherlands: Sdu Uitgeverij Plantijnstraat, ’s-Gravenhage, 1991. 3. van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. (Hlth Policy Monogr 22 [1/2] Special issue) Amsterdam: Elsevier, 1992. Pp 262. Dutch Guilders 257. ISBN 0-444 892788. 1.
van
a
John Maurice
Abuse of disabled children Two reports1.2 published this week highlight the vulnerability of disabled children to physical, emotional, and sexual abuse. They remind doctors that, contrary to the assumption that disability protects from abuse, children with the highest dependency needs and limited communication skills are at risk from abuse, particularly from their carers.
554
THE LANCET
The diagnosis of some forms of abuse is especially difficult when the child’s ability to describe the experience is limited. One report, based on interviews with 15 persons aged between 7 and 17 years with severe physical disabilities,l found that communication boards used by children with little or no normal speech, for example, had no words for genitalia. Moreover, children with disorders such as cerebral palsy had difficulty in holding and manipulating dolls to demonstrate forms of abuse. Ways of modifying interview techniques to suit the needs of disabled children are highlighted in this report. The second report, based upon interviews with 34 adults (17 able-bodied and 17 disabled) who were abused as children,2 describes the vulnerability felt by many of the disabled adults, largely because of an inability to defend themselves and physical immobility. Lack of self-worth, a sense of depersonalisation, lack of general and sexual education, and dependence on others for care are other factors thought to contribute to abuse of the disabled. The two reports point out that disabled children have fewer opportunities than able-bodied children to receive counselling. Referrals to specialist services were turned down because of difficulty of access to buildings or the belief that counsellors lacked the necessary skills for advising children with disabilities.1 The reports also emphasise the need for doctors, residential care workers, and those involved in child protection to work together to care for and protect disabled children. Astrid James
1. Marchant R, Page M. Bridging the gap: child protection work with children with multiple disabilities. London: National Society for the Prevention of Cruelty to Children. 1993. Pp 45. £5.95. ISBN 0-90249841X. 2. Westcott HL. Abuse of children and adults with disabilities. London: National Society for the Prevention of Cruelty to Children. 1993. Pp 60. £6.99. ISBN 0-902498401.
Supporting torture’s victims At a fund-raising reception for the Medical Foundation for the Care of Victims of Torture at the Groucho Club, London, on Feb 18, former hostage Brian Keenan began on a humorous note, quoting Groucho Marx’s observation that the best thing is to have integrity and the second-best is to know how to fake it. The reference to integrity had a serious point because he went on to describe how torturers aim to break, literally to disintegrate, the body and the personality of their victims; survivors emerge physically and emotionally bruised, fearful, and traumatised. Through a combination of medical treatment, psychotherapy, and social work, the Foundation seeks to repair the damage, helping people rebuild their lives and regain trust, confidence, and hope. Founded by Helen Bamber in 1986, this charity is funded entirely by contributions and grants, and its services are free to clients. During 1992 between 2500 and 3000 people were directly assisted by the Foundation, and many others indirectly through training programmes for and advice to professionals. Support has been generous, but closure looms unless more is forthcoming from personal donations or fund-raising events. The Medical Foundation for the Care of Victims of Torture is Grafton Road, London NW5 (071-284 4321).
