- Email: [email protected]
Medical triage and legal protection in Japan
CORRESPONDENCE
3
4
Bryan JP, Henry CH, Hoffman AG, et al. Randomised, cross-over, controlled comparison of two inactivated hepatitis A vaccines. Vaccine 2000; 19: 743–50. Ashur Y, Adler R, Rowe M, Shouval D. Comparison of immunogenicity of two hepatitis A vaccines: VAQTA and HAVRIX in young adults. Vaccine 1999; 17: 2290–96.
Medical triage and legal protection in Japan Sir—Triage to prioritise urgency of treatment enables efficient use of limited human resources and medical supplies. Naturally, lowest priority is given to patients who will recover without treatment and those with severe injuries who are not expected to survive even with treatment. Triage must be quick, especially if there is a large number of casualties. The Kobe-Awaji earthquake, Japan, Jan 17, 1995, was the worst natural disaster in Japan since the Second World War. The final death toll was 6400, and more than 35 000 people were injured. Limited medical supplies were used inefficiently because of insufficient triage training. The importance of triage in the event of such a disaster and the necessity for relevant training were pointed out after the earthquake, and triage training has since been done in many places throughout Japan. Despite the lessons supposedly learned from the Kobe-Awaji earthquake, triage was poorly done after an accident involving more than 160 casualties that occurred on July 21, 2001, in Akashi City. Spectators returning from a fireworks display tried to cross a bridge that was already crowded with people who had gathered there to watch the display. Many spectators fell over, and some who could not escape were crushed or suffocated. According to an article that appeared in the Kobe Newspaper,1 triage was not started at the scene until about 80 min after the accident had occurred. According to the article, licensed paramedics were too busy transporting injured people to hospitals, and it was fire department workers stationed at the fireworks site who actually did the triage. The accuracy of the triage was criticised in the article, since some people who had been judged to have only moderate injuries had serious injuries at later examination. Since an inappropriate decision made during triage could be lifethreatening for injured people, it should be done by a doctor. If doctors cannot reach or will take a long time to reach the scene of a large-scale disaster,
triage done by paramedics, nurses, or both could be equated with emergency evacuation, which would be legally acceptable. However, a decision is needed about who should take responsibility in the event of a misjudgment in triage. The accident that occurred in Akashi City provided a good opportunity for discussion of an appropriate triage system, but there has been little debate so far. If individuals doing triage have to worry about their legal accountability for misjudgments, it will be difficult for them to be effective at the scene of a disaster. The rationale for triage comes from a medical point of view, not from the victims’ point of view. Lawsuits might come from family members of disaster victims who were judged during triage to have no chance of surviving. Thus, legal protection for those doing triage is an issue in Japan that requires immediate attention. *Takashi Yokota, Shuichi Ishiyama, Yasuo Yamada, Hidemi Yamauchi Department of Gastroenterological Surgery, Sendai National Hospital, Sendai 983-8520, Japan. (e-mail: [email protected]) 1
Planning Report Department. Despite the lessons learned from the Kobe-Awaji earthquake, triage was poorly done after the fireworks accident. Kobe Newspaper, July 27, 2001.
Experience of leprosy Sir—I was drawn to the reports on leprosy by Euzenir Nunes Sarno and Maria Cristina Vidal Pessolani (suppl 2001, p s39)1 and Ester Pinto Alves and Judith Grevan (suppl 2001, p s40).2 On one hand, we are presented with fascinating state of the art research about Mycobacterium leprae, done by a leading Brazilian institution, on the other one we were faced with an unacceptable delay in the diagnosis of a disorder whose identification is expected to be straightforward. To embark on a lengthy, and costly, work up to misdiagnose carpal tunnel syndrome when combined involvement of the ulnar and median nerves was so clearly the case, only points to the huge gap between existing science and clinical expertise. The patient’s suffering and handicap could have been greatly reduced had a sensible physical diagnostic investigation been done. We are just too used to this scenario in which clinical skills are taken for granted and breakthrough research is all that is called for. As a lecturer who teaches semiotics, I am concerned about textbooks that put together
THE LANCET • Vol 359 • June 1, 2002 • www.thelancet.com
encyclopaedic information about physical examination, only to fail miserably when the reader has to refer to them for a real patient. The rational clinical examination3 should be a priority target for every medical curriculum. Ricardo Rocha Bastos Faculdade de Medicina da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais 36010-020, Brazil (e-mail: [email protected]) 1
2
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Nunes Sarno E, Vidal Pessolani MC. Oldest and most feared disease. Lancet 2001; 358 (suppl): s39. Pinto Alves E, Grevan J. Pots and pans fell out of my hands. Lancet 2001; 358 (suppl): s40. D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000; 283: 3110–17.
