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CONSULTANTS AND GOVERNMENT
678 treatment of ischaemic heart-disease". Like Dr Khosla, I, too, have argued for increased sporting activity among the general population,l although we do not yet have sufficient evidence to be sure that increased leisure-time sport in the general population will of necessity reduce the incidence of ischaemic heart-disease. The use of the word " enthusiasts " to describe Dr Khosla’s sportsmen may indicate part of the problem, which seems to be that some sportsmen continue to play when their friends or relatives or their symptoms warn
prophylaxis and
Letters
to
the Editor
INADEQUATE ANALGESIA SIR,-Dr Freed’s plea (March 1, p. 519) for more liberal analgesia at night is timely. Suffering from the pain, however, is not the only consequence of this defect in treatment which is so common at present. As patients recover more quickly from modern surgery, there is a tendency to forget the importance of relieving pain, and minor discomfort too. Patients therefore fail to become mobile as quickly as they might and complications develop which could otherwise be avoided. The most serious of these is that patients fail to aerate the lungs adequately because movement of the diaphragm is painful, and the blame for many postoperative chest complications is laid on the anxsthetist when in fact the cause is insufficient analgesia to allow adequate respiration in the early stages. Similarly, patients who do not move limbs are more liable to venous thrombosis and similar complications. Whilst the immediate blame for this rests on the resident staff and nurses, who either fail to order or to give drugs sufficiently frequently, the root cause is the bad teaching that they receive, particularly applied to the dictum " morphine depresses respiration ". Almost any drug given in excessive doses will do this, but usually depressed respiration is due to inadequate dosage of morphine to relieve pain, not the reverse. Junior staff should be taught the proper doses of these drugs for the individual size or age of patient and not be allowed to give what are at times homoeopathic doses of inadequate preparations at far too long intervals. If this fault were corrected, patients would be happier and their postoperative courses much smoother. General Hospital, Steelhouse Lane, Birmingham B4 6NH.
GEORGE T. WATTS.
SUDDEN DEATH AND SPORT
SiR,—Iappreciate the valuable comments made by Dr Khosla (Feb. 15, p. 395) about the age of sportsmen. If a sportsman wanted to identify himself as being at positive risk of sudden death, my article (Feb. 1, p. 263) suggests that an age above 30 (younger for rugby), a positive family history, and the presence of symptoms might be a useful combination of warning signs. Dr Khosla is quite right in emphasising smoking as an additional feature. In such a small series it is not possible to suggest which of the above four factors is of greatest importance, nor whether the factors are additive. As far as age is concerned, emphasising a mean age of 40 might suggest to the sportsman that there was no risk until that age, whereas half the sportsmen (and all the rugby players) in my series were at risk although below 40. Hence my specific wording, which was: " A mean age above 30 (above 25 for rugby players)". I am not sure that age considerations based on Olympic finalists are necessarily relevant to the general sporting populations of South Africa or any other country. In populations of sportsmen who neither smoke nor have a positive family history, it may well be correct that an age of 40 or even more could be viewed as a safe age to retire from serious competitive sport. But much would depend on the sport and the sportsman concerned, as Dr Khosla also suggests. Further evidence is needed to clarify this point. I should re-emphasise the sentence of my article which read: " The links between sporting exercise and sudden death recorded here do not constitute statistical evidence against the possible benefits of exercise training in the
against playing. Ischæmic Heart Disease Laboratory, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.
L. H. OPIE.
THE NEED TO PRESERVE THE "OPEN"
CONTRACT
SiR,—You are surely right in believing (March 1, p. 506) some consultants may not have thought out the full implications of a closed " contract. Mr Lythgoe’s point of view (March 8, p. 570) is shared by very many of us. The Government’s proposals, whatever one may feel about them, have at least had the effect of bringing home to closed " contract would more consultants what exactly a Is there a single one of us who would actually mean. prefer a closed " contract for its own sake ? The hope presumably was that this would be a means, consistent with Government policies, of increasing our pay; but that would be a very poor bargain indeed-to sacrifice the right to get on with our job in our own way for the prospect of a few extra (heavily taxed) pounds and a life of clock-watching. Doctoring is a dimension of our lives, not a thing to
that
"
"
"
be measured in hours. It is important that those of us who wish to preserve " open " contracts should be heard; we must write and say so to Ministers, medical negotiators, and Members of Parliament. There may still be time to shift the direction of negotiations away from a " closed " contract. If not, we must at least ensure that we (and future consultants) should be allowed the option to keep " open " contracts without significant detriment. Goodmayes Hospital, Goodmayes, Ilford, Essex IG3 8XJ.
TOM ARIE.
CONSULTANTS AND GOVERNMENT SIR,-May I suggest a compromise in the consultantGovernment deadlock ? The best compromise is, of course, one by which each side accepts the other’s proposals ; therefore, I suggest that the Secretary of State agrees to discuss the details of a choice of contract between " a " fee for item of service ", a ten-session " contract and the present contract, while the consultants (old style), to no work agree longer directly to their present contract. It is clear to most of us that no one contract could be expected to be equally applicable to such a diversity of
clinical, non-clinical, part-time, or full-time specialtiesas found in present-day medicine. Any proposals to cover such allowances as car, telephone, &c., or payments (e.g., merit, seniority, extra responsibility) could be equally and uniformly arranged outside any one particular contract.
are
9 Greenacres,
Birdham, Chichester, Sussex. 1.
