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RESUSCITATION AMBULANCES
415 tion. This programme should be flexible and could include both new buildings and conversion of suitable old houses. (3) Hospitals that are severely overcrowded should be given a prefabricated type of villa with a life-expectancy of ten to twenty years. These would cope with the present overcrowding which will slowly abate when the above two procedures are put into ooeration. Whixley Hospital, York.
J. NEWCOMBE.
PSYCHIATRIC UNIT IN THE DISTRICT GENERAL HOSPITAL SIR,-Whilst it is encouraging that psychiatry is becoming more integrated with general medicine, it does seem premature to claim, as does the Bonham-Carter Report,l that all psychiatric care can take place in the district general hospital. The two most recent papers, by Baker2 and Oldham,3 described the functioning of units in a general hospital serving metropolitan urban areas. It is important to recognise that these areas are ones in which there is an above-average amount of social drift and a below-average concentration of elderly people. Both factors are likely to result in an under recording of morbidity in the two major psychoses, schizophrenic and senile-conditions in which a major share of hospital beds is necessary and more floor area essential for effective therapy. The comprehensive hospital plan of the Manchester region, laudable though it is, has not resulted in.a dissolution of the vast psychiatric hospitals. It is as yet unproven that schizophrenia can be cared for as
effectively in a general-hospital setting as in the traditional psychiatric hospital milieu. The danger of the studies cited above is that this will be assumed. No mention has been made of the increasing numbers of patients dealt with under sections 60, 65, and 72 of the Mental Health Act. Are we really saying that we can manage these people on the district general hospital campus, and is it believed that the elderly brain-damaged patient with parietal-lobe symptoms will be best cared for in a restricted space on, say, the tenth floor ? It has been said that, if the district general hospital and area hospital operate concomitantly, the one must " cream off " from the other. What is important is that the patient’s needs should be adequately met, for otherwise both patient and community suffer, as Grad and Sainsbury’s studies show.44 The problem detailed above is not confined to psychiatry and the following principles of growth of the hospital service are worth consideration.
(1) That the patient is selected for the district general hospital existing area hospital according to his needs. It shall be seen that together they provide a comprehensive service. (2) That some medical and nursing staff of the district general hospital and area hospital shall be interchangeable and work in both types of hospital (rotational schemes or sessional redistribution). (3) That urgent consideration shall be given to the implementation of combined and reciprocal training schemes of nursing staff of the area and district hospitals, so that the services can be seen to be integrated, and the vast amount of specialised knowledge amongst nursing personnel of the area hospitals can be made available to the developing service. or
If these measures are adopted we shall do much to avoid two-tier level of hospital care, and, at the same time, ensure that morale is maintained in the existing peripheral
a
hospitals. Hellingly Hospital, Hailsham. Sussex.
R. MAGGS.
1. The Functions of the District General Hospital. H.M. Office, 1969. 2. Baker, A. A. Lancet, 1969, i, 1090. 3. Oldham, A. J. Br. J. Psychiat. 1969, 115, 465. 4. Grad, J., Sainsbury, P. ibid. 1968, 114, 265.
Stationery
RESUSCITATION AMBULANCES SiR,-The Brighton resuscitation ambulance was evolved almost entirely from the experience and help of Dr. Pantridge and his department. Quite obviously, we too realise that speedy resuscitation must be carried out wherever the patient may be; transport comes later. Our case-load has a different spectrum from that in Belfast. We have a disproportionate number of bathing, skindiving, and boating accidents, and of suicides. In these circumstances, I would use the ambulance, halted at the site of the incident, as a one-bed ward. We are at a disadvantage compared with Belfast, firstly because we have fewer experienced hospital staff available for clinical help and secondly because I am not sure that I have convinced all the local consultants of the value of
taking
treatment to
Health Department, Brighton, Sussex.
the
patient. W. S. PARKER.