Industry funding in medical education Sir—Arrigo Schieppati and colleagues (Nov 10, p 1638)1 discuss how the profit motive of pharmaceutical and biotechnology industries has led clinical research away from the needs of patients in the less-developed world. I believe the lack of investment by the pharmaceutical industry into developing drugs for diseases of the poorer nations spills over from research into education. In the first half of 2001, the UK had an unprecedented number of tuberculosis outbreaks. One outbreak, in Leicester, was the largest since chemotherapy became available. In this and at least one other outbreak, the index patient was diagnosed as having asthma,2 these patients were treated for asthma for many months before the diagnostic error was realised, meanwhile infecting their friends and relatives. How can respectable, and otherwise competent, doctors keep making the same mistake? I am sure biased postgraduate education that is far too dependent on pharmaceutical sponsorship, plays an important part in misdiagnosis of diseases. There are many companies with asthma drugs to sell repeating the mantra “Cough? Think of asthma”. None says “Cough? Think of tuberculosis”. As Schieppati and colleagues point out, the last effective drug for tuberculosis was invented more than 30 years ago. I support Schieppati and colleagues’ call for scientific bodies to guarantee the impartiality of scientific communication and this guarantee must include education. It seems that UK scientific organisations dealing with respiratory
1949
For personal use. Only reproduce with permission from The Lancet Publishing Group.
3
4
Bryan JP, Henry CH, Hoffman AG, et al. Randomised, cross-over, controlled comparison of two inactivated hepatitis A vaccines. Vaccine 2000; 19: 743–50. Ashur Y, Adler R, Rowe M, Shouval D. Comparison of immunogenicity of two hepatitis A vaccines: VAQTA and HAVRIX in young adults. Vaccine 1999; 17: 2290–96.
Medical triage and legal protection in Japan Sir—Triage to prioritise urgency of treatment enables efficient use of limited human resources and medical supplies. Naturally, lowest priority is given to patients who will recover without treatment and those with severe injuries who are not expected to survive even with treatment. Triage must be quick, especially if there is a large number of casualties. The Kobe-Awaji earthquake, Japan, Jan 17, 1995, was the worst natural disaster in Japan since the Second World War. The final death toll was 6400, and more than 35 000 people were injured. Limited medical supplies were used inefficiently because of insufficient triage training. The importance of triage in the event of such a disaster and the necessity for relevant training were pointed out after the earthquake, and triage training has since been done in many places throughout Japan. Despite the lessons supposedly learned from the Kobe-Awaji earthquake, triage was poorly done after an accident involving more than 160 casualties that occurred on July 21, 2001, in Akashi City. Spectators returning from a fireworks display tried to cross a bridge that was already crowded with people who had gathered there to watch the display. Many spectators fell over, and some who could not escape were crushed or suffocated. According to an article that appeared in the Kobe Newspaper,1 triage was not started at the scene until about 80 min after the accident had occurred. According to the article, licensed paramedics were too busy transporting injured people to hospitals, and it was fire department workers stationed at the fireworks site who actually did the triage. The accuracy of the triage was criticised in the article, since some people who had been judged to have only moderate injuries had serious injuries at later examination. Since an inappropriate decision made during triage could be lifethreatening for injured people, it should be done by a doctor. If doctors cannot reach or will take a long time to reach the scene of a large-scale disaster,
triage done by paramedics, nurses, or both could be equated with emergency evacuation, which would be legally acceptable. However, a decision is needed about who should take responsibility in the event of a misjudgment in triage. The accident that occurred in Akashi City provided a good opportunity for discussion of an appropriate triage system, but there has been little debate so far. If individuals doing triage have to worry about their legal accountability for misjudgments, it will be difficult for them to be effective at the scene of a disaster. The rationale for triage comes from a medical point of view, not from the victims’ point of view. Lawsuits might come from family members of disaster victims who were judged during triage to have no chance of surviving. Thus, legal protection for those doing triage is an issue in Japan that requires immediate attention. *Takashi Yokota, Shuichi Ishiyama, Yasuo Yamada, Hidemi Yamauchi Department of Gastroenterological Surgery, Sendai National Hospital, Sendai 983-8520, Japan. (e-mail: [email protected]) 1
Planning Report Department. Despite the lessons learned from the Kobe-Awaji earthquake, triage was poorly done after the fireworks accident. Kobe Newspaper, July 27, 2001.
