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LEAVING NO RIPPLE
247
APOPHYSEAL JOINTS AND BACK PAIN ONE of the biggest obstacles to treatment of disorders of the lower back is the difficulty in finding the site of origin of the pain. Generally, routine radiographic examination adds little to the precision of diagnosis unless there is an obvious site of mechanical weakness or focal disease. In a survey on 1803 males and 1572 females,’ lumbar-disc degeneration was found in 65% of males and 52% of females aged 35 years and over. Improved radiological techniques, among them computerised axial tomography and myelography with water-soluble contrast media, should tell us more about the lesions. In addition a simple technique employing the stereoplotter2 has now been shown to enhance the information obtainable from standard radiographs of the lumbar spine. Binocular stereovision allows the apophyseal joints to be examined with greater precision. In seven patients SimsWilliams and others2 identified only one fracture on conventional anteroposterior and lateral films, and a second fracture on oblique views; but stereovision revealed fractures in all seven. The relevance of these fractures to symptoms is not clear. Sims-Williams et al. suggest that they resulted from repeated minor stresses in the bone with eventual fatigue failure. It is also possible that, as Harris and MacNab3 describe, the articular surface of the apophyseal joints becomes frayed and pieces flake off. Occasionally quite large osteochondral fractures are found. As in other joints these fragments may form loose bodies which lie free in the joint or become secondarily attached to the synovial membrane. Disorders of the intervertebral disc do not explain all the lower-limb pain found with backache. Injection of irritant fluid precisely in the apophyseal joint caused referred pain patterns indistinguishable from that associated with a prolapsed disc.4 With techniques such as the stereoplotter and a more detailed look at the posterior elements of the vertebrae these disorders should become less obscure.
LOCAL EXCISION OF EARLY COLO-RECTAL CANCER ORTHODOX surgical teaching has stressed the need for radical surgery in cancer of the colon and rectum. This policy is entirely correct for a lesion which is potentially completely curable, especially if it is low-grade and at an early stage. However, as in all branches of surgery justice must be tempered with mercy, especially in the elderly, frail patient. If a polyp is removed and found to have a malignant change, should the surgeon always go back and do a major excision? Supposing the polyp is low down in the rectum, would it always be right to give the patient a permanent colostomy? The problem has been accentuated by the increasing use of colonoscopic polypectomy. Sometimes the resected polyp is not retrieved or the resection line is too superficial to allow examination of the pedicle for signs of invasion.s
early
1. Lawrence, J. S. Ann. rheum. Dis. 1969, 28, 121. 2. Sims-Williams, H., Jayson, M. I. V., Baddeley, H. ibid. 1978, 37, 262. 3. Harris, R. I., MacNab, I.J. Bone Jt Surg. 1954, 36B, 304. 4. Mooney, V., Robertson, J. Clin. Orthop. 1976, 115, 149. 5. Britton, D. C., Tregoning, D., Bone, G., McKelvey, S. T. D Br.
1977, i, 149.
Lock et al. have recently reviewed the experience at St. Mark’s Hospital of 143 patients with early colo-rectal cancer treated by local excision (before the introduction of colonoscopy). It is a retrospective review and so the reason for the surgeon choosing this particular course of action is not known, but these cases managed by local excision represent 4% of the total number of cases of colorectal cancer treated. Lock and his coworkers conclude that it is a safe policy provided there are certain very important safeguards. There must be close collaboration with the pathologist to ensure that the excision has been complete, and follow-up must be scrupulous, with examination of the excision site at each visit. They also advocate a preliminary biopsy, because poorly differentiated tumours should not be treated in this way. In the case of colonoscopic polypectomy where a preliminary biopsy is impracticable, early radical surgery should be performed when histology shows a highgrade tumour or if the specimen is not adequate to exclude invasion of the stalk. Except possibly in cases of villous papilloma of the rectum,’ a local recurrence showing malignant change should be treated by radical resection, not a further local excision. There is perhaps a parallel with simple "lumpectomy" for early carcinoma of the breast. But carcinoma of the rectum spreads in a far more predictable way, and Morson found that, until penetration of the bowel wall has occurred, the chance of lymphatic metastases was only 10% whereas a minute primary in the breast may give widespread metastases. The danger of recommending any local excision for a metastasising tumour is that safeguards will be forgotten and the indications extended, leading to sloppy and inadequate surgery. While the surgeon takes a calculated risk, he must always remember he is dealing with a potentially lethal disease.
