Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

Casualty departments and the monitoring of drug dependence.

In a month-long prospective survey of patients attending London casualty departments with drug-related problems, 395 drug-dependent patients were identified. A check against the official Home Office index of notified addicts showed that 226 (57%) were not known to the Home Office. Of 92 patients who used narcotics only 53% were known with certainty to the Home Office, and when the source of notification was checked it became clear that in at least 77% of incidents involving narcotic addicts in casualty departments the addict was not reported. Repeated research in casualty departments could play a valuable role in monitoring drug dependence and might provide information supplementary to that obtained from the specialised drug treatment clinics and other sources of notification.     

Reducing errors in the accident department: a simple method using radiographers.

The assessments by radiographers of 1628 consecutive patients referred for radiography in the casualty department were analysed. The radiographers missed abnormalities in the radiographs in 68 of the cases. Casualty officers missed abnormalities in 63 cases, but only 35 patients were common to both groups. Twenty eight of the radiographs interpreted wrongly by casualty officers were interpreted correctly by radiographers; 16 of these 28 were thought by the accident and emergency consultant to be clinically important. It is suggested that a system whereby radiographers signal abnormalities should be standard practice.     

Demand incidence and episode rates of ophthalmic disease in a defined urban population.

OBJECTIVES--To estimate demand incidence and episode rates of ophthalmic disease in a defined urban population over one year. DESIGN--Study of patients presenting with eye problems to general practice and eye casualty department. SETTING--General practice and ophthalmic services in west Nottingham. SUBJECTS--36,018 people from the combined practice lists of 17 Nottingham general practitioners. MAIN OUTCOME MEASURES--Ophthalmic disorder, age and sex of patient, and where presented. RESULTS--587 consultations were recorded for ophthalmic problems, 1771 with general practitioners and 816 with eye casualty. Most consultations to general practice were by females (1066 (60%)), whereas men aged 15-44 accounted for most work in eye casualty. These men commonly presented with trauma. Infective conjunctivitis, the commonest condition, had an episode rate of 13.5/1000 population/year. Demand incidence for cataracts was 1.9/1000 population/year. Demand incidence for chronic conditions increased with age. CONCLUSIONS--As the average age of the population increases demand for ophthalmic services will rise. Planning and provision of resources to meet this increased demand should be considered now.     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Potential risk zone for anthropogenic mortality of carnivores in Gandaki Province,Nepal

Anthropogenic pressures in human‐dominated landscapes often contribute to wildlife mortality. Carnivores are especially vulnerable to human‐induced mortality due to the perceived threat to livestock and humans. Despite having widespread conservation implications, carnivore mortality data have been largely underutilized within Nepal. This study utilized Maxent to identify high‐risk areas and explore the contribution of habitat attributes associated with carnivore mortality using the casualty database within the Gandaki province of central Nepal. We categorized the risk to carnivore species in three taxonomic groups, Felid, Viverridae, and Herpestidae, and identified a 3704‐km² area within the province at high risk for carnivore casualty. The middle mountains were the riskiest physiographic zone, and the Annapurna Conservation Area represented the largest risk zone among the four protected areas. Agricultural land was the most problematic area in terms of carnivore casualty. The human population was positively associated with high‐risk areas and the number of casualties, whereas protected area cover had a negative association. This study identified that the common leopard was at the highest risk of mortality and therefore would benefit from the implementation of an action plan and species‐specific conservation strategies, especially within identified high‐risk zones. An expansion of protected areas in the middle mountain region would serve to greatly reduce carnivore casualty. Species distribution modeling can be further used with national‐level spatial and temporal mortality data to identify the most prominent casualty times and pinpoint potential casualty locations throughout the country.     

Use of hospital services by homeless families in an inner London health district.

Over the past decade the number of families in London who were considered officially to be homeless appreciably increased. In response to this many families have been given temporary accommodation, usually in bed and breakfast hotels, while awaiting permanent rehousing. About 200 of the roughly 600 hotels in London that provide such accommodation are located in the area of the former Paddington and North Kensington Health Authority, now part of Parkside Health Authority. The use made by the homeless population of hospital services was studied by finding out the numbers of inpatients admitted to hospital and the numbers presenting to the walk in paediatric clinic and the casualty department at one hospital. These figures were compared with those for local residents and the overall workload. The bed and breakfast population were high users of inpatient beds, the casualty department, and the paediatric clinic. Overall, about one tenth of the beds were used by these people. The health authority receives no additional funding for this group of patients. Further research is needed to find out if the high use of hospital services made by these patients reflects their increased morbidity or their inability to obtain primary care services.     

