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PREVENTION OF VENOUS THROMBOSIS AND PULMONARY EMBOLISM IN INJURED PATIENTS
1411
direct
relationship
to
the presence of
unconjugated
plasma-ETio. This
study
was
aided by grants from the National Institute of
Arthritis and Metabolic Diseases. Department of Pediatrics, State University of New York, Syracuse, New York.
FRANCISCO BEAS JOSÉ CARA LYTT I. GARDNER.
PRACTICE IN SASKATCHEWAN SIR,-Your note on the proposed medical care scheme for Saskatchewan (June 23, p. 1363) raises a point of great importance. I have examined the Acts concerned, and I think the method of payment is fair. It is by feefor-service on a generous scale, with refunds of the amounts paid, to the patient. Thus the doctor is not immediately involved. The hardship, if hardship it can be called, is that doctors who overcharge are penalised by having to refund the excess charged. There is, however, one subsection of the Amending Act-clause 49(1)g-to which exception can be taken. It appears to give the Government unlimited powers of direction over the way doctors practise. If the Government of Saskatchewan is prepared to repeal this subsection, I do not think any fair-minded doctor need feel scruples about participating in the scheme. House of
Lords,
London, S.W.1.
TAYLOR.
SIR,-The passage you quoted (June 23, p. 1363) from the article by Dr. Gilder in your issue of May 19 was as follows: " On July 1 it will become illegal for a doctor to practise in Saskatchewan except through the agency of a Government commission, and it has even been suggested that a physician who announces now to his patients that he will not be participating in the official scheme for compulsory health insurance is liable to prosecution, since he is announcing his intention to break the law of the land." A cable from Mr. D. D. Tansley, chairman of the Saskatchewan Medical Care Insurance Commission, states:
" There is nothing in Medical Care Insurance Act which makes it illegal to practise medicine privately where the patient wishes to pay the bill on his behalf. There is no penalty of any kind enforceable against a doctor who wishes to limit his practice to such private arrangements. The agency provision to which Dr. Gilder refers is a common one in insurance law in North America. The Statute states that the Medical Care Commission is the agent of an insured patient in matters related to the payment of a doctor’s bill. Any patient who wishes may withdraw from this arrangement upon application. " The agency clause permits the Commission to do three things: first, to obtain the information necessary to pay a patient’s bill; second, to pay the bill; and third, to represent the patient in any dispute which arises over payment of a bill. This is all it does. May I point out that none of this applies to the patient who wants to pay his own bill. He may say at any time with respect to any treatment that the commission is not his agent. On Thursday last (June 21) Premier W. S. Lloyd made the following statement which should clarify the Government’s position: We are anxious to assure to all citizens the right to secure physician’s services either inside or outside the plan as the citizen may choose and to assure to all physicians the right to render physician’s services either inside or outside the plan as the physicians may choose with the sole proviso that the right would not be used to impair the rights of citizens using the public plan. We believe the present Act permits the exercise of these rights and it will be administered in this way but if there be doubt on this point we are willing to consider "
suggested changes in the Act or the regulations which would be consistent with these two principles.’ " In this same statement Mr. Lloyd offered, given certain assurances by the medical profession, to remove from the Act the agency provision referred to above." any
GRAHAM SPRY Saskatchewan House, London, S.W.1.
Agent General for the Government of Saskatchewan in the United Kingdom and Europe.
PREVENTION OF VENOUS THROMBOSIS AND PULMONARY EMBOLISM IN INJURED PATIENTS SIR,-Thromboembolism is not an act of God, and Dr. Sevitt (June 23) is to be congratulated for once again our attention to the possibility of its prevention. drawing " Treatment should be begun on the day of admission ... and be continued during the whole period of venous stasis, that is, the period of bed rest and restricted mobility and until the patient is reasonably and independently
mobile." This principle is admirable and perhaps there is a simpler alternative to prolonged anticoagulant therapy. In
cases (1952-59) of fractured neck of be published shortly, there were 35 cases of thromboembolus (8-7%), which included 15 cases of pulmonary embolus (3-7%), and 13 were of sudden onset a
survey of 400
femur,
to
(3-2%). During the past two years the problem as follows:
we
have
attempted
to
tackle
As soon as the patient arrives in hospital, full-length elastic stockings are fitted to both legs and retained continuously through operation and early ambulation, until the patient is walking normally again. At Fulham Hospital during the year 1961 there were 25
of fractured neck of femur treated in this way. There of pulmonary embolus and only 1 case of mild calf tenderness with no clinical evidence of oedema of the affected limb. Statistically the method is still unproven, but appears worth a trial. cases
were no cases
LIPMANN KESSEL ALEXANDER KATZ.
