- Email: [email protected]
THE VALUE OF ANÆSTHESIA OUTPATIENT CLINICS
446 or oxygen consumption. The drugs, then, did their inhibitory effect at the energy-production stage-an observation confirmed by Glynn .20 Using the movement of potassium as a mirror of the sodium pump’s effectiveness, Joyce and Weatherall 21 showed that relatively large doses of digitoxin (10 mg. per kg.) inhibited the rate of ion exchange. Soon, it became clear that, in suitable concentrations, many other cardiac glycosides could inhibit the cellular movements of potassium and sodium.22 Since Shatzmann ls 23 had shown that energy production was not the stage affected by the drugs, two alternatives remained: the glycosides could act (a) by preventing energy released during glycolysis from reaching the ionic pump (e.g., by inactivating adenosine triphosphate), or (b) by interfering with the carrier mechanism. If the former were true then only those cation fluxes dependent on the presence of glucose would be altered by digitalis. But Glynn showed that the same flux effects could be demonstrated even if the cells were deprived of glucose.24 On the other hand, digitalis directly inhibits sodium efflux in the proximal tubule. 23 Thus, at least one direct diuretic action of digitalis affects the carrier mechanism. Recently, Strickler and Kessler 25 have noted that only with a specific chemical compositionglycosides " a having C-17, B oriented lactone ring unsaturated in the a-B position "-have direct diuretic properties. This same chemical form is necessary to the glycosides’ cardiac effects. The possible importance of the structural similarity of digitalis and the corticosteroids was first noted by Farber et a1.14 They postulated a diuretic mechanism . based on competition between digitalis and " some desoxycorticosterone-like hormone " that acted as a saltretainer in the cells of the renal tubules. The following year, when aldosterone was isolated, this hypothesis was investigated .26 27 But attempts to isolate a glycoside with predominantly renal and negligible cardiac effects have met with no success.28 There are several basic objections to this antialdosterone theory of the diuretic action of digitalis.25 Whereas aldosterone stimulates the reabsorption of less than 2-3% of the filtered sodium load, the injection of active cardiac glycosides into one renal artery resulted in 35-40% of the filtered sodium load appearing in the urine. Thus, direct inhibition of the ion-transport system in the proximal tubule remains the best current explanation of the direct diuretic effect of digitalis.
formation not exert
*
*
*
Attempts to elucidate the cellular and subcellular renal mechanism of digitalis action are a long way from the empirical use of the drug in the 18th century, a long way from conflicts about its systemic mode of action, a long way even from awareness of its direct renal action. But need for further investigation remains. Studies are required in the spheres of structural chemistry, of hormonal mechanisms in cation control, and of human pharmacology in the various disease states characterised by excessive fluid retention. These would provide the cardiologist with a clearer physiological concept of the exact renal action of his most important drug. 20. 21. 22. 23. 24. 25. 26. 27. 28.
Glynn, I. J. Physiol. 1955, 128, 55P. Joyce, C., Weatherall, M. ibid. 1955, 127, 33P. Kahn, J., Acheson, G. J. Pharmacol. 1953, 115, 305. Shatzmann, H., Windhager, H., Solomon, A. Amer. J. Physiol. 1958, 195, 570. Glynn, I. J. Physiol. 1957, 136, 148. Strickler, J., Kessler, R. J. clin. Invest. 1961, 40, 311. Kawaga, C., Cella, J., Vanarman, C. Science, 1957, 126, 1015. Liddle, G. ibid. p. 1016. Drill, V. A., Riegel, B. Rec. Progr. Hormone Res. 1958, 14, 29.
