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MEDICINE WITHIN THE ATLANTIC COMMUNITY
669 correct in saying that the Working Dr. Russell Party does not include an unestablished practitioner. On the other hand, the views of the Subcommittee have been fully expressed to the Working Party, and will continue to be as and when required. The G.M.S. Committee has gone to considerable trouble in establishing a democratically elected Subcommittee to represent assistants and young practitioners, and your readers may well wonder on what grounds the " Unestablished Practitioners’ Group " can genuinely claim to represent the unestablished
is
practitioner. Tavistock House, W.O.l. London, W.C.1.
F. GRAY Chairman, Assistants and Young Practitioners J-’ractitiono! Subcommittee. ubcommittee.
INJECTION ROUTINE IN OPERATING-THEATRES SiR,-We have read with interest the article (Feb. 23) by General Dimond, Miss Pollard, and Mr. Adamson, under the above title, and agree that many of their suggestions would help to reduce the risk of accidental administration of noxious substances. There is one proposal, however, with which we must disagree as a result of recent tests. This is 13(b) which states: " All non-injectable fluids used for storage of ampoules and syringes should have a distinctive colour. Any contamination of the contents of a cracked ampoule could then be seen." This practice is fairly widespread in operating-theatres although it has been condemned
by Macintosh.1 Since finding a cracked ampoule that had been stored a coloured solution and which had not acquired any colour, we have carried out several tests to ascertain whether in fact sufficient colour can be absorbed from dyed antiseptic solutions to make detection of contamination certain : in
Quantitative Chemical Tests Twelve imperfectly sealed or very slightly cracked ampoules of distilled water were placed in a solution containing 1 in 40 of liquefied phenol coloured with about 1 in 600,000 of eosin, and were kept in this solution for four days at
room-temperature. At the end of that time they were removed and examined. All were covered with a faint pink coating which made the contents appear pink until the ampoule was thoroughly cleaned with a cloth. Two of the ampoules were so badly cracked that they came to pieces and were discarded. Three showed sufficient pink colour for it to be quite obvious that they were contaminated. One of the remaining seven showed a very slight trace of pink at the meniscus when carefully examined at a certain angle only. The other six were completely water-white, and three observers could not see any These last seven ampoules were tested trace of pink colour. with ferric chloride solution and bromine water with the following results : (1) using the ferric chloride test, three ampoules gave a strongly positive reaction, one a weakly positive reaction, and three a negative reaction ; (2) using the bromine water test, five ampoules gave a strongly positive result, one a weakly positive result, and one a negative result. Quantitative Chemical Tests (A) Six ampoules, three containing 10 ml. and three 20 ml. of distilled water, were slightly cracked and were stored in coloured phenol solution as in the tests described above. When removed they were all coated with pink dye, but on careful washing and vigorous wiping with a clean cloth no pink colour remained. (It must be emphasised that the pink dye adheres persistently to the outside of the ampoules, and, unless they are carefully washed, this film could be mistaken for a coloured solution.) 10 ml. quantities of the fluid from the 20 ml. ampoules and 5 ml. quantities from the 10 ml. ampoules were assayed for phenol by the method of the British Pharmacopaeia. The amount of phenol in ] 0 ml. of solution was as follows : 9-3 mg., 18-3 mg., 11-3 mg., 22-2 mg., 19-4 mg., and 32-8 mg. (B) It was then suggested that these tests should be Twelve repeated under operating-theatre conditions. ampoules of saline were slightly cracked and allowed to stand in coloured 1-in-40 phenol solution for one week. The con-
1. Macintosh, R. R. Lumbar Puncture Edinburgh, 1951 ; p. 142.
and
Spinal Analgesia.