LEAVING NO RIPPLE THERE are many false trails in the advancement of medical care. This is nowhere more true than in the development of new apparatus for diagnosis or treatment. We have all seen examples of equipment which, as a result of some flaw in its conception, ended like Captain Scott’s motor sledges as "a heap of useless metal in the snow". This seems to be the fate of the alternating-pressure ripple bed which began its career so hopefully about ten years ago. This device, which consists simply of a polyethylene mattress and a pump, is so arranged that the ribs of the mattress inflate alternately every few minutes, supporting the patient on quite distinct pressure areas each time, thus allowing complete relief of pressure to all areas far more often than could ever be achieved by simple nursing. The initial carefully controlled trial carried out by Exton-Smith at the Whittington Hospital1 showed that heel and sacral sores could be prevented far more effectively by these beds than by simple basic nursing, -even in the most debilitated patients, and even when no attempt was made to turn the patient 6. Lock, M. R., Cairns, D. W., Ritchie, J. K., Lockhart-Mummery, H. E. Br.
J. Surg. 1978, 65, 346. med. J.
7. Parks, A. G., Stuart, E. A. ibid. 1973, 60, 688. 8. Morson, B. C. ibid. 1968, 55, 725. 1. Bliss, M. R., MacLaren, R., Exton-Smith, A.N. Mon. Bull. Min. Hlth,
25, 238.
1966,
248
The nurses anyway found it very difficult to sustain a regular twenty-four-hour turning routine, even in these test conditions. The idea swept through the country and hundreds went into use, at first by hiring, but later (on Department instruction) by purchase, with the assumption that hospitals would attend to their own maintenance problems. By 1973 it was becoming evident that all was not well. Baker2 noted how often nursing staff seemed oblivious to the fact that the ripple beds were not working properly. Bliss3 now records how, in a few years, ripple beds have fallen into such disuse and disrepute that manufacturers are considering phasing them out altogether. The irony is that nurses have lost faith in them not because they did not work, but because
regularly.
they
were
not
working correctly—the
pump
tubing
could become detached or kinked; the mattress could leak.- The failure was in nursing instruction and in maintenance by hospital engineers. Doctors seem to have played very little part in this because of the ambiguous status of the humble pressure sore, and the feeling that it is somehow not the doctor’s concern. With the same supervision and maintenance as other hospital medical equipment, ripple beds work well enough. They seem to represent a signal example of the failure of multidisciplinary management where no one authority feels ultimately responsible. Bliss points out that it is not too late to resuscitate what may be our most valuable weapon against pressure sores, provided that each hospital authority works out a proper scheme of supervision and maintenance. Otherwise the ripple bed will simply disappear. ’
THE
NURSING PROCESS
THERE is
widespread impression that standards of in the National Health Service are falling and that they will continue to do so until the service can afford to employ more nurses. It is therefore perhaps curious that the nursing profession should at this time be giving’a warm welcome to a new approach to nursing care which seems likely to add to the demands on nursing time and dedication. There is, however, more to "the nursing process" than meets the eye. The concept, and the term, originated in the United States, but in the last year or two have become familiar to British nurses as a result of work done in university departments of nursing-notably, under Prof. Jean McFarlane at Manchester. The last 18 months have seen a spate of articles in the nursing journals4 and a policy statement by the General Nursing Council for England and Wales commending the concept to schools of nursing as "a unifying thread for the study of patient care and a helpful framework of nursing practice".’ The nursing process can be seen as an attempt to replace some of the time-honoured rituals of nursing with a more thoughtful and discriminating approach to meeting patients’ needs. As taught at Manchester, the nursing process consists of five stages: data collection about the patient; assessment of nursing needs from the data; nursing
a
care
Baker, A. A. Annual Report of Hospital Advisory Service for 1972; p. 10. H.M. Stationery Office, 1973. 3. Bliss, M. R. Hosp. Hlth. Serv. Rev. 1978, 74, 190. 4. Crow, J. Nursing Times, 1977, 73, 24. 5. A Statement of Educational Policy. General Nursing Council for England and Wales, 1977. 2.