THE VALUE OF ANÆSTHESIA OUTPATIENT CLINICS VERNON R. KEEP M.R.C.S., D.A. ANESTHETIC REGISTRAR TO THE HASTINGS HOSPITAL GROUP *
THE specialty of anaesthesiology has progressed rapidly in the last two decades, and the more widespread use of anxsthesia outpatient clinics has produced some unfavourable comment from the less well informed members of our profession, usually with vague references to " empire building ". The purpose of this paper is to show the value of this relatively new function of the anaesthetist to the patient, the surgeon, the hospital, and not least to the anaesthetist. For many years it has been the prerogative of the physician-it still is in some hospitals-to examine the patient for his fitness to undergo surgery under anxsthesia. But the physician of today cannot possibly keep abreast of advances in modern anaesthesia, and he is usually the first to admit his unsuitability for this task. The general surgeons of the past are vanishing; we now have specialisation within a specialty, and many of the younger entrants have only a limited knowledge and experience of disease outside their own narrow fields. The penalty we pay for this overspecialisation is that patients may be operated on when they are not fit or when some disability may have been missed (Green and Howat The anaesthetist can contribute in preparing the patient for safer surgery by careful preoperative examination of the patient as a whole. To expect to achieve this in a hurried examination the night before operation, at the end of a day’s work, is unreasonable; but if a session or two is set aside for outpatient clinics much will be gained. The first duty of the anaesthetist is to assure himself that the patient is as fit as possible for surgery. If he is not, the anaesthetist should institute immediate investigation and treatment of the condition, or, if this is beyond his scope, he should refer the patient to his specialist colleagues. The clinic should never function as a second-class medical outpatients (Lee 1949), and there is no shame in admitting an inability to diagnose or treat the more obscure pathological processes. Individuality should be sacrificed for teamwork. Many surgeons are today working at a far from leisurely pace, and their waiting-lists may be long. The amount of time devoted to each case may be limited. The patient may be momentarily confused by the news of contemplated surgery and may fail to absorb the surgeon’s remarks as to the nature of the operation; probably by the time this has been assimilated the next patient is being seen, and a solid door separates the first patient from the surgeon. A talk with the anaesthetist gives the patient a second chance to learn what is going to happen to him, and to ask the questions which the surgeon has little time to answer fully. Many of the elderly patients will be coming into hospital for the first time in their lives, and the anaesthetist is the ideal person to put their fears at rest with reassurance and explanation. This can be a most important function of the anaesthetic clinic, not only for the patient but also for the anxsthetist, because successful reassurance and premedication help greatly in smooth induction. The patient may have definite views about the choice between general and local anaesthesia and Lee (1949) has pointed out that the patient’s preference should be considered. Often a patient asks for an unsuitable type of
1952).
*
Present address:
Royal
Perth
Hospital, Western Australia.
447
anesthesia. The anaesthetist must then take time to explain and give the patient confidence in the alternative method. We have no
right to ignore a patient’s intelligent request. ADVANTAGES
To the Patient
the patient of this early is one of reassurance. anaesthetist meeting with the Patients are far more impressed by what the anaesthetist says to them, by how much he hurts them, and by how much he appears to understand their individual difficulties than by the most skilful acts he can practise on their unconscious bodies (Karp 1957). Many patients are overjoyed to be pronounced fit for an anaesthetic. Hidden fears about the condition of [their hearts and lungs may come to light during the medical examination, and reassurance often causes them to leave the outpatient department greatly unburdened of their worries. A not uncommon complaint of patients who have had anaesthetics is postoperative sickness. Knowledge of the drugs previously used for premedication will often reveal a likely cause and steps;may be taken to ensure an uneventful recovery at the next anaesthesia. This presupposes accurate records of previous anaesthetics and a cumulative record system for closed communities or special units, as described by Middleton (1958). One disadvantage for the patients is that they probably have to make a second visit to the hospital before admission, but this is a small matter if increased efficiency and safer anaesthesia results. Not all the anxsthetists can see the patients they will personally anaesthetise, although this is the ideal it is difficult to arrange in practice. The
To the
principal advantage
to
Surgeon