tainer was moved about in the theatre by the staff each day. The period of one week was chosen since this seems to be an average time for ampoules to remain in an antiseptic solution. At the end of this time five ampoules were so badly damaged that their contents were obviously contaminated. Of the remaining seven, that with the smallest crack was colourless, and a test with bromine water was strongly positive. The remaining six, which showed no colour change, were assayed by the British Pharrnacopaeia method. The amount of phenol in 10 ml. of solution in these ampoules was as follows : 35 mg., 48 mg., 92 mg., 19 mg., 25 mg., and 26 mg. To determine how much coloured phenol solution could be added to a colourless ampoule before the addition became detectable, quantities of coloured phenol solution were added from a micro-burette to 20 ml. ampoules of water. When 1-75 ml. was added it was impossible to detect any colour. With 2-0 ml. it was just possible to perceive a faint pink colour when looking at a white background through the depth of the ampoule. Several observers examined the latter ampoules and were unable to detect colour in the solutions. In artificial light it became almost impossible to notice colour in any ampoule. 2 ml. of 1-in-40 phenol solution represents 50 mg. of liquefied phenol. It was -also suggested that the use of blue colour might make detection more certain ; therefore the quantitative’ tests were repeated, using 1 in 600,000 of methylene-blue. Each of four ampoules tested showed a slight trace of blue colour at’ the meniscus when very carefully examined at certain angles ; but the colour was certainly not sufficient to render contamination obvious. When tested with bromine water the ampoules gave a strongly positive result. Further tests were carried out with more deeply coloured solutions of phenol. If was found that the depth of colour of the storage solution had to be such that the ampoules themselves were invisible in the solution before the contents of each cracked ampoule became coloured. -
--
These experiments show that appreciable quantities of phenol may pass into cracked ampoules even if the crack is exceedingly small ; but, except when the phenol solutions are very deeply coloured or the ampoules are grossly cracked, the contamination may not be obvious. We suggest, therefore, -that other methods should be sought. R. W. COPE F. PRESCOTT T. D. WHITTET. London. MEDICINE WITHIN THE ATLANTIC COMMUNITY
SiR,—Whilst agreeing in essence with Dr. Meiklejohn’s second article (Feb. 16), I feel that the arrangements for young British doctors to work in American hospitals are rather better than he suggests. I am at present working in Canada under an exchange fellowship of the British Empire Cancer Campaign, and recently was able to pay a very brief visit to a few of the hospitals in New York, Philadelphia, and Boston. In the course of less than two weeks I met no fewer than five British doctors and heard talk of three others ; two are in receipt of fellowships, three are working as junior interns, and two have recently come to settle on this side of the Atlantic. This is a better " haul" than the three young British doctors whom Dr. Meiklejohn met during his three months’ travel through the U.S.A. ; and I would emphasise that I was not attempting to contact my
fellow-countrymen.
In Canada it is equally possible for postgraduate students from Britain to work in hospitals, and the resident staff here includes at least five doctors from the " Old Country " who are widening their experience. Others are working elsewhere in the city and, I understand, throughout Canada. I do not wish to detract in any way from the most valuable and illuminating analysis of medicine across the Atlantic which Dr. Meiklejohn has given us ; but lest others should be discouraged from attempting to cross the seemingly unbridgeable ocean, I think it worth recording my small experience. Toronto General Hospital, R J. R. J DICKSON. D SON ICK
Canada. Ontario, Canada.
.
is
practitioner. Tavistock House, W.O.l. London, W.C.1.
F. GRAY Chairman, Assistants and Young Practitioners J-’ractitiono! Subcommittee. ubcommittee.
INJECTION ROUTINE IN OPERATING-THEATRES SiR,-We have read with interest the article (Feb. 23) by General Dimond, Miss Pollard, and Mr. Adamson, under the above title, and agree that many of their suggestions would help to reduce the risk of accidental administration of noxious substances. There is one proposal, however, with which we must disagree as a result of recent tests. This is 13(b) which states: " All non-injectable fluids used for storage of ampoules and syringes should have a distinctive colour. Any contamination of the contents of a cracked ampoule could then be seen." This practice is fairly widespread in operating-theatres although it has been condemned
by Macintosh.1 Since finding a cracked ampoule that had been stored a coloured solution and which had not acquired any colour, we have carried out several tests to ascertain whether in fact sufficient colour can be absorbed from dyed antiseptic solutions to make detection of contamination certain : in
Quantitative Chemical Tests Twelve imperfectly sealed or very slightly cracked ampoules of distilled water were placed in a solution containing 1 in 40 of liquefied phenol coloured with about 1 in 600,000 of eosin, and were kept in this solution for four days at
room-temperature. At the end of that time they were removed and examined. All were covered with a faint pink coating which made the contents appear pink until the ampoule was thoroughly cleaned with a cloth. Two of the ampoules were so badly cracked that they came to pieces and were discarded. Three showed sufficient pink colour for it to be quite obvious that they were contaminated. One of the remaining seven showed a very slight trace of pink at the meniscus when carefully examined at a certain angle only. The other six were completely water-white, and three observers could not see any These last seven ampoules were tested trace of pink colour. with ferric chloride solution and bromine water with the following results : (1) using the ferric chloride test, three ampoules gave a strongly positive reaction, one a weakly positive reaction, and three a negative reaction ; (2) using the bromine water test, five ampoules gave a strongly positive result, one a weakly positive result, and one a negative result. Quantitative Chemical Tests (A) Six ampoules, three containing 10 ml. and three 20 ml. of distilled water, were slightly cracked and were stored in coloured phenol solution as in the tests described above. When removed they were all coated with pink dye, but on careful washing and vigorous wiping with a clean cloth no pink colour remained. (It must be emphasised that the pink dye adheres persistently to the outside of the ampoules, and, unless they are carefully washed, this film could be mistaken for a coloured solution.) 10 ml. quantities of the fluid from the 20 ml. ampoules and 5 ml. quantities from the 10 ml. ampoules were assayed for phenol by the method of the British Pharmacopaeia. The amount of phenol in ] 0 ml. of solution was as follows : 9-3 mg., 18-3 mg., 11-3 mg., 22-2 mg., 19-4 mg., and 32-8 mg. (B) It was then suggested that these tests should be Twelve repeated under operating-theatre conditions. ampoules of saline were slightly cracked and allowed to stand in coloured 1-in-40 phenol solution for one week. The con-
