- Email: [email protected]
WHAT IS AN URGENT CASE?
WHAT IS AN URGENT
youth of the patients. Yet in 2 other of his cases, aged twelve and thirteen years, the thickening wass striking. Obviously this glomerular capillary ch ange is not as significant as BELL would have us believe. In this country, DUNNhas adopted a somewhat similar view.
He too has stressed the abnormal permanent patency of the glomerular capillaries in nephrosis and has suggested that it was perhaps the result of previous inflammation. He has also observed abnormal thickening of the basement membranes in certain of his cases. While the tide is now running against the conception of nephrosis as an entity distinct from nephritis, advocates for the opposite view are not lacking. PANTIN,2 working at the nephritis clinic at Guy’s Hospital, has made a statistical study of glomerular size in nephritis, nephrosis and the normal kidney and has found that glomerular enlargement is a constant feature in glomerulonephritis, whereas in nephrosis there is no measurable difference from the normal. His 6 cases of nephrosis showed in fact no glomerular changes at all. Confirmation of his observations in a larger series would help to keep the controversy alive.
WHAT IS AN URGENT CASE? DURING the past three weeks many people have been asking themselves the meaning of the word urgent," for our hospitals have been dealing only with urgent cases. It soon became clear that the word had to be extended beyond such familiar emergencies as intestinal obstruction and compound fractures. There were, for instance, cases of ear disease to be observed for a time before making a decision for or against operation. Those working in the London voluntary hospitals have been thinking over this matter since the emergency bed service of the King’s Fund was introduced. Under this scheme the hospitals agreed to take any case sent up as an emergency by any doctor without selection, in the way that the municipal hospitals have always done. The most striking thing about this service has been the number of times when the emergency has proved to be a false alarm, and the patient has been well return next day or the day after. to home enough This does not mean that the trouble was not urgent in the first place. The urgency must be assessed by the considerations in the mind of the doctor at the moment he sees the patient, and not on the report of the case when the patient is well again. Students have been taught for years that in certain conditions immediate transfer to hospital is necessary if a life is to be saved. We cannot criticise the man outside for failing to send in the acute appendix which might have been saved, and then turn round on him and grumble because he sends in all those other patients whose symptoms were identical at the moment he saw them but who were well next day, and back at work the day after. But here is the difficulty. When a patient has been admitted as an emergency it is impossible "
1. Dunn, J. S. J. Path. Bact. 1934, 39, 1. 2. Pantin, C. G., Guy’s Hosp. Rep. 1938, 88, 456.
CASE?
749
day, and difficult to do so the day after. He may have to be kept in for a week to be investigated so as to exclude possible chronic disease, of which the acute symptoms were merely an exacerbation, and when a patient has been kept in hospital for a week we cannot think of sending him back to work for another week. The results are a strain on hospital beds, a large call on national health insurance funds, and, perhaps most important of all, the manufacture of invalidism in many of that great group of patients in whom no organic disease is discovered. Perhaps good may come from the present stringency of beds by giving courage to hospital doctors to send out these cases in forty-eight hours. That they should be admitted we can hardly doubt, when it is remembered that the hospital medical officer is to the doctor outside what the latter is to the patient. It is well known that of a hundred emergency calls the anxiety of the relatives is the only reason for ninety-eight. In the ninety-ninth the doctor saves a life ; and in the hundredthusually the one to which he does not go-the patient dies, but would have died anyhow. The public have been taught that certain symptoms are signs of grave disease and that they must call in their doctor at once. Through its insurance committees the nation demands that the family doctor should go out at all times and in all weathers to see such patients. It would be most unjust to him of the power to deal with such cases if deprive he finds the patients’ fears may be justified. The criterion of urgency in the G.P.-patient relationship is the anxiety of the patient and his relatives, while in the hospital-G.P. relationship it is the suspicion rather than the certainty of serious disease. But there is another way in which the relativity of the word urgent is being demonstrated. As our patients return to the outpatient departments which are now opening again we have to ask ourselves to whom shall precedence in admission be given ? This will need careful consideration. It would probably do no harm, with the coming of the winter, if all tonsillectomies in children were deferred until the spring. On the other hand, the ingrowing toenails, the hammer toes, and other minor maladies of the feet that form the most important work, from the national standpoint, of our orthopaedic departments, become increasingly urgent as the limitation of transport compels the population to resort to its legs. Precedence must also be given to those cases of malignant disease in which there is a hope of cure. Here also our knowledge may be extended if clinicians have to distinguish more carefully between cases in which hope really exists and those in which operative surgery is but a placebo and radiotherapy a mask of black magic. Nor must it be assumed that delay is a misfortune. A wait for three weeks will not have materially affected those growths which are curable ; the rapid development of others should not be interpreted as a missed opportunity, for it may all too often be evidence that the growth was from the first incurable with our present powers. to send him out next on
youth of the patients. Yet in 2 other of his cases, aged twelve and thirteen years, the thickening wass striking. Obviously this glomerular capillary ch ange is not as significant as BELL would have us believe. In this country, DUNNhas adopted a somewhat similar view.