at
96-98
Judy Chambers
In
England Now
If you’re destined to have a "coronary", there are many worse places to do so than in an Austrian ski resort-or such is my experience. After an enjoyable morning trying out new skis, my wife and I had arranged to meet some friends for lunch at a restaurant on the fringe of the village. The pain started as the waiter left the table with our order. I remember being surprised at how closely it mimicked the textbook description-crushing, central, deep inside,
before it radiated to lower jaw and down both arms to elbows. I sat absolutely still, unable at first to believe what I was feeling. The reality came when a cold sweat broke out on my forehead and one of the party asked, "What’s up with you? Why have you gone the colour of an unripe banana?" We got a taxi back to our hotel, where I committed the heinous offence of walking through the main hall to the lift in my ski boots. Upstairs I lay on the bed, mute with the pressure in my chest. Within minutes the nearest of the three general practitioners in the village arrived accompanied by his nurse and a paramedical, all three dressed in white uniform. An intravenous drip was set up, iv morphine given, and I was connected to a portable ECG machine cum defibrillator. The GP explained that I couldn’t go to hospital by ambulance because the pass was closed by the recent heavy snow falls. With his mobile telephone he summoned a helicopter; ten minutes later we were driven in an ambulance to a snow-covered field just down the lane from the hotel. A perfunctory goodbye to my wife (no room in the helicopter for her) and with the GP in attendance we were off. All I could see from my stretcher was the blue sky above. We flew towards the local hospital deep in the valley below but as we descended we were enveloped in a thick blanket of impenetrable cloud. The pilot was shouting to his base down the intercom. The helicopter climbed quickly into the blue sky again. We swung in a sharp banking turn and flew north towards the Austro-German border. Twenty minutes later we landed on the helipad adjoining a new 250-bed district general hospital. I was greeted in the 4-bed coronary care unit by the 38-year-old oberatz cardiologist who proved efficient and well trained. After taking a careful history, examining me, and doing an ECG (it showed ST-segment and T-wave changes from VI to V6), the attractive lady said, "I’d like to give you thrombolytic therapy". I nodded my head in agreement. "Would you like streptokinase, urokinase, Eminase, or tPA?" All I could think of was the differentials in cost. I asked her to decide. "I have participated in ISIS trials 1, 2, 3", she said. "We have had very good results with urokinase-no side effects and it’s singularly non-antigenic." So urokinase was injected within 2t hours of the onset of the pain. Tactfully I inquired about magnesium which, just before we came on holiday, had been reported in the British medical press as being a useful prophylactic anti-arrhythmic agent. "We’ve been using it for a long time", said the lady cardiologist, who later I called Sophie. "I gave you some as soon as you were admitted."Heparin was infused from a pump. Every day Dr Sophie visited me early in the morning and in the evening. Despite her busy schedule (in addition to being the cardiologist she ran a 6-bed renal dialysis unit) she found time to sit at the end of my bed twice a day and talk about medicine. The nursing care was dedicated, like it used to be at home. All the staff understood the seemingly inevitable eccentricities of the cardiac monitoring equipment which sounded false alarms at any hour of the day or night. On the wall in the corridor opposite the nurses’ station was a wooden plaque on which was carved a quotation from Florence Nightingale, the first sentence of which read "Nursing is not a holiday". The nurses knew all about Miss Nightingale and seemed interested that I had trained at the hospital in London where she had once been matron. Compared with England, a high proportion of the student nurses were male. One, aged 30, married with a son of 6, "specialed" me for a few days. Wasn’t he taking up nursing rather late in life? He told me that after leaving school he had become a custom’s officer at a small crossing on the Austro-German frontier. With the likelihood that Austria would join the EC he predicted his job would disappear and so he had applied to the government for relocation and training as a nurse. Eight days later, and symptom-free, I walked out of the hospital with feelings of affection and admiration together with the thought that I couldn’t have been better looked after. My travel medical insurance met the costs, which were low by London standards. In round figures, and calculated at an exchange rate of OS20=1, eight days in hospital, including medication, cost [740; the GP’s bill was 150 (including 20% VAT); the cardiologist’s account, including daily ECGs and repeated creatine phosphokinase assays, 800 (including 20% VAT). The most expensive item was the
helicopter flight at cl 100.
THE LANCET
Landmine
injuries
What it takes to be
a
doctor
Landmines, the legacy of countless regional conflicts, continue to kill and mutilate. In 1990 mines killed 12 000 Cambodians and caused 6000 amputations. 1 in every 236 Cambodians, 1 in every 470 Angolans, and 1 in every 650 Somalis is an amputee. The scale of the problem was reiterated at a seminar on landmine injuries held by MEDACT (Medical Action for Global Security) last week in London. MEDACT’s is the latest in a growing number of campaigns to reduce and ultimately eliminate the human and environmental damage from mines. It highlighted the need for resources to treat existing and potential victims of landmines-up to 200 million mines are still lying in the ground around the world. Mr Robin Coupland, a surgeon with the International Committee of the Red Cross, said that many war wounds such as mine injuries were badly managed. Often, operations have to be repeated and complications ensue when surgeons do not recognise the extent of limb injuries or when they attempt to close wounds immediately. Coupland said that following amputation the stump should be treated by delayed primary closure after five days. Repeated dressings cause unnecessary suffering in areas where no anaesthetic is available. The ICRC publishes a booklet on amputation for war wounds and is working on a video for medical personnel working in areas where mine injuries occur. There is a spectrum of opinion as to how far campaigns against mines can effectively go. Physicians for Human Rights have called for a total ban, whereas the ICRC wants tighter legislation, with use of only detectable and self-destructing mines with a finite shelf life. Whatever the chosen end-point there was agreement that ratification of the 1981 UN Weapons Convention prohibiting the indiscriminate use of mines would be a helpful first step. Many major arms suppliers, including the United Kingdom, Belgium, and Spain, have not ratified the convention.