Positive-pressure ventilation equipment for mass casualty respiratory failure

In the event of an influenza pandemic, patients with severe acute respiratory failure (ARF) due to influenza will require positive-pressure ventilation (PPV) in order to survive. In countries with widely available critical care services, PPV is delivered almost exclusively through use of full-feature mechanical ventilators in intensive care units (ICUs) or specialized hospital wards. But the supply of these ventilators is limited even during the normal course of hospital functioning. Purchasing and maintaining additional full-feature mechanical ventilators to be held in reserve and used only during mass casualty events is too expensive to allow the stockpiling of such equipment. Consequently, planning and preparedness efforts to respond to a severe influenza pandemic have stimulated consideration of limited-feature, less-expensive ventilation devices to augment traditional PPV capacity. This article offers guidance to authorities charged with preparing for mass casualty PPV in deciding which PPV equipment would be adequate for ventilating patients for days, weeks, or even months during a medical catastrophe.     

Indication for computed tomography of the brain in patients with first uncomplicated generalised seizure.

OBJECTIVES--To assess the yield of emergency computed tomography of the brain in patients with a first generalised epileptic seizure and to evaluate a four item screening questionnaire on alcohol misuse (CAGE questionnaire) as a triage tool to avoid unnecessary scans in cases of seizures related to withdrawal from alcohol. DESIGN--Prospective, observational. SETTING--Medical casualty unit in a university hospital. PATIENTS--119 adult patients presenting to casualty within one hour of a generalised seizure. MEASUREMENTS--A clinical examination focusing on focal neurological symptoms, the CAGE questionnaire, and computed tomography of the brain with contrast enhancement. RESULTS--Computed tomography showed a focal, structural lesion of the brain in 40 patients (34% (95% confidence interval 25% to 42%)). In 20 patients (17% (10% to 24%)) an important therapeutic intervention resulted. The presence of a focal neurological deficit had a sensitivity of 50% and a specificity of 89% in predicting focal lesions on computed tomography. Answering "yes" to fewer than two CAGE questions had a sensitivity of 90% and specificity of 44% in identifying patients with focal computed tomography lesions. Focal lesions were not detected on computed tomography in any of the 35 patients (0% (0% to 10%)) who showed no focal neurological symptoms and answered "yes" to two or more CAGE questions. CONCLUSIONS--The diagnostic yield of computed tomography of the brain in adults after a first generalised seizure is high. Combined with the clinical examination, the CAGE questionnaire can reliably identify patients with uncomplicated seizures related to withdrawal from alcohol, in whom computed tomography may not be absolutely necessary.     

Alcohol and the emergency service patient.

To determine the prevalence of alcohol use in casualty patients breath-alcohol analysis was performed on 702 patients attending the accident and emergency department of a large teaching hospital during the evening. Forty per cent of patients had consumed alcohol before attending and 32% had a blood alcohol concentration exceeding 17.4 mmol/l (80 mg/100 ml). Clinical assessment of intoxication resulted in a false-negative diagnosis in 10% of inebriated patients, indicating that an objective measurement of the blood alcohol concentration by a test, such as breath-alcohol analysis, may be of additional value. These findings confirm that a high proportion of emergency-service patients are affected by alcohol and suggest that alcoholism treatment facilities need to be integrated with accident and emergency services.     

Referral routes to hospital of patients with chronic open-angle glaucoma.

An analysis of the referral routes of Southampton Eye Hospital of 191 patients who had been diagnosed as having chronic open-angle glaucoma showed that 121 patients (63.4%) were diagnosed as a result of the patient seeking advice for ocular symptoms (118) or because they had a family history of glaucoma (3). Advice had been sought from general practitioners (48), ophthalmic medical practitioners (19), and ophthalmic opticians (46). The remaining eight patients had gone directly to the casualty department. Seventy patients had been identified by chance, the majority of ophthalmic medical practitioners (26) or ophthalmic opticians (32).     

Management of the Acute Radiation Syndrome

Classification of radiation injury on a clinical basis is useful for determining priorities of evacuation and treatment in a mass casualty situation. Victims of nuclear attack would probably also suffer traumatic and thermal injuries. Four categories of surgical injury have therefore been combined with three categories of radiation injury to yield 12 classes of patients whose disposition is described. The treatment of the acute radiation syndrome is briefly discussed and concurrent injuries from trauma and burns and their possible implications are considered.     

Microcomputer system in an accident unit.

A microcomputer-based records system has been developed for use in the accident unit of a district general hospital. Patient details are entered directly at the reception desk and the computer generates a casualty card that is updated after the patient has been seen by the doctor, who determines the diagnosis to be recorded and specifies the injury coding. Information is stored on floppy discs, each holding the details of 3400 patients. The computer is used to produce a daily log-book of attendances, including revisits. The stored data may be examined and analysed for both administrative and medical purposes. The work load can be rapidly analysed according to various options that include the nature, type, and site of injuries. The system was introduced in December 1980. Location within the unit allows control over its operation, and many of the limitations of a manual system have been overcome.     

Treatment of acute abscesses in the casualty department.