Experience of leprosy Sir—I was drawn to the reports on leprosy by Euzenir Nunes Sarno and Maria Cristina Vidal Pessolani (suppl 2001, p s39)1 and Ester Pinto Alves and Judith Grevan (suppl 2001, p s40).2 On one hand, we are presented with fascinating state of the art research about Mycobacterium leprae, done by a leading Brazilian institution, on the other one we were faced with an unacceptable delay in the diagnosis of a disorder whose identification is expected to be straightforward. To embark on a lengthy, and costly, work up to misdiagnose carpal tunnel syndrome when combined involvement of the ulnar and median nerves was so clearly the case, only points to the huge gap between existing science and clinical expertise. The patient’s suffering and handicap could have been greatly reduced had a sensible physical diagnostic investigation been done. We are just too used to this scenario in which clinical skills are taken for granted and breakthrough research is all that is called for. As a lecturer who teaches semiotics, I am concerned about textbooks that put together
THE LANCET • Vol 359 • June 1, 2002 • www.thelancet.com
encyclopaedic information about physical examination, only to fail miserably when the reader has to refer to them for a real patient. The rational clinical examination3 should be a priority target for every medical curriculum. Ricardo Rocha Bastos Faculdade de Medicina da Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais 36010-020, Brazil (e-mail: [email protected]) 1
2
3
Nunes Sarno E, Vidal Pessolani MC. Oldest and most feared disease. Lancet 2001; 358 (suppl): s39. Pinto Alves E, Grevan J. Pots and pans fell out of my hands. Lancet 2001; 358 (suppl): s40. D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000; 283: 3110–17.
Industry funding in medical education Sir—Arrigo Schieppati and colleagues (Nov 10, p 1638)1 discuss how the profit motive of pharmaceutical and biotechnology industries has led clinical research away from the needs of patients in the less-developed world. I believe the lack of investment by the pharmaceutical industry into developing drugs for diseases of the poorer nations spills over from research into education. In the first half of 2001, the UK had an unprecedented number of tuberculosis outbreaks. One outbreak, in Leicester, was the largest since chemotherapy became available. In this and at least one other outbreak, the index patient was diagnosed as having asthma,2 these patients were treated for asthma for many months before the diagnostic error was realised, meanwhile infecting their friends and relatives. How can respectable, and otherwise competent, doctors keep making the same mistake? I am sure biased postgraduate education that is far too dependent on pharmaceutical sponsorship, plays an important part in misdiagnosis of diseases. There are many companies with asthma drugs to sell repeating the mantra “Cough? Think of asthma”. None says “Cough? Think of tuberculosis”. As Schieppati and colleagues point out, the last effective drug for tuberculosis was invented more than 30 years ago. I support Schieppati and colleagues’ call for scientific bodies to guarantee the impartiality of scientific communication and this guarantee must include education. It seems that UK scientific organisations dealing with respiratory
1949
For personal use. Only reproduce with permission from The Lancet Publishing Group.