LITHIUM TOXICITY to draw attention to some of the dangers wish SIR,-We which may be encountered with lithium even when the drug is used within the accepted range of dosage. Since the opening of our department 18 months ago, four patients have been given lithium (300 mg. twice or thrice daily) for manicdepressive psychosis (depressive phase) and for reactive depression. Subjective assessment suggests that three patients responded favourably and tolerated lithium without side-effects for a period of 6 months. The range of serum-lithium levels, on repeated determinations, was 0.50-1.50 meq. per litre. The fourth patient was a woman of 68, admitted with the primary diagnosis of involutional melancholia. She had had repeated depressive episodes during the past 15 years, for which she had been treated with antidepressants, tranquillisers, and electroconvulsive therapy (E.C.T.). As time progressed, the symptom-free periods became shorter. In addition to her mental illness, she had primary hypothyroidism (treated with maintenance L-thyroxine), maturity-onset diabetes mellitus (treated with oral hypoglycaemic agents), and essential hypertension. On admission the following features were noted: severely depressed affect, great anxiety, severe hypochrondriasis, irritability, loss of interest, insomnia with early awakening, and fully developed paranoid delusions. Lithium carbonate was started in a dose of 300 mg. thrice daily. The serum-lithium slowly increased from 0-11 meq. per litre but never exceeded 1-62 meq. During the 24 days of drug administration per litre. there was no change in the patient’s emotional illness, but, rather suddenly, her speech became slurred, her gait became unsteady and ataxic, and her level of consciousness deteriorated progressively until she was stuporose. The skin was flushed and there was evidence of dehydration. Deep tendon reflexes were hyperactive, but no focal or lateralising abnormalities of the motor and sensory systems were found. The cranial nerves appeared to be intact and the optic discs were normal. Serum-lithium was 0-88 meq. per litre. Serum sodium, potassium, and chloride were 137.0, 3-2, and 94.0 meq. per litre respectively. Blood-ureawas normal; fasting blood-sugar was raised at 154 mg. per 100 ml. Since there were no detectable neurological or metabolic abnormalities -of decisive nature her clinical state was attributed to lithium toxicity. This diagnosis received further support when lithium was withdrawn and the patient was rehvdrated she quickly regained her alertness, and the extrapyramidal signs disappeared. Thus, in one out of four patients randomly selected for lithium treatment the drug produced a serious toxic state necessitating intensive supportive care. It might be argued
nitrogen
J. NEWCOMBE.
PSYCHIATRIC UNIT IN THE DISTRICT GENERAL HOSPITAL SIR,-Whilst it is encouraging that psychiatry is becoming more integrated with general medicine, it does seem premature to claim, as does the Bonham-Carter Report,l that all psychiatric care can take place in the district general hospital. The two most recent papers, by Baker2 and Oldham,3 described the functioning of units in a general hospital serving metropolitan urban areas. It is important to recognise that these areas are ones in which there is an above-average amount of social drift and a below-average concentration of elderly people. Both factors are likely to result in an under recording of morbidity in the two major psychoses, schizophrenic and senile-conditions in which a major share of hospital beds is necessary and more floor area essential for effective therapy. The comprehensive hospital plan of the Manchester region, laudable though it is, has not resulted in.a dissolution of the vast psychiatric hospitals. It is as yet unproven that schizophrenia can be cared for as
effectively in a general-hospital setting as in the traditional psychiatric hospital milieu. The danger of the studies cited above is that this will be assumed. No mention has been made of the increasing numbers of patients dealt with under sections 60, 65, and 72 of the Mental Health Act. Are we really saying that we can manage these people on the district general hospital campus, and is it believed that the elderly brain-damaged patient with parietal-lobe symptoms will be best cared for in a restricted space on, say, the tenth floor ? It has been said that, if the district general hospital and area hospital operate concomitantly, the one must " cream off " from the other. What is important is that the patient’s needs should be adequately met, for otherwise both patient and community suffer, as Grad and Sainsbury’s studies show.44 The problem detailed above is not confined to psychiatry and the following principles of growth of the hospital service are worth consideration.