development of a nursing-care plan; implementation of the plan; and evaluation. In the first stage the nurse takes a history which differs in several respects from the medical history that will be taken by the doctor. It will concern itself, for instance, with the patient’s normal routines for meeting his daily needs, and how these have been affected by his illness. In taking it, the nurse will have in mind that "the unique function of the nurse is to assist the individ. ual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary.strength, will or knowledge".6 Included in this definition is the nurse’s traditional role of helping the patient to observe the regimen prescribed for his illness by the doctor; this help may include administering drugs and carrying out treatment that is prescribed. But it is argued that the nurse will not meet the patient’s full needs for care if she relies exclusively on the medical history and diagnosis. The second stage follows logically from the first, and the third from the second, but in these two respects the nursing process departs radically from traditional nursing practice. Nursing work on hospital wards has commonly been organised on the basis of task assignment rather than patient assignment. That is individual nurses have been responsible for doing particular tasks for all patients, rather than for the total care of particular patients. This assembly-line method of nursing tends to make little allowance for individual needs; thus, the patient with unusual requirements disturbs the smooth running of the ward. The nursing process insists on proper attention to individual needs. Furthermore, it is all but mandatory that the plan by which each patient is to be nursed should be set down in writing. Again this reflects the detailed consideration of individual needs. Nurses can cope informally with a limited range of variations in nursing routine, but once the pattern becomes more complex, then nursing care, as well as drugs and medical treatments, must be prescribed in writing. In principle the nursing process clearly represents a higher standard of nursing care than is likely to be achieved by traditional means. There can be argument about whether this is a luxury standard that can hardly be afforded in a health service that is having difficulty in meeting the cost of bare essentials. Nonetheless, there are ways in which the nursing process may in fact conserve nursing resources. Firstly, if it should prove as satisfying a way to nurse as its supporters claim, then it may do something for the morale of a profession which is at present bearing heavy burdens. Secondly, the detailed consideration of each patient’s needs is as likely to disclose things that do not need to be done for that patient-but which would otherwise be done as a matter of unthinking routine-as it is to indicate additional requirements. Thirdly, if patient’s needs are met more fully, then, in theory at least, patients should not only be more satisfied with the care they have received; they can also be expected to recover promptly. Finally, the evaluation of care, which is regarded as a vitally important stage, should operate as a continuing review of standards and effectiveness. 6.
Henderson, V. Basic Principles of Nursing Care. International Council of Nurses, Geneva, 1961.
APOPHYSEAL JOINTS AND BACK PAIN ONE of the biggest obstacles to treatment of disorders of the lower back is the difficulty in finding the site of origin of the pain. Generally, routine radiographic examination adds little to the precision of diagnosis unless there is an obvious site of mechanical weakness or focal disease. In a survey on 1803 males and 1572 females,’ lumbar-disc degeneration was found in 65% of males and 52% of females aged 35 years and over. Improved radiological techniques, among them computerised axial tomography and myelography with water-soluble contrast media, should tell us more about the lesions. In addition a simple technique employing the stereoplotter2 has now been shown to enhance the information obtainable from standard radiographs of the lumbar spine. Binocular stereovision allows the apophyseal joints to be examined with greater precision. In seven patients SimsWilliams and others2 identified only one fracture on conventional anteroposterior and lateral films, and a second fracture on oblique views; but stereovision revealed fractures in all seven. The relevance of these fractures to symptoms is not clear. Sims-Williams et al. suggest that they resulted from repeated minor stresses in the bone with eventual fatigue failure. It is also possible that, as Harris and MacNab3 describe, the articular surface of the apophyseal joints becomes frayed and pieces flake off. Occasionally quite large osteochondral fractures are found. As in other joints these fragments may form loose bodies which lie free in the joint or become secondarily attached to the synovial membrane. Disorders of the intervertebral disc do not explain all the lower-limb pain found with backache. Injection of irritant fluid precisely in the apophyseal joint caused referred pain patterns indistinguishable from that associated with a prolapsed disc.4 With techniques such as the stereoplotter and a more detailed look at the posterior elements of the vertebrae these disorders should become less obscure.