In the treatment of acute pyogenic soft-tissue abscess incision, curettage, and primary suture was compared with incision and drainage alone in a randomised prospective trial. Operations were performed under antibiotic cover by casualty officers, and patients were reviewed by an independent observer in a septic dressing clinic. Altogether 114 patients were studied, of whom 54 were treated by curettage and primary suture and 60 by simple drainage. The mean healing time was 8.9 days in those treated by primary suture and 7.8 days in those treated by simple drainage (p less than 0.05). Primary healing failed to occur in 19 (35%) of the sutured wounds, but there were no other complications in either group. It is concluded that incision and drainage alone is adequate treatment for acute soft-tissue abscess.     

Should all casualty radiographs be reviewed?

The effect on the management of patients of routine reporting of casualty radiographs by radiologists was reviewed. The overall prevalence of error by casualty doctors was 6.2%. Many of these errors, however, were trivial and did not alter treatment. In only 1.1% of the cases reviewed did the report of x ray films appreciably alter the management of the patient. A severity score was introduced to highlight those anatomical areas in which important lesions were overlooked most often. Radiologists'' reports on radiographs of the chest, face, skull, and wrist had the greatest effect on management of patients, while reports on radiographs of fingers, hands, shoulders, long bones, and toes seldom altered treatment.     

Application of human bone marrow-derived mesenchymal stem cells in the treatment of radiation-induced gastrointestinal syndrome

Nuclear accidents and terrorism present a serious threat for mass casualty.Accidental or intended radiation exposure leads to radiation-induced gastrointestinal(GI)syndrome.However,currently there are no approved medical countermeasures for GI syndrome.Thus,developing novel treatments for GI syndrome is urgent.Mesenchymal stem cells(MSCs)derived from bone marrow are a subset of multipotent adult somatic stem cells that have the ability to undergo self-renewal,proliferation and pluripotent differentiation.MSCs have advantages over other stem cells;they can be easily isolated from patients or donors,readily expanded ex vivo,and they possess reparative and immunomodulatory properties.Moreover,MSCs have been shown to be powerful tools in gene therapy and can be effectively transduced with vectors containing therapeutic genes.Therefore,the therapeutic potential of MSCs has been brought into the spotlight for the clinical treatment of GI syndrome.In this review,we discuss the possible role of MSCs in radiation-induced GI syndrome.     

Cyanide Self-poisoning

Four cases of cyanide self-poisoning were admitted to one hospital over a period of two years. Two of the patients died. The diagnosis in the unconscious patient may be suggested by the finding of bradycardia and the absence of cyanosis (despite inadequate ventilation). The diagnosis can be confirmed in 5 to 10 minutes by a simple test on gastric aspirate, performed by the casualty officer. Cardiac pacing was used in two patients and may have a place in the supportive management of severe cases.     

Trial of Phenoxymethylpenicillin,Phenethicillin, and Lincomycin in Treatment of Staphylococcal Sepsis in a Casualty Department

A comparative trial of phenoxymethylpenicillin (penicillin V), phenethicillin (Broxil), and lincomycin (Lincocin) against superficial staphylococcal infections seen in a casualty department showed no difference in the efficacy of the three agents, though half the staphylococci isolated were resistant to penicillin. Possible reasons include the fact that antibiotic treatment may not affect superficial staphylococcal infections, or that the organisms concerned may have been weak formers of penicillinase.Half the patients treated with lincomycin complained of diarrhoea and 5% of those treated with phenethicillin suffered from nausea.     

Role of medical teams in a community disaster plan.

In London, Ont. two mock disaster exercises have indicated the need for re-evaluating the role of medical disaster teams. To coordinate and direct these teams a medical on-site coordinating team, composed of three emergency physicians with an expanded and more clearly defined role, was formed. The role of the triage teams deployed from the hospital to assess and resuscitate casualties is reviewed in detail. In addition, the communication systems, availability and deployment of medical supplies, identification of medical personnel and tagging of casualties are discussed. Because a mass casualty episode is possible in any community, disaster planning and clear outlining of the role of medical disaster teams are needed.     

Out of hours workload of a suburban general practice: deprivation or expectation.

The out of hours workload of a training practice in a suburban and semirural area on the south coast of England was studied for one year. An overall rate of contact of 273/1000 patients was found, which indicated a workload greater than that reported in most other studies. The duty doctor received over 35 telephone calls from patients during some Saturdays (1200 Saturday to 0800 Sunday) and Sundays (0800 to 0800 Monday), up to five being between 2300 and 0700. Of the patients who contacted a general practitioner, 44% were given advice by telephone and 4.9% were admitted to hospital. The admission rate was lower than that given in other studies. A considerable proportion of the workload arose from doctors covering the casualty department of a cottage hospital. Patients having a high expectation of 24 hour care by general practitioners in an area of comparative affluence (Jarman indices -13.8 to 1.7) may account for this aspect of the workload.