Following review of its undergraduate courses, the Faculty of Medicine, London University, has issued a statement on the minimum skills expected of doctors on their first day as house officers. Newly qualified doctors must be able to take and record a history from all patients (or parents of infants and children), and must be able to perform the appropriate clinical examination, including rectal and pelvic examination. They must know how to use a stethoscope, ophthalmoscope, otoscope, and vaginal speculum. They will be competent to prescribe most drugs for inpatients, but will need additional training to prescribe or administer highly toxic agents such as those used in the treatment of cancer. House officers are not expected to be competent at giving intravenous drugs or fluids without formal training. All other procedures, including the insertion of peripheral lines, and cardiopulmonary resuscitation, require instruction after qualification. Newly qualified doctors are not expected to be able to break bad news to patients, but should be present, if possible, when such news is given. Commenting on these minimum requirements, Prof Sir Colin Dollery, Pro Vice-Chancellor for Medicine and Dentistry, London University, and co-author of the statement, pointed out that they provide the basis for a structured educational programme for pre-registration doctors. Such a programme is being devised by the Faculty of Medicine, London University, and is likely to recommend formal teaching of pre-registration doctors for 5 hours per week. Professor Dollery hoped that an improved educational programme for house officers would be in place within 2-3 years.
Cathy Read
The recent vote by the Dutch Government ensures that euthanasia remains illegal in the Netherlands (see Lancet Feb 13, p 426), although criteria being drawn up by the Dutch Medical Association are likely to protect some doctors from prosecution. This failure of the Government to decriminalise euthanasia contrasts with public opinion-a recent survey showed that 71 % of 1100 Dutch people over the age of 18 years were in favour of euthanasia legalisation. The Dutch Government’s decision comes in the wake of results of an investigation into medical decisions concerning the end of life. Readers may remember the first results of this investigation,l which revealed that medical decisions that might hasten death were common practice in the Netherlands: doctors were found to have made such a decision in 38% of all deaths studied; and euthanasia (the administration of lethal drugs at the patient’s request) was involved in 1 ’8% of these deaths. The full report of this investigation, first published in Dutchis now available in English.3 This report, in addition to the results already published,l gives full details of the 3 studies that contributed to this investigation: a retrospective study involving interviews with doctors, a death certificate study, and a prospective questionnairebased study.
European laboratory for study of integrins With the official opening in Luxembourg last week of a French-Luxembourg biomedical research laboratory, the two countries hope to boost the Grand-Duchy’s virtually non-existent research facilities. France, through its National Centre for Scientific Research (CNRS), will provide about a third of the approximately 200 000 annual budget of the new laboratory and the Grand Duchy and Recherche Cancer et Sang, a private Luxembourg foundation, the rest. The Luxembourg Government is also providing 300m2 of floor space for the laboratory in the capital’s
recently created university. The laboratory, the first CNRS-funded "bilateral" research facility to be set up outside France, will, like any of the 300
or so
CNRS research groups, focus
on a
research
topic-in this case, integrins, the family of cell-membrane receptors that mediate cell adhesion. Discovered only 6 years ago, integrins-about 20 have been identified-play a key role in a range of biological processes, including cell differentiation and proliferation, embryo development, platelet aggregation, immunity, tissue repair, and cancer metastasis. Scientific interest in these proteins is great,
particularly among pharmaceutical industry researchers, who see the potential for developing antithrombotic, and-inflammatory, and anti-cancer drugs. A San Francisco firm, COR Therapeutics, has a head start in this process with an integrin-based antithrombotic agent (Integrelin), which is about to enter phase II clinical trials. Dr Nelly Kieffer, director of the Luxembourg laboratory, who is native of Luxembourg who has spent much of her research career with CNRS in Paris, plans to form working relationships with other European groups. Luxembourg students have traditionally gone abroad, particularly to France, to complete their studies and establish research careers. The laboratory, Kieffer hopes, "will be a first step in encouraging many of these graduates to come back and embark on scientific careers in their home country".