LOCAL EXCISION OF EARLY COLO-RECTAL CANCER ORTHODOX surgical teaching has stressed the need for radical surgery in cancer of the colon and rectum. This policy is entirely correct for a lesion which is potentially completely curable, especially if it is low-grade and at an early stage. However, as in all branches of surgery justice must be tempered with mercy, especially in the elderly, frail patient. If a polyp is removed and found to have a malignant change, should the surgeon always go back and do a major excision? Supposing the polyp is low down in the rectum, would it always be right to give the patient a permanent colostomy? The problem has been accentuated by the increasing use of colonoscopic polypectomy. Sometimes the resected polyp is not retrieved or the resection line is too superficial to allow examination of the pedicle for signs of invasion.s
early
1. Lawrence, J. S. Ann. rheum. Dis. 1969, 28, 121. 2. Sims-Williams, H., Jayson, M. I. V., Baddeley, H. ibid. 1978, 37, 262. 3. Harris, R. I., MacNab, I.J. Bone Jt Surg. 1954, 36B, 304. 4. Mooney, V., Robertson, J. Clin. Orthop. 1976, 115, 149. 5. Britton, D. C., Tregoning, D., Bone, G., McKelvey, S. T. D Br.
1977, i, 149.
Lock et al. have recently reviewed the experience at St. Mark’s Hospital of 143 patients with early colo-rectal cancer treated by local excision (before the introduction of colonoscopy). It is a retrospective review and so the reason for the surgeon choosing this particular course of action is not known, but these cases managed by local excision represent 4% of the total number of cases of colorectal cancer treated. Lock and his coworkers conclude that it is a safe policy provided there are certain very important safeguards. There must be close collaboration with the pathologist to ensure that the excision has been complete, and follow-up must be scrupulous, with examination of the excision site at each visit. They also advocate a preliminary biopsy, because poorly differentiated tumours should not be treated in this way. In the case of colonoscopic polypectomy where a preliminary biopsy is impracticable, early radical surgery should be performed when histology shows a highgrade tumour or if the specimen is not adequate to exclude invasion of the stalk. Except possibly in cases of villous papilloma of the rectum,’ a local recurrence showing malignant change should be treated by radical resection, not a further local excision. There is perhaps a parallel with simple "lumpectomy" for early carcinoma of the breast. But carcinoma of the rectum spreads in a far more predictable way, and Morson found that, until penetration of the bowel wall has occurred, the chance of lymphatic metastases was only 10% whereas a minute primary in the breast may give widespread metastases. The danger of recommending any local excision for a metastasising tumour is that safeguards will be forgotten and the indications extended, leading to sloppy and inadequate surgery. While the surgeon takes a calculated risk, he must always remember he is dealing with a potentially lethal disease.
LEAVING NO RIPPLE THERE are many false trails in the advancement of medical care. This is nowhere more true than in the development of new apparatus for diagnosis or treatment. We have all seen examples of equipment which, as a result of some flaw in its conception, ended like Captain Scott’s motor sledges as "a heap of useless metal in the snow". This seems to be the fate of the alternating-pressure ripple bed which began its career so hopefully about ten years ago. This device, which consists simply of a polyethylene mattress and a pump, is so arranged that the ribs of the mattress inflate alternately every few minutes, supporting the patient on quite distinct pressure areas each time, thus allowing complete relief of pressure to all areas far more often than could ever be achieved by simple nursing. The initial carefully controlled trial carried out by Exton-Smith at the Whittington Hospital1 showed that heel and sacral sores could be prevented far more effectively by these beds than by simple basic nursing, -even in the most debilitated patients, and even when no attempt was made to turn the patient 6. Lock, M. R., Cairns, D. W., Ritchie, J. K., Lockhart-Mummery, H. E. Br.
J. Surg. 1978, 65, 346. med. J.
7. Parks, A. G., Stuart, E. A. ibid. 1973, 60, 688. 8. Morson, B. C. ibid. 1968, 55, 725. 1. Bliss, M. R., MacLaren, R., Exton-Smith, A.N. Mon. Bull. Min. Hlth,
25, 238.
1966,
248
The nurses anyway found it very difficult to sustain a regular twenty-four-hour turning routine, even in these test conditions. The idea swept through the country and hundreds went into use, at first by hiring, but later (on Department instruction) by purchase, with the assumption that hospitals would attend to their own maintenance problems. By 1973 it was becoming evident that all was not well. Baker2 noted how often nursing staff seemed oblivious to the fact that the ripple beds were not working properly. Bliss3 now records how, in a few years, ripple beds have fallen into such disuse and disrepute that manufacturers are considering phasing them out altogether. The irony is that nurses have lost faith in them not because they did not work, but because
regularly.
