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SUBCLAVIAN VENEPUNCTURE
1152
actually waiting it is pitals for the chronic sick was extremely poor." The unnecessary to have large depressing waiting areas. standard of meal service in large hospitals was indifferent: it was described as bad and in Sixty new outpatient departments are now being built in in 29% of larger hospitals to 34% (compared 52% in small hospitals) as good. England and Wales alone,23 and those responsible might only The causes that Platt and his colleagues identify are: do well to consider the use of automatic monitoring old-fashioned cramped kitchens; communication and systems to establish and maintain appointment schedules distribution difficulties imposed by badly planned and
Moreover, when few patients
are
in them. This is yet another
example of the use of electrical equipment to improve the efficiency of hospital service., Like some of the monitoring devices being developed for use in the wards, it should give nurses more time to help their patients. But we must not forget that all such equipment needs periodic maintenance. If capital spent on electrical equipment is not to be wasted, the National Health Service will need staff qualified in medical electronics.24
Annotations FOOD FOR PATIENTS
LAST week’s gloomy report 25 of a study of the feeding arrangements and the nutritional value of meals in hospitals in this country has understandably attracted indignant notice. Professor Platt and his two lecturers at the London School of Hygiene and Tropical Medicine have demonstrated how indifferently many of our hospitals are applying the great amount of knowledge and experience that is available to help them in their duty of feeding patients properly. The inquiry, which was sponsored by the Nuffield Provincial Hospitals Trust, included a random survey of 152 hospitals, in each of which the diet of one patient was sampled over a period of twenty-four hours, and then evaluated. The best food and the closest attention to patients’ needs were found in some of the small hospitals, mostly those with fewer than 50-60 beds. The larger the hospital the lower was the efficiency of administration and the quality of food when it was served. Excessive waste of food was often evident: only 55-60% of the food supplied was eaten by the patients, the bulk of the remainder going to swill. Cleanliness and hygiene were notably defective in many ward kitchens " where the contrast with the antiseptic and aseptic procedures of normal ward routine was sometimes remarkable ". Vegetables were often over-cooked; and delays in service marred many meals. Defects in preparation and service sometimes damaged the food, causing nearly complete loss of vitamin C in potatoes and 75% loss in green
vegetables. One cause of waste was a failure by hospitals to assess the requirements for ordinary diets on the basis of the estimated nutritional needs of patients. Failure to consider the structure of the diet as a whole tended to upset the balance of the diet. Patients with the highest requirements were inclined to eat disproportionately large amounts of their own sweets, soft drinks, fruit, and other imported delicacies. The sad story continues : " There was a lack of variety and a poor quality of food in large acute hospitals ... the quality of meals in longstay hos23. National Health Service Hospital Building, England and Wales. Progress report no. 4. H.M. Stationery Office, 1963. 24. Lancet, 1962, ii, 1365. 25. Food in Hospitals. By B. S. PLATT, T. P. EDDY, and P. L. PELLETT. London: Oxford University Press, for the Nuffield Provincial Hospitals Trust. 1963. Pp. 201. 21s.
inconvenient buildings; and faults in the organisation of catering, particularly a division of responsibility between catering officers, nursing staff, and dietitians. (" Too much depends upon administrative routine and too little upon direct observation of the patients to discover what they need, what they eat, and when they eat.") Moreover, attention is concentrated too closely on the special dietary requirements of particular diseases and upon nutrition in its relationship to specific deficiency diseases, to the exclusion of the general requirements of patients and the difficulties imposed by the restrictions of illness upon their
satisfaction. How can hospitals do better-as they plainly must? For one thing, Platt and his associates suggest that in every hospital one person should be made responsible for all aspects of hospital catering and for the supervision and control of all staff concerned with the preparation, cooking, and service of food to the patient. Usually, this responsibility would fall to the matron, catering officer, or dietitian. A new kind of auxiliary is envisaged-a ward caterer, who would be under the control of the ward sister and would cooperate with the nursing staff in the care and attention to feeding of patients. Dietary scales should be formulated to meet the predicted nutritional requirements of different types of patient. The status of catering officers should be raised, and more catering staff should receive instruction in dietetics and take part in the serving and distribution of food to patients. Dietitians should be less exclusively interested in the provision of special diets-they should be concerned more with
everyday problems
of
hospital catering.