Astrid James
Dutch euthanasia survey revisited
Astrid James
der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-74. 2. van der Maas PJ, van Delden JJM, Pijnenborg L. Medische Beslissingen Rond Het Levenseinde. Netherlands: Sdu Uitgeverij Plantijnstraat, ’s-Gravenhage, 1991. 3. van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. (Hlth Policy Monogr 22 [1/2] Special issue) Amsterdam: Elsevier, 1992. Pp 262. Dutch Guilders 257. ISBN 0-444 892788. 1.
van
a
John Maurice
Abuse of disabled children Two reports1.2 published this week highlight the vulnerability of disabled children to physical, emotional, and sexual abuse. They remind doctors that, contrary to the assumption that disability protects from abuse, children with the highest dependency needs and limited communication skills are at risk from abuse, particularly from their carers.
554
THE LANCET
The diagnosis of some forms of abuse is especially difficult when the child’s ability to describe the experience is limited. One report, based on interviews with 15 persons aged between 7 and 17 years with severe physical disabilities,l found that communication boards used by children with little or no normal speech, for example, had no words for genitalia. Moreover, children with disorders such as cerebral palsy had difficulty in holding and manipulating dolls to demonstrate forms of abuse. Ways of modifying interview techniques to suit the needs of disabled children are highlighted in this report. The second report, based upon interviews with 34 adults (17 able-bodied and 17 disabled) who were abused as children,2 describes the vulnerability felt by many of the disabled adults, largely because of an inability to defend themselves and physical immobility. Lack of self-worth, a sense of depersonalisation, lack of general and sexual education, and dependence on others for care are other factors thought to contribute to abuse of the disabled. The two reports point out that disabled children have fewer opportunities than able-bodied children to receive counselling. Referrals to specialist services were turned down because of difficulty of access to buildings or the belief that counsellors lacked the necessary skills for advising children with disabilities.1 The reports also emphasise the need for doctors, residential care workers, and those involved in child protection to work together to care for and protect disabled children. Astrid James
1. Marchant R, Page M. Bridging the gap: child protection work with children with multiple disabilities. London: National Society for the Prevention of Cruelty to Children. 1993. Pp 45. £5.95. ISBN 0-90249841X. 2. Westcott HL. Abuse of children and adults with disabilities. London: National Society for the Prevention of Cruelty to Children. 1993. Pp 60. £6.99. ISBN 0-902498401.
Supporting torture’s victims At a fund-raising reception for the Medical Foundation for the Care of Victims of Torture at the Groucho Club, London, on Feb 18, former hostage Brian Keenan began on a humorous note, quoting Groucho Marx’s observation that the best thing is to have integrity and the second-best is to know how to fake it. The reference to integrity had a serious point because he went on to describe how torturers aim to break, literally to disintegrate, the body and the personality of their victims; survivors emerge physically and emotionally bruised, fearful, and traumatised. Through a combination of medical treatment, psychotherapy, and social work, the Foundation seeks to repair the damage, helping people rebuild their lives and regain trust, confidence, and hope. Founded by Helen Bamber in 1986, this charity is funded entirely by contributions and grants, and its services are free to clients. During 1992 between 2500 and 3000 people were directly assisted by the Foundation, and many others indirectly through training programmes for and advice to professionals. Support has been generous, but closure looms unless more is forthcoming from personal donations or fund-raising events. The Medical Foundation for the Care of Victims of Torture is Grafton Road, London NW5 (071-284 4321).
