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BLEEDING AND PERIOPERATIVE HEPARIN
286 than it would be by psychiatrists who will devote all of their time to the care of these people ? F. E. JAMES Fieldhead Hospital, B. WINOKUR. Wakefield WF1 3SP.
proportion,
GENERAL-PRACTICE DILEMMA
SiR,—Dr Courtenay (July 20, p. 152) says " the G.P. constantly beware of raising new barriers between himself and the patient". But is this not increasingly the the trend in modern general practice ? It seems a foregone must
conclusion that an open-access system with the absolute minimum of appointments is out for good. Such a verdict is to be resisted. Immediate availability is of the essence of primary medical care. The most valuable therapy the G.P. can give is reassurance, and the sooner this is given the better. Having excluded organic disease a good deal of a G.P.’s work is symptom tolerance. A high index of suspicion coupled with a high threshold for psychogenically determined symptoms makes for good doctoring, and for this the fewer barriers between patient and doctor the better. There is really no substitute for open-ended burdenbearing if the G.P. is to be effective. Elaborate organisation is only the latest attempt to shelve this inescapable duty. Portland House,
Lindley,
S. L. HENDERSON SMITH
Huddersfield.
SIR,-Dr Courtenay’s description of the generalpractice dilemma complicates what seems a simple situation : the services provided by the general practitioner can only be defined by deciding what is acceptable (to doctor, patient, and society) as an illness " and its " treatment ". No two general practitioners are likely to agree on a definition of either, nor would their patients. It is not possible for a general practitioner to be the best sort of doctor for every sort of patient: he is bound to develop "
enthusiasms and aversions and these affect the way he
practises. This is the dilemma of general practice-that under the lists " he is obliged to do his present system of fixed best to conform to his patients’ idea of what a doctor ought to be, knowing that, in most cases, he has not been sought as a medical adviser for his merits: he and his patient have This come together as an administrative convenience. system does give each patient a family doctor by right, but makes it difficult for him to choose who this should be. The dilemma on both sides will not be solved until the system allows a greater degree of freedom for the doctor to specialise in ailments in which he has a particular interest and for the patient to choose the doctor whom he considers will give him the most effective treatment. "
The Surgery,
Newport,
and his conversation; they consult him but seldom and refer to him not at all. I ask myself-why should this be ? Are my other colleagues so embarrassed that they adopt the herd attitude and leave the sick member in isolation, or act so that he may feel isolated and so isolate himself by absenting himself completely and finally ?Few, if any, can enjoy the ebbing of the tide of days: nothing would seem more natural than to continue ordinary work to make life seem natural for as long as possible. Why therefore " should this be and " antibodies " appear to this abnormal clone " ? Is it that attitudes have altered, that none wants to know, and certainly none wants to see ? Or have I got it all wrong ?
J.
BLEEDING AND PERIOPERATIVE HEPARIN
SIR,-We should like to add our names to the growing numbers of doctors who are worried about the possible adverse effect of perioperative subcutaneous heparin in the prophylaxis of postoperative deep-venous thrombosis. We have met with a potentially fatal complication after what was otherwise a minor operation. The patient, a seventy-year-old woman, was admitted for closure of colostomy, after anterior resection of rectum. After her previous operation she had had a deep-venous thrombosis, and for this reason some form of prophylaxis against a further D.V.T. was decided upon. Heparin rather than dextran was chosen as the patient had incipient cardiac failure. The regimen described by Williamswas used. The operation itself was straightforward and no unusual bleeding was encountered. On the morning of the second postoperative day a large wound haematoma developed; this was evacuated and was found to contain about2 litres of clotted blood. The patient was transfused with four units of blood, but her systolic blood-pressure dropped to 70 mm. Hg by the end of the procedure. Shortly after this atrial fibrillation developed, which spontaneously reverted to sinus rhythm some hours later. Heparin was stopped as soon as the haematoma was discovered. On the next day the heematoma had reaccumulated, and the patient was taken to theatre for a full exploration. No source for the bleeding was found and coagulation studies showed no abnormality. She was transfused a further two units of blood and again developed atrial fibrillation and also acute pulmonary oedema, which responded to frusemide. She reverted to sinus rhythm the following day, and the haematoma did not reaccumulate. Total blood-loss was estimated at 3 litres. The patient has now recovered, although she did have a minor wound infection, and a faecal fistula developed on the tenth postoperative day. Dunfermline and West Fife Hospital, Reid Street, Dunfermline KY12 7EZ.
R. MCWILLIAM
J. ST. C. MCCORMICK A. AULAQI.
J. C. BIGNALL.
Pembrokeshire.
REJECTION SIR,-For the third time in recent years I find myself working with a close colleague with obvious weight-loss in the early cachectic state from spreading carcinoma with metastases. From like experience very early in postgraduate years, when two of my seniors continued working for a time until overtaken, the one by the Pel-Ebstein fever, the other by the Mickulicz syndrome, I was taught to regard such sick colleagues in a normal way, to work with them, and to visit them as usual. Now, while I behave in an ordinary manner towards my sick colleague, others in the mess and in the hospital seem to want to avoid his company
SUBCUTANEOUS HEPARIN AND POSTOPERATIVE DEEP VENOUS THROMBOSIS SiR,—We reported2 the results of a trial of two regimens of subcutaneous heparin in the prophylaxis of postoperative deep venous thrombosis (D.V.T.). In that study subcutaneous heparin, in doses of 5000 l.u. of sodium heparin, was shown to be effective in reducing the incidence of D.v.T. after operation in all types of patient if given with the premedication and continued for a full five days. Heparin given with the premedication and 12 and 24 hours after1. 2.