The surgeon profits by the anaathesia outpatient clinic because he knows, when he arranges his operating-list for the next day, he will rarely find that the first major case has been postponed by the anaesthetist with a consequent waste of two hours’ operating-time. Few surgeons have as many beds as they would like, and the anaesthetist can divert cases which require long preoperative medical treatment from them so that the maximum use of the acute surgical beds is obtained. It is an advantage also for the surgeon and the anxsthetist to discuss a difficult case together at an early stage, so that the patient’s operation is not delayed. To the Anaesthetist The anaesthetist in these circumstances has first-hand knowledge of his patients, and knows they are having their operation under the best conditions, for he has had ample time to choose the best anaesthetic for the difficult case, and arrange special apparatus if required. An advantage to the anxsthetist-not immediately obvious-is that he has to keep abreast of general medical advances, because today many medical conditions are treated with drugs which may influence the action of anaesthetic agents (Dundee 1958). To the Hospital Service The better utilisation of hospital beds compensates for the few extra hours of outpatient work each week. THE
HASTINGS
SYSTEM
The system of anaesthetic outpatient clinics in use throughout the Hastings Group of hospitals was begun by A. H. Grace in 1950. Over the years it has been modified into an easily workable system, willingly accepted by the surgical staff. The clinics are held in the outpatient department of the main surgical hospital of the Group and immediate
X-ray, electrocardiographic, and laboratory examination of patients is possible. This ensures immediate results of all investigations at a single visit to the clinic, as suggested by Loder and Richardson (1954). Selection Not every
surgical patient is seen by the anaesthetist, because this would through sheer numbers overburden the resources of the staff. The decision to refer a patient to the clinic is left to the surgeon, who indicates this by stamping the patient’s notes with an "A" , when placing the name on his waiting list. The Hastings area has a high proportion of older people. Many cases are referred by our surgical colleagues, who only intend to perform minor surgery; but because of the patient’s advanced years they feel we should see them first. The system of selection may appear haphazard but, in practice, with cooperative surgeons, it works very well, and few patients who are not good risks escape the clinics. The surgeons give about two weeks’ notice of the intended admission of a patient, and with this notification, the patient receives an appointment for the next anaesthesia clinic. An urgent case may be seen the same day if both clinics are open, or the patient can be seen just before admission to the wards. Procedure
The anaesthetist records a general medical history with special reference to previous surgery and anaesthesia. This is followed by a general medical examination and-if the patient is found fit for anaesthesia-a few words about modern anaesthesia. When a patient’s condition warrants further investigation-e.g., an unexplained anxmia-investigation and treatment
begin
at once. REFERENCES
Dundee, J. W. (1958) Brit. med. J. i, 1433. Green, R. A., Howat, D. D. C. (1952) Anœsthesia, 7, 40. Karp, M. (1957) Curr. Res. Anesth. 36, 36. Lee, J. A. (1949) Anœsthesia. 4, 169. Loder, R. E., Richardson, H. J. (1954) Lancet, i, 1177. Middleton, H. (1958) Anœsthesia, 13, 337.
The Wider World MEDICINE IN THE SOUTHERN CAMEROONS
J. L. H. O’RIORDAN M.A., B.M., B.Sc. Oxon. M.R.C.P. LATE CAPTAIN
R.A.M.C.*
WHEN young doctors are urged to visit tropical countries for a time, it is usually large modern hospitals like those at the University Colleges of Ibadan and Jamaica that are recommended. There is much to be learnt and perhaps more good to be done, however, at more primitive places, where the practice of medicine differs even more markedly from that of the teaching hospitals of Britain. This article describes the conditions I saw during nine months in the Southern Cameroons in West Africa, 4° north of the Equator. Gerald Durrell went there to collect animals a few years ago, and in The Overloaded Ark wrote that the country had "... remained much as it was when Africa was first discovered." But conditions did improve in the last few years of trusteeship ; for example, it was possible to undertake a journey to Bamenda, 250 miles up-country by road, with a reasonable hope of getting there in two days. When British troops went there in September, 1960, for the first time since the 1914-18 war, it was with the *
Present address: Institute of Nuclear London, W.1.
Medicine, Middlesex Hospital,
formation not exert
*
*
*
Attempts to elucidate the cellular and subcellular renal mechanism of digitalis action are a long way from the empirical use of the drug in the 18th century, a long way from conflicts about its systemic mode of action, a long way even from awareness of its direct renal action. But need for further investigation remains. Studies are required in the spheres of structural chemistry, of hormonal mechanisms in cation control, and of human pharmacology in the various disease states characterised by excessive fluid retention. These would provide the cardiologist with a clearer physiological concept of the exact renal action of his most important drug. 20. 21. 22. 23. 24. 25. 26. 27. 28.
Glynn, I. J. Physiol. 1955, 128, 55P. Joyce, C., Weatherall, M. ibid. 1955, 127, 33P. Kahn, J., Acheson, G. J. Pharmacol. 1953, 115, 305. Shatzmann, H., Windhager, H., Solomon, A. Amer. J. Physiol. 1958, 195, 570. Glynn, I. J. Physiol. 1957, 136, 148. Strickler, J., Kessler, R. J. clin. Invest. 1961, 40, 311. Kawaga, C., Cella, J., Vanarman, C. Science, 1957, 126, 1015. Liddle, G. ibid. p. 1016. Drill, V. A., Riegel, B. Rec. Progr. Hormone Res. 1958, 14, 29.