at
96-98
Judy Chambers
In
England Now
If you’re destined to have a "coronary", there are many worse places to do so than in an Austrian ski resort-or such is my experience. After an enjoyable morning trying out new skis, my wife and I had arranged to meet some friends for lunch at a restaurant on the fringe of the village. The pain started as the waiter left the table with our order. I remember being surprised at how closely it mimicked the textbook description-crushing, central, deep inside,
before it radiated to lower jaw and down both arms to elbows. I sat absolutely still, unable at first to believe what I was feeling. The reality came when a cold sweat broke out on my forehead and one of the party asked, "What’s up with you? Why have you gone the colour of an unripe banana?" We got a taxi back to our hotel, where I committed the heinous offence of walking through the main hall to the lift in my ski boots. Upstairs I lay on the bed, mute with the pressure in my chest. Within minutes the nearest of the three general practitioners in the village arrived accompanied by his nurse and a paramedical, all three dressed in white uniform. An intravenous drip was set up, iv morphine given, and I was connected to a portable ECG machine cum defibrillator. The GP explained that I couldn’t go to hospital by ambulance because the pass was closed by the recent heavy snow falls. With his mobile telephone he summoned a helicopter; ten minutes later we were driven in an ambulance to a snow-covered field just down the lane from the hotel. A perfunctory goodbye to my wife (no room in the helicopter for her) and with the GP in attendance we were off. All I could see from my stretcher was the blue sky above. We flew towards the local hospital deep in the valley below but as we descended we were enveloped in a thick blanket of impenetrable cloud. The pilot was shouting to his base down the intercom. The helicopter climbed quickly into the blue sky again. We swung in a sharp banking turn and flew north towards the Austro-German border. Twenty minutes later we landed on the helipad adjoining a new 250-bed district general hospital. I was greeted in the 4-bed coronary care unit by the 38-year-old oberatz cardiologist who proved efficient and well trained. After taking a careful history, examining me, and doing an ECG (it showed ST-segment and T-wave changes from VI to V6), the attractive lady said, "I’d like to give you thrombolytic therapy". I nodded my head in agreement. "Would you like streptokinase, urokinase, Eminase, or tPA?" All I could think of was the differentials in cost. I asked her to decide. "I have participated in ISIS trials 1, 2, 3", she said. "We have had very good results with urokinase-no side effects and it’s singularly non-antigenic." So urokinase was injected within 2t hours of the onset of the pain. Tactfully I inquired about magnesium which, just before we came on holiday, had been reported in the British medical press as being a useful prophylactic anti-arrhythmic agent. "We’ve been using it for a long time", said the lady cardiologist, who later I called Sophie. "I gave you some as soon as you were admitted."Heparin was infused from a pump. Every day Dr Sophie visited me early in the morning and in the evening. Despite her busy schedule (in addition to being the cardiologist she ran a 6-bed renal dialysis unit) she found time to sit at the end of my bed twice a day and talk about medicine. The nursing care was dedicated, like it used to be at home. All the staff understood the seemingly inevitable eccentricities of the cardiac monitoring equipment which sounded false alarms at any hour of the day or night. On the wall in the corridor opposite the nurses’ station was a wooden plaque on which was carved a quotation from Florence Nightingale, the first sentence of which read "Nursing is not a holiday". The nurses knew all about Miss Nightingale and seemed interested that I had trained at the hospital in London where she had once been matron. Compared with England, a high proportion of the student nurses were male. One, aged 30, married with a son of 6, "specialed" me for a few days. Wasn’t he taking up nursing rather late in life? He told me that after leaving school he had become a custom’s officer at a small crossing on the Austro-German frontier. With the likelihood that Austria would join the EC he predicted his job would disappear and so he had applied to the government for relocation and training as a nurse. Eight days later, and symptom-free, I walked out of the hospital with feelings of affection and admiration together with the thought that I couldn’t have been better looked after. My travel medical insurance met the costs, which were low by London standards. In round figures, and calculated at an exchange rate of OS20=1, eight days in hospital, including medication, cost [740; the GP’s bill was 150 (including 20% VAT); the cardiologist’s account, including daily ECGs and repeated creatine phosphokinase assays, 800 (including 20% VAT). The most expensive item was the
helicopter flight at cl 100.