SUBCLAVIAN VENEPUNCTURE
THE insertion of an indwelling needle or cannula into a vein is an everyday event in a hospital ward; all the more reason for the method to be simple, safe, and speedy. For this, the operator must be able to see where the needle is going. Because the veins of the arm and the forearm are easily seen and readily accessible, these are commonly used. If the veins are collapsed, or if the patient is fat and they cannot be seen or felt, patience and a little skill will almost always overcome the difficulty; and, in an emergency when these fail, a cut-down is justifiable. If, owing to thrombophlebitis, the vein is obstructed, another vein in the same arm or in the other arm can be used; indeed, when infusion must be continued for long, thrombophlebitis can often be averted by the addition of small amounts of heparin to the infusion fluids. There is much, then, to be said for the accepted practice of resorting to the veins of the arm for intravenous therapy; but elsewhere in this issue the use in certain circumstances of the subclavian vein for this purpose and for monitoring venous pressure is advocated. Dr. Ashbaugh and Mr. Thomson, after practice on cadavers, gave fluids through this vein to 19 patients; and, except for a pneumothorax in 1 patient, there were no complications. These workers believe that subclavian venepuncture may be suitably undertaken when for one reason or another the arm veins cannot be used; but they add that anatomical
1153 further studies (supported by the British Heart Foundahis the Dr. and coworkers Davidson tion) of cardiovascular disease in animals, including an adopted procedures. in for 83 intravenous subclavian approach patients therapy analysis of their nutritional background. Clinical chemical to obtain blood for biochemical and in 17 patients analysis. data will also be collected from as many species as possible; not found on 6 in could be occasions The vein (5 the first and a third subject will be disorders of the nervous system was 20 patients); a pneumothorax produced in 1 patient in stress and shock. Later work will include a survey of who had had an operation for bilateral vagotomy and pathogenic and " silent " viruses in wild animals and their pyloroplasty the day before; and hsematomas formed in relation to cancer. The new building, designed by Prof. Richard Llewelyn 3 patients. There were no other complications, but this warn of the of Davies and Mr. John Musgrove, will house three departof workers hazard airpotential group embolism. ments-pathology (under the society’s pathologist, Mr. The weightiest objection to the subclavian route for R. N. T.-W.-Fiennes), chemistry, and infectious diseases. intravenous medication is that the operator cannot see The apparatus within will include X-ray equipment, an electron microscope, and facilities for the use of radiowhere the needle is going, and the vein is surrounded by structures. is an added burden active materials. The basement will contain large workPneumothorax important to an already ill patient, and, although hxmatomas are shops where workers may devise their own equipment. The Institute will be an exciting new element in common enough in arm-vein infusions, they are more in the dealt with the arm than in readily non-compressible cooperative research; and it will certainly draw workers of the neck where the root brachial plexus and stellate from many countries and disciplines. To those organisaganglion lie close to the vein. Ashbaugh and Thomson tions whose support the society seeks in this important mention as an advantage that fluids and blood can be venture, we warmly commend the appeal. administered rapidly through the subclavian vein. But the volume of fluid delivered into a vein is determined by the CHILD VICTIMS OF SEX OFFENCES diameter of the cannula and not by the size of the vein; and if the cannula is inserted through a needle (as it must THE theme of the pamphlet on this subject by Dr. be, in the case of the subclavian vein) this can scarcely T. C. N. Gibbens and Miss Joyce Prince1 can almost be exceed the diameter of the needles used ordinarily in armsummarised in one of the phrases they use when disvein infusions. Also, the introduction of a plastic cannula cussing two pregnant girls victimised by strangers: through a needle which is then withdrawn sometimes ends " There is little doubt that many girls can make a good in the disappearance of part of the tube into the vein.If recovery from a disaster of this kind, if given the peace the vein is the subclavian, the cannula will almost certainly to do so." Yet the present law requires interrogation by the police, often more than once, a medical examination, pass into the right atrium. Again, thrombophlebitis in this situation is likely to arouse greater anxiety than when it perhaps giving evidence in a magistrate’s court in the affects the veins of the arm and forearm. presence of the assailant, and then a delay of two to three Subclavian venepuncture demands skill and practice; months before the trial at a higher court. Appearance in so, of course, does arm-vein infusion. But if, as both court, however, is not the main cause of harm. It is subclavian should be assure rather that such appearance leads the parents, and indeed us, venepuncture groups reserved for exceptional circumstances, the acquisition of the whole local community, to create an atmosphere, the necessary skill may prove very difficult. And, even if lasting for weeks or months, which turns the child’s ideas this difficulty is overcome, the clinical benefit may prove " towards an adult interpretation of the offence and its no more than marginal. punishment ", and that she has to adjust to an altered attitude within the family circle. It is well known to moral welfare workers that a child may appear to be " NUFFIELD INSTITUTE OF COMPARATIVE MEDICINE wonderfully brave " in court, only to develop severe at home after the trial is over; and Dr. disturbances THE systematic study