THE VALUE OF ANÆSTHESIA OUTPATIENT CLINICS VERNON R. KEEP M.R.C.S., D.A. ANESTHETIC REGISTRAR TO THE HASTINGS HOSPITAL GROUP *
THE specialty of anaesthesiology has progressed rapidly in the last two decades, and the more widespread use of anxsthesia outpatient clinics has produced some unfavourable comment from the less well informed members of our profession, usually with vague references to " empire building ". The purpose of this paper is to show the value of this relatively new function of the anaesthetist to the patient, the surgeon, the hospital, and not least to the anaesthetist. For many years it has been the prerogative of the physician-it still is in some hospitals-to examine the patient for his fitness to undergo surgery under anxsthesia. But the physician of today cannot possibly keep abreast of advances in modern anaesthesia, and he is usually the first to admit his unsuitability for this task. The general surgeons of the past are vanishing; we now have specialisation within a specialty, and many of the younger entrants have only a limited knowledge and experience of disease outside their own narrow fields. The penalty we pay for this overspecialisation is that patients may be operated on when they are not fit or when some disability may have been missed (Green and Howat The anaesthetist can contribute in preparing the patient for safer surgery by careful preoperative examination of the patient as a whole. To expect to achieve this in a hurried examination the night before operation, at the end of a day’s work, is unreasonable; but if a session or two is set aside for outpatient clinics much will be gained. The first duty of the anaesthetist is to assure himself that the patient is as fit as possible for surgery. If he is not, the anaesthetist should institute immediate investigation and treatment of the condition, or, if this is beyond his scope, he should refer the patient to his specialist colleagues. The clinic should never function as a second-class medical outpatients (Lee 1949), and there is no shame in admitting an inability to diagnose or treat the more obscure pathological processes. Individuality should be sacrificed for teamwork. Many surgeons are today working at a far from leisurely pace, and their waiting-lists may be long. The amount of time devoted to each case may be limited. The patient may be momentarily confused by the news of contemplated surgery and may fail to absorb the surgeon’s remarks as to the nature of the operation; probably by the time this has been assimilated the next patient is being seen, and a solid door separates the first patient from the surgeon. A talk with the anaesthetist gives the patient a second chance to learn what is going to happen to him, and to ask the questions which the surgeon has little time to answer fully. Many of the elderly patients will be coming into hospital for the first time in their lives, and the anaesthetist is the ideal person to put their fears at rest with reassurance and explanation. This can be a most important function of the anaesthetic clinic, not only for the patient but also for the anxsthetist, because successful reassurance and premedication help greatly in smooth induction. The patient may have definite views about the choice between general and local anaesthesia and Lee (1949) has pointed out that the patient’s preference should be considered. Often a patient asks for an unsuitable type of
1952).
*
Present address:
Royal
Perth
Hospital, Western Australia.