they
were
not
working correctly—the
pump
tubing
could become detached or kinked; the mattress could leak.- The failure was in nursing instruction and in maintenance by hospital engineers. Doctors seem to have played very little part in this because of the ambiguous status of the humble pressure sore, and the feeling that it is somehow not the doctor’s concern. With the same supervision and maintenance as other hospital medical equipment, ripple beds work well enough. They seem to represent a signal example of the failure of multidisciplinary management where no one authority feels ultimately responsible. Bliss points out that it is not too late to resuscitate what may be our most valuable weapon against pressure sores, provided that each hospital authority works out a proper scheme of supervision and maintenance. Otherwise the ripple bed will simply disappear. ’
THE
NURSING PROCESS
THERE is
widespread impression that standards of in the National Health Service are falling and that they will continue to do so until the service can afford to employ more nurses. It is therefore perhaps curious that the nursing profession should at this time be giving’a warm welcome to a new approach to nursing care which seems likely to add to the demands on nursing time and dedication. There is, however, more to "the nursing process" than meets the eye. The concept, and the term, originated in the United States, but in the last year or two have become familiar to British nurses as a result of work done in university departments of nursing-notably, under Prof. Jean McFarlane at Manchester. The last 18 months have seen a spate of articles in the nursing journals4 and a policy statement by the General Nursing Council for England and Wales commending the concept to schools of nursing as "a unifying thread for the study of patient care and a helpful framework of nursing practice".’ The nursing process can be seen as an attempt to replace some of the time-honoured rituals of nursing with a more thoughtful and discriminating approach to meeting patients’ needs. As taught at Manchester, the nursing process consists of five stages: data collection about the patient; assessment of nursing needs from the data; nursing
a
care
Baker, A. A. Annual Report of Hospital Advisory Service for 1972; p. 10. H.M. Stationery Office, 1973. 3. Bliss, M. R. Hosp. Hlth. Serv. Rev. 1978, 74, 190. 4. Crow, J. Nursing Times, 1977, 73, 24. 5. A Statement of Educational Policy. General Nursing Council for England and Wales, 1977. 2.
development of a nursing-care plan; implementation of the plan; and evaluation. In the first stage the nurse takes a history which differs in several respects from the medical history that will be taken by the doctor. It will concern itself, for instance, with the patient’s normal routines for meeting his daily needs, and how these have been affected by his illness. In taking it, the nurse will have in mind that "the unique function of the nurse is to assist the individ. ual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary.strength, will or knowledge".6 Included in this definition is the nurse’s traditional role of helping the patient to observe the regimen prescribed for his illness by the doctor; this help may include administering drugs and carrying out treatment that is prescribed. But it is argued that the nurse will not meet the patient’s full needs for care if she relies exclusively on the medical history and diagnosis. The second stage follows logically from the first, and the third from the second, but in these two respects the nursing process departs radically from traditional nursing practice. Nursing work on hospital wards has commonly been organised on the basis of task assignment rather than patient assignment. That is individual nurses have been responsible for doing particular tasks for all patients, rather than for the total care of particular patients. This assembly-line method of nursing tends to make little allowance for individual needs; thus, the patient with unusual requirements disturbs the smooth running of the ward. The nursing process insists on proper attention to individual needs. Furthermore, it is all but mandatory that the plan by which each patient is to be nursed should be set down in writing. Again this reflects the detailed consideration of individual needs. Nurses can cope informally with a limited range of variations in nursing routine, but once the pattern becomes more complex, then nursing care, as well as drugs and medical treatments, must be prescribed in writing. In principle the nursing process clearly represents a higher standard of nursing care than is likely to be achieved by traditional means. There can be argument about whether this is a luxury standard that can hardly be afforded in a health service that is having difficulty in meeting the cost of bare essentials. Nonetheless, there are ways in which the nursing process may in fact conserve nursing resources. Firstly, if it should prove as satisfying a way to nurse as its supporters claim, then it may do something for the morale of a profession which is at present bearing heavy burdens. Secondly, the detailed consideration of each patient’s needs is as likely to disclose things that do not need to be done for that patient-but which would otherwise be done as a matter of unthinking routine-as it is to indicate additional requirements. Thirdly, if patient’s needs are met more fully, then, in theory at least, patients should not only be more satisfied with the care they have received; they can also be expected to recover promptly. Finally, the evaluation of care, which is regarded as a vitally important stage, should operate as a continuing review of standards and effectiveness. 6.
Henderson, V. Basic Principles of Nursing Care. International Council of Nurses, Geneva, 1961.