of disease in animals has contriand his colleague emphasise that the behaviour Gibbens buted much to medical progress and it can clearly do much of the family is the main source of difficulty. Indeed in more. To speed this work, the Nuffield Foundation gave section of the pamphlet on child victims and parents, a the Zoological Society of London E140,000 towards the forward convincing arguments that, quite apart they put cost of building and equipping an Institute of Comparative such obvious from examples as incest, the parents are and the is half finished on a Medicine; building already site adjoining the society’s offices in Regent’s Park. themselves responsible by negligence, inconsistency, and Sl 10,000 of the cost is being found by the Zoological cruelty in their methods of upbringing for producing Society, but another E100,000 is needed for capital a cooperative victim, if this paradoxical description may equipment and E200,000 for operating costs in the first be used. An inquiry made possible by the cooperation of few years. An appeal committee, under the chairmanship the Federation of Committees for the Moral Welfare of Children showed that in only 27% of families of a child of Mr. Archibald Chisholm, is therefore at work to raise this further sum, and they will be in touch with scientific, victim was it possible to describe the home background " professional, industrial, and commercial organisations who as all well ". Clearly there is a place for more preventive work in may be able to help. The operating costs of the Institute general, perhaps at the infant-welfare level as suggested when it is fully under way are put at E50,000 a year, and a in a Harben lecture2 earlier this year, and also for " an substantial endowment is to be raised to secure these officer trained in social casework and child welfare " to costs in perpetuity and to provide research fellowships. work with the family after the legal proceedings to try to As its director designate, Dr. L. G. Goodwin, put it, lessen the effect on the child. Fundamentally, however, the difficulty in planning the work of the Institute is what not to do first. Among the earliest projects will be 1. Institute for the Study and Treatment of Delinquency, 8, Bourdon
variations and gross obesity may call for alternative
,
1.
Lancet, 1963, i,
762.
2.
Street, London, W.1. 1963. 2s. Moncrieff, A. J. R. Inst. Publ. Hlth, March, 1963, p. 65.
actually waiting it is pitals for the chronic sick was extremely poor." The unnecessary to have large depressing waiting areas. standard of meal service in large hospitals was indifferent: it was described as bad and in Sixty new outpatient departments are now being built in in 29% of larger hospitals to 34% (compared 52% in small hospitals) as good. England and Wales alone,23 and those responsible might only The causes that Platt and his colleagues identify are: do well to consider the use of automatic monitoring old-fashioned cramped kitchens; communication and systems to establish and maintain appointment schedules distribution difficulties imposed by badly planned and
Moreover, when few patients
are
in them. This is yet another
example of the use of electrical equipment to improve the efficiency of hospital service., Like some of the monitoring devices being developed for use in the wards, it should give nurses more time to help their patients. But we must not forget that all such equipment needs periodic maintenance. If capital spent on electrical equipment is not to be wasted, the National Health Service will need staff qualified in medical electronics.24
Annotations FOOD FOR PATIENTS
LAST week’s gloomy report 25 of a study of the feeding arrangements and the nutritional value of meals in hospitals in this country has understandably attracted indignant notice. Professor Platt and his two lecturers at the London School of Hygiene and Tropical Medicine have demonstrated how indifferently many of our hospitals are applying the great amount of knowledge and experience that is available to help them in their duty of feeding patients properly. The inquiry, which was sponsored by the Nuffield Provincial Hospitals Trust, included a random survey of 152 hospitals, in each of which the diet of one patient was sampled over a period of twenty-four hours, and then evaluated. The best food and the closest attention to patients’ needs were found in some of the small hospitals, mostly those with fewer than 50-60 beds. The larger the hospital the lower was the efficiency of administration and the quality of food when it was served. Excessive waste of food was often evident: only 55-60% of the food supplied was eaten by the patients, the bulk of the remainder going to swill. Cleanliness and hygiene were notably defective in many ward kitchens " where the contrast with the antiseptic and aseptic procedures of normal ward routine was sometimes remarkable ". Vegetables were often over-cooked; and delays in service marred many meals. Defects in preparation and service sometimes damaged the food, causing nearly complete loss of vitamin C in potatoes and 75% loss in green
vegetables. One cause of waste was a failure by hospitals to assess the requirements for ordinary diets on the basis of the estimated nutritional needs of patients. Failure to consider the structure of the diet as a whole tended to upset the balance of the diet. Patients with the highest requirements were inclined to eat disproportionately large amounts of their own sweets, soft drinks, fruit, and other imported delicacies. The sad story continues : " There was a lack of variety and a poor quality of food in large acute hospitals ... the quality of meals in longstay hos23. National Health Service Hospital Building, England and Wales. Progress report no. 4. H.M. Stationery Office, 1963. 24. Lancet, 1962, ii, 1365. 25. Food in Hospitals. By B. S. PLATT, T. P. EDDY, and P. L. PELLETT. London: Oxford University Press, for the Nuffield Provincial Hospitals Trust. 1963. Pp. 201. 21s.