Williams, H. T. Lancet, 1971, ii, 950. Gordon-Smith, I., Grundy, D. J., Le Quesne, L. P., Newcombe, J. F., Bramble, F. J. Lancet, 1972, i, 1133.
proportion,
GENERAL-PRACTICE DILEMMA
SiR,—Dr Courtenay (July 20, p. 152) says " the G.P. constantly beware of raising new barriers between himself and the patient". But is this not increasingly the the trend in modern general practice ? It seems a foregone must
conclusion that an open-access system with the absolute minimum of appointments is out for good. Such a verdict is to be resisted. Immediate availability is of the essence of primary medical care. The most valuable therapy the G.P. can give is reassurance, and the sooner this is given the better. Having excluded organic disease a good deal of a G.P.’s work is symptom tolerance. A high index of suspicion coupled with a high threshold for psychogenically determined symptoms makes for good doctoring, and for this the fewer barriers between patient and doctor the better. There is really no substitute for open-ended burdenbearing if the G.P. is to be effective. Elaborate organisation is only the latest attempt to shelve this inescapable duty. Portland House,
Lindley,
S. L. HENDERSON SMITH
Huddersfield.
SIR,-Dr Courtenay’s description of the generalpractice dilemma complicates what seems a simple situation : the services provided by the general practitioner can only be defined by deciding what is acceptable (to doctor, patient, and society) as an illness " and its " treatment ". No two general practitioners are likely to agree on a definition of either, nor would their patients. It is not possible for a general practitioner to be the best sort of doctor for every sort of patient: he is bound to develop "
enthusiasms and aversions and these affect the way he
practises. This is the dilemma of general practice-that under the lists " he is obliged to do his present system of fixed best to conform to his patients’ idea of what a doctor ought to be, knowing that, in most cases, he has not been sought as a medical adviser for his merits: he and his patient have This come together as an administrative convenience. system does give each patient a family doctor by right, but makes it difficult for him to choose who this should be. The dilemma on both sides will not be solved until the system allows a greater degree of freedom for the doctor to specialise in ailments in which he has a particular interest and for the patient to choose the doctor whom he considers will give him the most effective treatment. "
The Surgery,
Newport,
and his conversation; they consult him but seldom and refer to him not at all. I ask myself-why should this be ? Are my other colleagues so embarrassed that they adopt the herd attitude and leave the sick member in isolation, or act so that he may feel isolated and so isolate himself by absenting himself completely and finally ?Few, if any, can enjoy the ebbing of the tide of days: nothing would seem more natural than to continue ordinary work to make life seem natural for as long as possible. Why therefore " should this be and " antibodies " appear to this abnormal clone " ? Is it that attitudes have altered, that none wants to know, and certainly none wants to see ? Or have I got it all wrong ?
J.
BLEEDING AND PERIOPERATIVE HEPARIN
SIR,-We should like to add our names to the growing numbers of doctors who are worried about the possible adverse effect of perioperative subcutaneous heparin in the prophylaxis of postoperative deep-venous thrombosis. We have met with a potentially fatal complication after what was otherwise a minor operation. The patient, a seventy-year-old woman, was admitted for closure of colostomy, after anterior resection of rectum. After her previous operation she had had a deep-venous thrombosis, and for this reason some form of prophylaxis against a further D.V.T. was decided upon. Heparin rather than dextran was chosen as the patient had incipient cardiac failure. The regimen described by Williamswas used. The operation itself was straightforward and no unusual bleeding was encountered. On the morning of the second postoperative day a large wound haematoma developed; this was evacuated and was found to contain about2 litres of clotted blood. The patient was transfused with four units of blood, but her systolic blood-pressure dropped to 70 mm. Hg by the end of the procedure. Shortly after this atrial fibrillation developed, which spontaneously reverted to sinus rhythm some hours later. Heparin was stopped as soon as the haematoma was discovered. On the next day the heematoma had reaccumulated, and the patient was taken to theatre for a full exploration. No source for the bleeding was found and coagulation studies showed no abnormality. She was transfused a further two units of blood and again developed atrial fibrillation and also acute pulmonary oedema, which responded to frusemide. She reverted to sinus rhythm the following day, and the haematoma did not reaccumulate. Total blood-loss was estimated at 3 litres. The patient has now recovered, although she did have a minor wound infection, and a faecal fistula developed on the tenth postoperative day. Dunfermline and West Fife Hospital, Reid Street, Dunfermline KY12 7EZ.
R. MCWILLIAM
J. ST. C. MCCORMICK A. AULAQI.
J. C. BIGNALL.
Pembrokeshire.
REJECTION SIR,-For the third time in recent years I find myself working with a close colleague with obvious weight-loss in the early cachectic state from spreading carcinoma with metastases. From like experience very early in postgraduate years, when two of my seniors continued working for a time until overtaken, the one by the Pel-Ebstein fever, the other by the Mickulicz syndrome, I was taught to regard such sick colleagues in a normal way, to work with them, and to visit them as usual. Now, while I behave in an ordinary manner towards my sick colleague, others in the mess and in the hospital seem to want to avoid his company
SUBCUTANEOUS HEPARIN AND POSTOPERATIVE DEEP VENOUS THROMBOSIS SiR,—We reported2 the results of a trial of two regimens of subcutaneous heparin in the prophylaxis of postoperative deep venous thrombosis (D.V.T.). In that study subcutaneous heparin, in doses of 5000 l.u. of sodium heparin, was shown to be effective in reducing the incidence of D.v.T. after operation in all types of patient if given with the premedication and continued for a full five days. Heparin given with the premedication and 12 and 24 hours after1. 2.
Williams, H. T. Lancet, 1971, ii, 950. Gordon-Smith, I., Grundy, D. J., Le Quesne, L. P., Newcombe, J. F., Bramble, F. J. Lancet, 1972, i, 1133.