1. Macintosh, R. R. Lumbar Puncture Edinburgh, 1951 ; p. 142.
and
Spinal Analgesia.
tainer was moved about in the theatre by the staff each day. The period of one week was chosen since this seems to be an average time for ampoules to remain in an antiseptic solution. At the end of this time five ampoules were so badly damaged that their contents were obviously contaminated. Of the remaining seven, that with the smallest crack was colourless, and a test with bromine water was strongly positive. The remaining six, which showed no colour change, were assayed by the British Pharrnacopaeia method. The amount of phenol in 10 ml. of solution in these ampoules was as follows : 35 mg., 48 mg., 92 mg., 19 mg., 25 mg., and 26 mg. To determine how much coloured phenol solution could be added to a colourless ampoule before the addition became detectable, quantities of coloured phenol solution were added from a micro-burette to 20 ml. ampoules of water. When 1-75 ml. was added it was impossible to detect any colour. With 2-0 ml. it was just possible to perceive a faint pink colour when looking at a white background through the depth of the ampoule. Several observers examined the latter ampoules and were unable to detect colour in the solutions. In artificial light it became almost impossible to notice colour in any ampoule. 2 ml. of 1-in-40 phenol solution represents 50 mg. of liquefied phenol. It was -also suggested that the use of blue colour might make detection more certain ; therefore the quantitative’ tests were repeated, using 1 in 600,000 of methylene-blue. Each of four ampoules tested showed a slight trace of blue colour at’ the meniscus when very carefully examined at certain angles ; but the colour was certainly not sufficient to render contamination obvious. When tested with bromine water the ampoules gave a strongly positive result. Further tests were carried out with more deeply coloured solutions of phenol. If was found that the depth of colour of the storage solution had to be such that the ampoules themselves were invisible in the solution before the contents of each cracked ampoule became coloured. -
--
These experiments show that appreciable quantities of phenol may pass into cracked ampoules even if the crack is exceedingly small ; but, except when the phenol solutions are very deeply coloured or the ampoules are grossly cracked, the contamination may not be obvious. We suggest, therefore, -that other methods should be sought. R. W. COPE F. PRESCOTT T. D. WHITTET. London. MEDICINE WITHIN THE ATLANTIC COMMUNITY
SiR,—Whilst agreeing in essence with Dr. Meiklejohn’s second article (Feb. 16), I feel that the arrangements for young British doctors to work in American hospitals are rather better than he suggests. I am at present working in Canada under an exchange fellowship of the British Empire Cancer Campaign, and recently was able to pay a very brief visit to a few of the hospitals in New York, Philadelphia, and Boston. In the course of less than two weeks I met no fewer than five British doctors and heard talk of three others ; two are in receipt of fellowships, three are working as junior interns, and two have recently come to settle on this side of the Atlantic. This is a better " haul" than the three young British doctors whom Dr. Meiklejohn met during his three months’ travel through the U.S.A. ; and I would emphasise that I was not attempting to contact my
fellow-countrymen.
In Canada it is equally possible for postgraduate students from Britain to work in hospitals, and the resident staff here includes at least five doctors from the " Old Country " who are widening their experience. Others are working elsewhere in the city and, I understand, throughout Canada. I do not wish to detract in any way from the most valuable and illuminating analysis of medicine across the Atlantic which Dr. Meiklejohn has given us ; but lest others should be discouraged from attempting to cross the seemingly unbridgeable ocean, I think it worth recording my small experience. Toronto General Hospital, R J. R. J DICKSON. D SON ICK
Canada. Ontario, Canada.
.