inconvenient buildings; and faults in the organisation of catering, particularly a division of responsibility between catering officers, nursing staff, and dietitians. (" Too much depends upon administrative routine and too little upon direct observation of the patients to discover what they need, what they eat, and when they eat.") Moreover, attention is concentrated too closely on the special dietary requirements of particular diseases and upon nutrition in its relationship to specific deficiency diseases, to the exclusion of the general requirements of patients and the difficulties imposed by the restrictions of illness upon their
satisfaction. How can hospitals do better-as they plainly must? For one thing, Platt and his associates suggest that in every hospital one person should be made responsible for all aspects of hospital catering and for the supervision and control of all staff concerned with the preparation, cooking, and service of food to the patient. Usually, this responsibility would fall to the matron, catering officer, or dietitian. A new kind of auxiliary is envisaged-a ward caterer, who would be under the control of the ward sister and would cooperate with the nursing staff in the care and attention to feeding of patients. Dietary scales should be formulated to meet the predicted nutritional requirements of different types of patient. The status of catering officers should be raised, and more catering staff should receive instruction in dietetics and take part in the serving and distribution of food to patients. Dietitians should be less exclusively interested in the provision of special diets-they should be concerned more with
everyday problems
of
hospital catering.
SUBCLAVIAN VENEPUNCTURE
THE insertion of an indwelling needle or cannula into a vein is an everyday event in a hospital ward; all the more reason for the method to be simple, safe, and speedy. For this, the operator must be able to see where the needle is going. Because the veins of the arm and the forearm are easily seen and readily accessible, these are commonly used. If the veins are collapsed, or if the patient is fat and they cannot be seen or felt, patience and a little skill will almost always overcome the difficulty; and, in an emergency when these fail, a cut-down is justifiable. If, owing to thrombophlebitis, the vein is obstructed, another vein in the same arm or in the other arm can be used; indeed, when infusion must be continued for long, thrombophlebitis can often be averted by the addition of small amounts of heparin to the infusion fluids. There is much, then, to be said for the accepted practice of resorting to the veins of the arm for intravenous therapy; but elsewhere in this issue the use in certain circumstances of the subclavian vein for this purpose and for monitoring venous pressure is advocated. Dr. Ashbaugh and Mr. Thomson, after practice on cadavers, gave fluids through this vein to 19 patients; and, except for a pneumothorax in 1 patient, there were no complications. These workers believe that subclavian venepuncture may be suitably undertaken when for one reason or another the arm veins cannot be used; but they add that anatomical
1153 further studies (supported by the British Heart Foundahis the Dr. and coworkers Davidson tion) of cardiovascular disease in animals, including an adopted procedures. in for 83 intravenous subclavian approach patients therapy analysis of their nutritional background. Clinical chemical to obtain blood for biochemical and in 17 patients analysis. data will also be collected from as many species as possible; not found on 6 in could be occasions The vein (5 the first and a third subject will be disorders of the nervous system was 20 patients); a pneumothorax produced in 1 patient in stress and shock. Later work will include a survey of who had had an operation for bilateral vagotomy and pathogenic and " silent " viruses in wild animals and their pyloroplasty the day before; and hsematomas formed in relation to cancer. The new building, designed by Prof. Richard Llewelyn 3 patients. There were no other complications, but this warn of the of Davies and Mr. John Musgrove, will house three departof workers hazard airpotential group embolism. ments-pathology (under the society’s pathologist, Mr. The weightiest objection to the subclavian route for R. N. T.-W.