Opie, L. H. Am. Heart J. 1974, 88, 539.
M. W. NICHOLLS.
prophylaxis and
Letters
to
the Editor
INADEQUATE ANALGESIA SIR,-Dr Freed’s plea (March 1, p. 519) for more liberal analgesia at night is timely. Suffering from the pain, however, is not the only consequence of this defect in treatment which is so common at present. As patients recover more quickly from modern surgery, there is a tendency to forget the importance of relieving pain, and minor discomfort too. Patients therefore fail to become mobile as quickly as they might and complications develop which could otherwise be avoided. The most serious of these is that patients fail to aerate the lungs adequately because movement of the diaphragm is painful, and the blame for many postoperative chest complications is laid on the anxsthetist when in fact the cause is insufficient analgesia to allow adequate respiration in the early stages. Similarly, patients who do not move limbs are more liable to venous thrombosis and similar complications. Whilst the immediate blame for this rests on the resident staff and nurses, who either fail to order or to give drugs sufficiently frequently, the root cause is the bad teaching that they receive, particularly applied to the dictum " morphine depresses respiration ". Almost any drug given in excessive doses will do this, but usually depressed respiration is due to inadequate dosage of morphine to relieve pain, not the reverse. Junior staff should be taught the proper doses of these drugs for the individual size or age of patient and not be allowed to give what are at times homoeopathic doses of inadequate preparations at far too long intervals. If this fault were corrected, patients would be happier and their postoperative courses much smoother. General Hospital, Steelhouse Lane, Birmingham B4 6NH.
GEORGE T. WATTS.
SUDDEN DEATH AND SPORT
SiR,—Iappreciate the valuable comments made by Dr Khosla (Feb. 15, p. 395) about the age of sportsmen. If a sportsman wanted to identify himself as being at positive risk of sudden death, my article (Feb. 1, p. 263) suggests that an age above 30 (younger for rugby), a positive family history, and the presence of symptoms might be a useful combination of warning signs. Dr Khosla is quite right in emphasising smoking as an additional feature. In such a small series it is not possible to suggest which of the above four factors is of greatest importance, nor whether the factors are additive. As far as age is concerned, emphasising a mean age of 40 might suggest to the sportsman that there was no risk until that age, whereas half the sportsmen (and all the rugby players) in my series were at risk although below 40. Hence my specific wording, which was: " A mean age above 30 (above 25 for rugby players)". I am not sure that age considerations based on Olympic finalists are necessarily relevant to the general sporting populations of South Africa or any other country. In populations of sportsmen who neither smoke nor have a positive family history, it may well be correct that an age of 40 or even more could be viewed as a safe age to retire from serious competitive sport. But much would depend on the sport and the sportsman concerned, as Dr Khosla also suggests. Further evidence is needed to clarify this point. I should re-emphasise the sentence of my article which read: " The links between sporting exercise and sudden death recorded here do not constitute statistical evidence against the possible benefits of exercise training in the
against playing. Ischæmic Heart Disease Laboratory, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.
L. H. OPIE.
THE NEED TO PRESERVE THE "OPEN"
CONTRACT
SiR,—You are surely right in believing (March 1, p. 506) some consultants may not have thought out the full implications of a closed " contract. Mr Lythgoe’s point of view (March 8, p. 570) is shared by very many of us. The Government’s proposals, whatever one may feel about them, have at least had the effect of bringing home to closed " contract would more consultants what exactly a Is there a single one of us who would actually mean. prefer a closed " contract for its own sake ? The hope presumably was that this would be a means, consistent with Government policies, of increasing our pay; but that would be a very poor bargain indeed-to sacrifice the right to get on with our job in our own way for the prospect of a few extra (heavily taxed) pounds and a life of clock-watching. Doctoring is a dimension of our lives, not a thing to
that
"
"
"
be measured in hours. It is important that those of us who wish to preserve " open " contracts should be heard; we must write and say so to Ministers, medical negotiators, and Members of Parliament. There may still be time to shift the direction of negotiations away from a " closed " contract. If not, we must at least ensure that we (and future consultants) should be allowed the option to keep " open " contracts without significant detriment. Goodmayes Hospital, Goodmayes, Ilford, Essex IG3 8XJ.
TOM ARIE.
CONSULTANTS AND GOVERNMENT SIR,-May I suggest a compromise in the consultantGovernment deadlock ? The best compromise is, of course, one by which each side accepts the other’s proposals ; therefore, I suggest that the Secretary of State agrees to discuss the details of a choice of contract between " a " fee for item of service ", a ten-session " contract and the present contract, while the consultants (old style), to no work agree longer directly to their present contract. It is clear to most of us that no one contract could be expected to be equally applicable to such a diversity of
clinical, non-clinical, part-time, or full-time specialtiesas found in present-day medicine. Any proposals to cover such allowances as car, telephone, &c., or payments (e.g., merit, seniority, extra responsibility) could be equally and uniformly arranged outside any one particular contract.
are
9 Greenacres,
Birdham, Chichester, Sussex. 1.
Opie, L. H. Am. Heart J. 1974, 88, 539.
M. W. NICHOLLS.