He too has stressed the abnormal permanent patency of the glomerular capillaries in nephrosis and has suggested that it was perhaps the result of previous inflammation. He has also observed abnormal thickening of the basement membranes in certain of his cases. While the tide is now running against the conception of nephrosis as an entity distinct from nephritis, advocates for the opposite view are not lacking. PANTIN,2 working at the nephritis clinic at Guy’s Hospital, has made a statistical study of glomerular size in nephritis, nephrosis and the normal kidney and has found that glomerular enlargement is a constant feature in glomerulonephritis, whereas in nephrosis there is no measurable difference from the normal. His 6 cases of nephrosis showed in fact no glomerular changes at all. Confirmation of his observations in a larger series would help to keep the controversy alive.
WHAT IS AN URGENT CASE? DURING the past three weeks many people have been asking themselves the meaning of the word urgent," for our hospitals have been dealing only with urgent cases. It soon became clear that the word had to be extended beyond such familiar emergencies as intestinal obstruction and compound fractures. There were, for instance, cases of ear disease to be observed for a time before making a decision for or against operation. Those working in the London voluntary hospitals have been thinking over this matter since the emergency bed service of the King’s Fund was introduced. Under this scheme the hospitals agreed to take any case sent up as an emergency by any doctor without selection, in the way that the municipal hospitals have always done. The most striking thing about this service has been the number of times when the emergency has proved to be a false alarm, and the patient has been well return next day or the day after. to home enough This does not mean that the trouble was not urgent in the first place. The urgency must be assessed by the considerations in the mind of the doctor at the moment he sees the patient, and not on the report of the case when the patient is well again. Students have been taught for years that in certain conditions immediate transfer to hospital is necessary if a life is to be saved. We cannot criticise the man outside for failing to send in the acute appendix which might have been saved, and then turn round on him and grumble because he sends in all those other patients whose symptoms were identical at the moment he saw them but who were well next day, and back at work the day after. But here is the difficulty. When a patient has been admitted as an emergency it is impossible "
1. Dunn, J. S. J. Path. Bact. 1934, 39, 1. 2. Pantin, C. G., Guy’s Hosp. Rep. 1938, 88, 456.
CASE?
749
day, and difficult to do so the day after. He may have to be kept in for a week to be investigated so as to exclude possible chronic disease, of which the acute symptoms were merely an exacerbation, and when a patient has been kept in hospital for a week we cannot think of sending him back to work for another week. The results are a strain on hospital beds, a large call on national health insurance funds, and, perhaps most important of all, the manufacture of invalidism in many of that great group of patients in whom no organic disease is discovered. Perhaps good may come from the present stringency of beds by giving courage to hospital doctors to send out these cases in forty-eight hours. That they should be admitted we can hardly doubt, when it is remembered that the hospital medical officer is to the doctor outside what the latter is to the patient. It is well known that of a hundred emergency calls the anxiety of the relatives is the only reason for ninety-eight. In the ninety-ninth the doctor saves a life ; and in the hundredthusually the one to which he does not go-the patient dies, but would have died anyhow. The public have been taught that certain symptoms are signs of grave disease and that they must call in their doctor at once. Through its insurance committees the nation demands that the family doctor should go out at all times and in all weathers to see such patients. It would be most unjust to him of the power to deal with such cases if deprive he finds the patients’ fears may be justified. The criterion of urgency in the G.P.-patient relationship is the anxiety of the patient and his relatives, while in the hospital-G.P. relationship it is the suspicion rather than the certainty of serious disease. But there is another way in which the relativity of the word urgent is being demonstrated. As our patients return to the outpatient departments which are now opening again we have to ask ourselves to whom shall precedence in admission be given ? This will need careful consideration. It would probably do no harm, with the coming of the winter, if all tonsillectomies in children were deferred until the spring. On the other hand, the ingrowing toenails, the hammer toes, and other minor maladies of the feet that form the most important work, from the national standpoint, of our orthopaedic departments, become increasingly urgent as the limitation of transport compels the population to resort to its legs. Precedence must also be given to those cases of malignant disease in which there is a hope of cure. Here also our knowledge may be extended if clinicians have to distinguish more carefully between cases in which hope really exists and those in which operative surgery is but a placebo and radiotherapy a mask of black magic. Nor must it be assumed that delay is a misfortune. A wait for three weeks will not have materially affected those growths which are curable ; the rapid development of others should not be interpreted as a missed opportunity, for it may all too often be evidence that the growth was from the first incurable with our present powers. to send him out next on