Fulham
Hospital, London, W.6.
ANTICOAGULANTS IN ACUTE MYOCARDIAL INFARCTION
SIR,-In his third letter (May 5) Professor Holten again expresses the belief that we had too many cases of bleeding in our treated cases, and he is not satisfied with our contention that all larger series contain a certain number of cases of severe bleeding and usually deaths from bleeding ". Surely this statement is supported by the papers we quoted (March 31) including Holten’s own "
paper. Holten specifically mentions 1586 cases of Hunter and Walker with a bleeding-rate of 4%. Unfortunately it is impossible to see from this paper whether cases of myocardial infarction were included, or how bleeding cases were registered. We wish to reiterate that every case of bleeding in our series was registered, because registration was planned in detail before the study began. Once again Holten is critical of our findings that anticoagulant treatment of acute myocardial infarction did not reduce mortality, although thromboembolism was greatly reduced. This phenomenon, he says, is unique. Holten will know from one of our answers1 to his four letters published in Danish that Wright et al.2had exactly the same experienceof 536 patients with acute myocardial infarction in the agegroup 40-60, 312 received treatment, and 224 did not. The 1. 2.
Hilder, T., Iversen, K., Raaschou, F., Schwartz, M. Ugeskr. Lœg. 1961, 123, 1434. Wright, I. S., Marble, C. D., Beck, D. F. Myocardial Infarction; pp. 319, 555. New York, 1954.
direct
relationship
to
the presence of
unconjugated
plasma-ETio. This
study
was
aided by grants from the National Institute of
Arthritis and Metabolic Diseases. Department of Pediatrics, State University of New York, Syracuse, New York.
FRANCISCO BEAS JOSÉ CARA LYTT I. GARDNER.
PRACTICE IN SASKATCHEWAN SIR,-Your note on the proposed medical care scheme for Saskatchewan (June 23, p. 1363) raises a point of great importance. I have examined the Acts concerned, and I think the method of payment is fair. It is by feefor-service on a generous scale, with refunds of the amounts paid, to the patient. Thus the doctor is not immediately involved. The hardship, if hardship it can be called, is that doctors who overcharge are penalised by having to refund the excess charged. There is, however, one subsection of the Amending Act-clause 49(1)g-to which exception can be taken. It appears to give the Government unlimited powers of direction over the way doctors practise. If the Government of Saskatchewan is prepared to repeal this subsection, I do not think any fair-minded doctor need feel scruples about participating in the scheme. House of
Lords,
London, S.W.1.
TAYLOR.