-Fiennes), chemistry, and infectious diseases. intravenous medication is that the operator cannot see The apparatus within will include X-ray equipment, an electron microscope, and facilities for the use of radiowhere the needle is going, and the vein is surrounded by structures. is an added burden active materials. The basement will contain large workPneumothorax important to an already ill patient, and, although hxmatomas are shops where workers may devise their own equipment. The Institute will be an exciting new element in common enough in arm-vein infusions, they are more in the dealt with the arm than in readily non-compressible cooperative research; and it will certainly draw workers of the neck where the root brachial plexus and stellate from many countries and disciplines. To those organisaganglion lie close to the vein. Ashbaugh and Thomson tions whose support the society seeks in this important mention as an advantage that fluids and blood can be venture, we warmly commend the appeal. administered rapidly through the subclavian vein. But the volume of fluid delivered into a vein is determined by the CHILD VICTIMS OF SEX OFFENCES diameter of the cannula and not by the size of the vein; and if the cannula is inserted through a needle (as it must THE theme of the pamphlet on this subject by Dr. be, in the case of the subclavian vein) this can scarcely T. C. N. Gibbens and Miss Joyce Prince1 can almost be exceed the diameter of the needles used ordinarily in armsummarised in one of the phrases they use when disvein infusions. Also, the introduction of a plastic cannula cussing two pregnant girls victimised by strangers: through a needle which is then withdrawn sometimes ends " There is little doubt that many girls can make a good in the disappearance of part of the tube into the vein.If recovery from a disaster of this kind, if given the peace the vein is the subclavian, the cannula will almost certainly to do so." Yet the present law requires interrogation by the police, often more than once, a medical examination, pass into the right atrium. Again, thrombophlebitis in this situation is likely to arouse greater anxiety than when it perhaps giving evidence in a magistrate’s court in the affects the veins of the arm and forearm. presence of the assailant, and then a delay of two to three Subclavian venepuncture demands skill and practice; months before the trial at a higher court. Appearance in so, of course, does arm-vein infusion. But if, as both court, however, is not the main cause of harm. It is subclavian should be assure rather that such appearance leads the parents, and indeed us, venepuncture groups reserved for exceptional circumstances, the acquisition of the whole local community, to create an atmosphere, the necessary skill may prove very difficult. And, even if lasting for weeks or months, which turns the child’s ideas this difficulty is overcome, the clinical benefit may prove " towards an adult interpretation of the offence and its no more than marginal. punishment ", and that she has to adjust to an altered attitude within the family circle. It is well known to moral welfare workers that a child may appear to be " NUFFIELD INSTITUTE OF COMPARATIVE MEDICINE wonderfully brave " in court, only to develop severe at home after the trial is over; and Dr. disturbances THE systematic study of disease in animals has contriand his colleague emphasise that the behaviour Gibbens buted much to medical progress and it can clearly do much of the family is the main source of difficulty. Indeed in more. To speed this work, the Nuffield Foundation gave section of the pamphlet on child victims and parents, a the Zoological Society of London E140,000 towards the forward convincing arguments that, quite apart they put cost of building and equipping an Institute of Comparative such obvious from examples as incest, the parents are and the is half finished on a Medicine; building already site adjoining the society’s offices in Regent’s Park. themselves responsible by negligence, inconsistency, and Sl 10,000 of the cost is being found by the Zoological cruelty in their methods of upbringing for producing Society, but another E100,000 is needed for capital a cooperative victim, if this paradoxical description may equipment and E200,000 for operating costs in the first be used. An inquiry made possible by the cooperation of few years. An appeal committee, under the chairmanship the Federation of Committees for the Moral Welfare of Children showed that in only 27% of families of a child of Mr. Archibald Chisholm, is therefore at work to raise this further sum, and they will be in touch with scientific, victim was it possible to describe the home background " professional, industrial, and commercial organisations who as all well ". Clearly there is a place for more preventive work in may be able to help. The operating costs of the Institute general, perhaps at the infant-welfare level as suggested when it is fully under way are put at E50,000 a year, and a in a Harben lecture2 earlier this year, and also for " an substantial endowment is to be raised to secure these officer trained in social casework and child welfare " to costs in perpetuity and to provide research fellowships. work with the family after the legal proceedings to try to As its director designate, Dr. L. G. Goodwin, put it, lessen the effect on the child. Fundamentally, however, the difficulty in planning the work of the Institute is what not to do first. Among the earliest projects will be 1. Institute for the Study and Treatment of Delinquency, 8, Bourdon
variations and gross obesity may call for alternative
,
1.
Lancet, 1963, i,
762.
2.
Street, London, W.1. 1963. 2s. Moncrieff, A. J. R. Inst. Publ. Hlth, March, 1963, p. 65.