447
anesthesia. The anaesthetist must then take time to explain and give the patient confidence in the alternative method. We have no
right to ignore a patient’s intelligent request. ADVANTAGES
To the Patient
the patient of this early is one of reassurance. anaesthetist meeting with the Patients are far more impressed by what the anaesthetist says to them, by how much he hurts them, and by how much he appears to understand their individual difficulties than by the most skilful acts he can practise on their unconscious bodies (Karp 1957). Many patients are overjoyed to be pronounced fit for an anaesthetic. Hidden fears about the condition of [their hearts and lungs may come to light during the medical examination, and reassurance often causes them to leave the outpatient department greatly unburdened of their worries. A not uncommon complaint of patients who have had anaesthetics is postoperative sickness. Knowledge of the drugs previously used for premedication will often reveal a likely cause and steps;may be taken to ensure an uneventful recovery at the next anaesthesia. This presupposes accurate records of previous anaesthetics and a cumulative record system for closed communities or special units, as described by Middleton (1958). One disadvantage for the patients is that they probably have to make a second visit to the hospital before admission, but this is a small matter if increased efficiency and safer anaesthesia results. Not all the anxsthetists can see the patients they will personally anaesthetise, although this is the ideal it is difficult to arrange in practice. The
To the
principal advantage
to
Surgeon
The surgeon profits by the anaathesia outpatient clinic because he knows, when he arranges his operating-list for the next day, he will rarely find that the first major case has been postponed by the anaesthetist with a consequent waste of two hours’ operating-time. Few surgeons have as many beds as they would like, and the anaesthetist can divert cases which require long preoperative medical treatment from them so that the maximum use of the acute surgical beds is obtained. It is an advantage also for the surgeon and the anxsthetist to discuss a difficult case together at an early stage, so that the patient’s operation is not delayed. To the Anaesthetist The anaesthetist in these circumstances has first-hand knowledge of his patients, and knows they are having their operation under the best conditions, for he has had ample time to choose the best anaesthetic for the difficult case, and arrange special apparatus if required. An advantage to the anxsthetist-not immediately obvious-is that he has to keep abreast of general medical advances, because today many medical conditions are treated with drugs which may influence the action of anaesthetic agents (Dundee 1958). To the Hospital Service The better utilisation of hospital beds compensates for the few extra hours of outpatient work each week. THE
HASTINGS
SYSTEM
The system of anaesthetic outpatient clinics in use throughout the Hastings Group of hospitals was begun by A. H. Grace in 1950. Over the years it has been modified into an easily workable system, willingly accepted by the surgical staff. The clinics are held in the outpatient department of the main surgical hospital of the Group and immediate
X-ray, electrocardiographic, and laboratory examination of patients is possible. This ensures immediate results of all investigations at a single visit to the clinic, as suggested by Loder and Richardson (1954). Selection Not every
surgical patient is seen by the anaesthetist, because this would through sheer numbers overburden the resources of the staff. The decision to refer a patient to the clinic is left to the surgeon, who indicates this by stamping the patient’s notes with an "A" , when placing the name on his waiting list. The Hastings area has a high proportion of older people. Many cases are referred by our surgical colleagues, who only intend to perform minor surgery; but because of the patient’s advanced years they feel we should see them first. The system of selection may appear haphazard but, in practice, with cooperative surgeons, it works very well, and few patients who are not good risks escape the clinics. The surgeons give about two weeks’ notice of the intended admission of a patient, and with this notification, the patient receives an appointment for the next anaesthesia clinic. An urgent case may be seen the same day if both clinics are open, or the patient can be seen just before admission to the wards. Procedure
The anaesthetist records a general medical history with special reference to previous surgery and anaesthesia. This is followed by a general medical examination and-if the patient is found fit for anaesthesia-a few words about modern anaesthesia. When a patient’s condition warrants further investigation-e.g., an unexplained anxmia-investigation and treatment
begin
at once. REFERENCES
Dundee, J. W. (1958) Brit. med. J. i, 1433. Green, R. A., Howat, D. D. C. (1952) Anœsthesia, 7, 40. Karp, M. (1957) Curr. Res. Anesth. 36, 36. Lee, J. A. (1949) Anœsthesia. 4, 169. Loder, R. E., Richardson, H. J. (1954) Lancet, i, 1177. Middleton, H. (1958) Anœsthesia, 13, 337.
The Wider World MEDICINE IN THE SOUTHERN CAMEROONS
J. L. H. O’RIORDAN M.A., B.M., B.Sc. Oxon. M.R.C.P. LATE CAPTAIN
R.A.M.C.*
WHEN young doctors are urged to visit tropical countries for a time, it is usually large modern hospitals like those at the University Colleges of Ibadan and Jamaica that are recommended. There is much to be learnt and perhaps more good to be done, however, at more primitive places, where the practice of medicine differs even more markedly from that of the teaching hospitals of Britain. This article describes the conditions I saw during nine months in the Southern Cameroons in West Africa, 4° north of the Equator. Gerald Durrell went there to collect animals a few years ago, and in The Overloaded Ark wrote that the country had "... remained much as it was when Africa was first discovered." But conditions did improve in the last few years of trusteeship ; for example, it was possible to undertake a journey to Bamenda, 250 miles up-country by road, with a reasonable hope of getting there in two days. When British troops went there in September, 1960, for the first time since the 1914-18 war, it was with the *
Present address: Institute of Nuclear London, W.1.
Medicine, Middlesex Hospital,