Minerva
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7207.460 (Published 14 August 1999) Cite this as: BMJ 1999;319:460All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Sir
Minerva's item in your issue of 14th August, about the "humiliation"
of doctors in Florida who are required to submit to fingerprinting,
reminded me that when I applied for registration in the state of
Queensland, Australia in 1956, a similar requirement was made. The
registration authorities may still have my prints on file. I thought it
odd at the time, but was told there was no other sure way of identifying
me. It seemed a sensible precaution, and I did not worry about it.
Yours faithfully
RP Ryan
Douvaine, France
Competing interests: No competing interests
Editor. We were interested in the recent European directive 93/42(2)
as highlighted in Minerva (1) which forces the manufacturers of medical
devices to comply with safety and performance standards. Currently the
quoted mortality from a ruptured abdominal aortic aneurysm is over 60%
(2). The most important part of the operation is controlling haemorrhage
by placing the clamp across the neck of the aneurysm and occasionally the
only way to gain control is to use the shaped wooden spoon to compress the
aorta. Despite the fact that the authors of the submission feel that its
use puts the doctors using them in a vulnerable position in cases of
medical negligence this has to be taken against the situation in which it
is used. Perhaps in future, until a device is produced which conforms with
European standards one option would be to inform the patient in the
consent that an improvised device may save their life !
1. Minerva. B.M.J. 1999:319;460.
2. Basynat P.S., Biffin A.H.B., Moseley L.G., Hedges A.R., Lewis M.H.
Mortality from ruptured aortic aneurysms in Wales. Brit. J. Surg.
1999:86;765-770.
Competing interests: No competing interests
Sir,
Irony abounds in Minerva's story of the wooden spoon (1).It
appears that it's life as a surgical instrument is threatened. If that,
perish the thought,were to happen then to whom should the wooden spoon be
presented; to surgeons like me, those of the North Middlesex Hospital and
the many others who have used it, safely and gratefully,for many years, to
the EEC bureaucrats who devised Directive 93/42(2) or to those from the
infection control service of the North Middlesex who have so
enthusiastically interpreted the Directive?
Like all good tools this wooden spoon, aka, in the submission in Minerva
as an 'improvised device' is simple, cheap and effective. The patient with
a ruptured aortic aneurysm is generally very ill and gaining access to the
abdomen must be expeditious. If bleeding is evident then immediate
control of the proximal aorta is essential.This 'device',though
'improvised' is designed to do just that. Downward pressure of the
sculptured concavity of the spoon onto the aorta compresses it against the
vertebrae and halting the haemmorhage. Seconds sometime count but control
with the spoon gives time to ensure that the inferior vena cava is safely
out of the way before a more 'proper' clamp is safely placed, under direct
vision, onto the aorta. This
'device' is not for routine use; when the aorta is not bleeding,(and these
are the majority of cases even in emergency aortic surgery), one has no
need of it but if the aneurysm is bleeding then I know of no conventional
instrument that will do the job as well. I have used it about 6 times in
20 years and it may have contributed to the satisfactory outcome of some
of those patients. I can recall no untoward events associated with it's
use.
Now that this Directive is in force, directing that 'all medical devices
must comply with European safety and performance standards', such is the
way of the world that it will reign supreme, no matter that the EEC has
never
demonstrated any evidence that their safety and performance standards will
ensure a better outcome for patients. Moreover,it appears from this
submission that the Directive can be interpreted locally by anyone so
minded to, no matter how tangential their expertise is to the 'device' in
question.
The infection control team do not tell us that the 'improvised device' is
unsafe,they provide no evidence that it causes infection nor that the
surgeons who use the device share their concerns.They would rather,it
appears,advocate adherence to these arbitrary,externally imposed dictats
than examine their validity or even speak to those who use them. For
them, as for the bureaucrats the usefulness of the device is of no
importance. They tell us that it 'should probably be abandoned'.
Am I being unrealistic in hoping that one day soon that both those who
legislate in clinical areas without consultation and those who so eagerly
interpret their rules from the sidelines would be made to face their
responsibility for such advocacy of factually unsupported interference in
patient care.
1.BMJ 1999; 319 416. (14 August)
J.L.Craven FRCS
20 Main St.,
Nether Poppleton,
York YO26 6HS
Competing interests: No competing interests
As a recently-qualified GP, very keen on practising evidence-based
medicine, I was very interested in the photograph in this week's BMJ
submitted by the North Middlesex infection control team. I wonder if I
might put these four questions -
1. Is there any evidence that the instrument worked?
2. Is there any evidence that the instrument was harmful?
3. Is there any evidence that infection control nurses reduce
morbidity and mortality?
4. Other than nursing, are there any other professions it's possible
to enter with 4 O-levels?
Competing interests: No competing interests
Wooden Spoon
Editor, We read with interest the article in minerva on the wooden
spoon (1), which was probably taken from an arterial, set by force!
This device is still very popular with vascular surgeons and the main
reason for this, is because it works. Its use may vary in different
institutions, but we however limit its use for the emergency situation,
especially in cases of ruptured abdominal aortic aneurysms. When we
consider a mortality rate of 80%, little concern is therefore given over
an insignificant infection rate. We feel that this device when used to
compress the aorta against the vertebral column is safe, not only for the
patient (it has no sharp edges to tear the aorta), but also for the
Surgeon and the scrub nurse. Is there an attempt to prevent individual
thought?
People who suggest hospital vulnerability are therefore acting with
typical bureaucratic stupidity, especially considering lives are saved.
(1) Drabu Y, Mehdi S, Migliozzi J, Miller T. BMJ 1999;319:460
EV WILLIAMS
Specialist Registrar General Surgery
University Hospital of Wales, Cardiff, CF14 4XW
MH LEWIS
Consultant Vascular Surgeon
Royal Glamorgan Hospital, Llantrisant, CF72 8XR
Competing interests: No competing interests