SIR,-The passage you quoted (June 23, p. 1363) from the article by Dr. Gilder in your issue of May 19 was as follows: " On July 1 it will become illegal for a doctor to practise in Saskatchewan except through the agency of a Government commission, and it has even been suggested that a physician who announces now to his patients that he will not be participating in the official scheme for compulsory health insurance is liable to prosecution, since he is announcing his intention to break the law of the land." A cable from Mr. D. D. Tansley, chairman of the Saskatchewan Medical Care Insurance Commission, states:
" There is nothing in Medical Care Insurance Act which makes it illegal to practise medicine privately where the patient wishes to pay the bill on his behalf. There is no penalty of any kind enforceable against a doctor who wishes to limit his practice to such private arrangements. The agency provision to which Dr. Gilder refers is a common one in insurance law in North America. The Statute states that the Medical Care Commission is the agent of an insured patient in matters related to the payment of a doctor’s bill. Any patient who wishes may withdraw from this arrangement upon application. " The agency clause permits the Commission to do three things: first, to obtain the information necessary to pay a patient’s bill; second, to pay the bill; and third, to represent the patient in any dispute which arises over payment of a bill. This is all it does. May I point out that none of this applies to the patient who wants to pay his own bill. He may say at any time with respect to any treatment that the commission is not his agent. On Thursday last (June 21) Premier W. S. Lloyd made the following statement which should clarify the Government’s position: We are anxious to assure to all citizens the right to secure physician’s services either inside or outside the plan as the citizen may choose and to assure to all physicians the right to render physician’s services either inside or outside the plan as the physicians may choose with the sole proviso that the right would not be used to impair the rights of citizens using the public plan. We believe the present Act permits the exercise of these rights and it will be administered in this way but if there be doubt on this point we are willing to consider "
suggested changes in the Act or the regulations which would be consistent with these two principles.’ " In this same statement Mr. Lloyd offered, given certain assurances by the medical profession, to remove from the Act the agency provision referred to above." any
GRAHAM SPRY Saskatchewan House, London, S.W.1.
Agent General for the Government of Saskatchewan in the United Kingdom and Europe.
PREVENTION OF VENOUS THROMBOSIS AND PULMONARY EMBOLISM IN INJURED PATIENTS SIR,-Thromboembolism is not an act of God, and Dr. Sevitt (June 23) is to be congratulated for once again our attention to the possibility of its prevention. drawing " Treatment should be begun on the day of admission ... and be continued during the whole period of venous stasis, that is, the period of bed rest and restricted mobility and until the patient is reasonably and independently
mobile." This principle is admirable and perhaps there is a simpler alternative to prolonged anticoagulant therapy. In
cases (1952-59) of fractured neck of be published shortly, there were 35 cases of thromboembolus (8-7%), which included 15 cases of pulmonary embolus (3-7%), and 13 were of sudden onset a
survey of 400
femur,
to
(3-2%). During the past two years the problem as follows:
we
have
attempted
to
tackle
As soon as the patient arrives in hospital, full-length elastic stockings are fitted to both legs and retained continuously through operation and early ambulation, until the patient is walking normally again. At Fulham Hospital during the year 1961 there were 25
of fractured neck of femur treated in this way. There of pulmonary embolus and only 1 case of mild calf tenderness with no clinical evidence of oedema of the affected limb. Statistically the method is still unproven, but appears worth a trial. cases
were no cases
LIPMANN KESSEL ALEXANDER KATZ.
Fulham
Hospital, London, W.6.
ANTICOAGULANTS IN ACUTE MYOCARDIAL INFARCTION
SIR,-In his third letter (May 5) Professor Holten again expresses the belief that we had too many cases of bleeding in our treated cases, and he is not satisfied with our contention that all larger series contain a certain number of cases of severe bleeding and usually deaths from bleeding ". Surely this statement is supported by the papers we quoted (March 31) including Holten’s own "
paper. Holten specifically mentions 1586 cases of Hunter and Walker with a bleeding-rate of 4%. Unfortunately it is impossible to see from this paper whether cases of myocardial infarction were included, or how bleeding cases were registered. We wish to reiterate that every case of bleeding in our series was registered, because registration was planned in detail before the study began. Once again Holten is critical of our findings that anticoagulant treatment of acute myocardial infarction did not reduce mortality, although thromboembolism was greatly reduced. This phenomenon, he says, is unique. Holten will know from one of our answers1 to his four letters published in Danish that Wright et al.2had exactly the same experienceof 536 patients with acute myocardial infarction in the agegroup 40-60, 312 received treatment, and 224 did not. The 1. 2.
Hilder, T., Iversen, K., Raaschou, F., Schwartz, M. Ugeskr. Lœg. 1961, 123, 1434. Wright, I. S., Marble, C. D., Beck, D. F. Myocardial Infarction; pp. 319, 555. New York, 1954.