(1) That the patient is selected for the district general hospital existing area hospital according to his needs. It shall be seen that together they provide a comprehensive service. (2) That some medical and nursing staff of the district general hospital and area hospital shall be interchangeable and work in both types of hospital (rotational schemes or sessional redistribution). (3) That urgent consideration shall be given to the implementation of combined and reciprocal training schemes of nursing staff of the area and district hospitals, so that the services can be seen to be integrated, and the vast amount of specialised knowledge amongst nursing personnel of the area hospitals can be made available to the developing service. or
If these measures are adopted we shall do much to avoid two-tier level of hospital care, and, at the same time, ensure that morale is maintained in the existing peripheral
a
hospitals. Hellingly Hospital, Hailsham. Sussex.
R. MAGGS.
1. The Functions of the District General Hospital. H.M. Office, 1969. 2. Baker, A. A. Lancet, 1969, i, 1090. 3. Oldham, A. J. Br. J. Psychiat. 1969, 115, 465. 4. Grad, J., Sainsbury, P. ibid. 1968, 114, 265.
Stationery
RESUSCITATION AMBULANCES SiR,-The Brighton resuscitation ambulance was evolved almost entirely from the experience and help of Dr. Pantridge and his department. Quite obviously, we too realise that speedy resuscitation must be carried out wherever the patient may be; transport comes later. Our case-load has a different spectrum from that in Belfast. We have a disproportionate number of bathing, skindiving, and boating accidents, and of suicides. In these circumstances, I would use the ambulance, halted at the site of the incident, as a one-bed ward. We are at a disadvantage compared with Belfast, firstly because we have fewer experienced hospital staff available for clinical help and secondly because I am not sure that I have convinced all the local consultants of the value of
taking
treatment to
Health Department, Brighton, Sussex.
the
patient. W. S. PARKER.
LITHIUM TOXICITY to draw attention to some of the dangers wish SIR,-We which may be encountered with lithium even when the drug is used within the accepted range of dosage. Since the opening of our department 18 months ago, four patients have been given lithium (300 mg. twice or thrice daily) for manicdepressive psychosis (depressive phase) and for reactive depression. Subjective assessment suggests that three patients responded favourably and tolerated lithium without side-effects for a period of 6 months. The range of serum-lithium levels, on repeated determinations, was 0.50-1.50 meq. per litre. The fourth patient was a woman of 68, admitted with the primary diagnosis of involutional melancholia. She had had repeated depressive episodes during the past 15 years, for which she had been treated with antidepressants, tranquillisers, and electroconvulsive therapy (E.C.T.). As time progressed, the symptom-free periods became shorter. In addition to her mental illness, she had primary hypothyroidism (treated with maintenance L-thyroxine), maturity-onset diabetes mellitus (treated with oral hypoglycaemic agents), and essential hypertension. On admission the following features were noted: severely depressed affect, great anxiety, severe hypochrondriasis, irritability, loss of interest, insomnia with early awakening, and fully developed paranoid delusions. Lithium carbonate was started in a dose of 300 mg. thrice daily. The serum-lithium slowly increased from 0-11 meq. per litre but never exceeded 1-62 meq. During the 24 days of drug administration per litre. there was no change in the patient’s emotional illness, but, rather suddenly, her speech became slurred, her gait became unsteady and ataxic, and her level of consciousness deteriorated progressively until she was stuporose. The skin was flushed and there was evidence of dehydration. Deep tendon reflexes were hyperactive, but no focal or lateralising abnormalities of the motor and sensory systems were found. The cranial nerves appeared to be intact and the optic discs were normal. Serum-lithium was 0-88 meq. per litre. Serum sodium, potassium, and chloride were 137.0, 3-2, and 94.0 meq. per litre respectively. Blood-ureawas normal; fasting blood-sugar was raised at 154 mg. per 100 ml. Since there were no detectable neurological or metabolic abnormalities -of decisive nature her clinical state was attributed to lithium toxicity. This diagnosis received further support when lithium was withdrawn and the patient was rehvdrated she quickly regained her alertness, and the extrapyramidal signs disappeared. Thus, in one out of four patients randomly selected for lithium treatment the drug produced a serious toxic state necessitating intensive supportive care. It might be argued
nitrogen