BMJ  2004;328:1050 (1 May), doi:10.1136/bmj.328.7447.1050

Filler

The acme of efficiency

In 1955 I was a registrar in a large mental hospital in the north of England. Most of the beds were in the old buildings, which had remained largely unchanged for nearly 100 years. There was also a modern building in the grounds, to which new patients were admitted. If these patients needed electroconvulsive therapy, they were anaesthetised and given a muscle relaxant. Electroconvulsive therapy was also widely used in the chronic wards, where it was the consequence of disturbed behaviour. There, it was given "straight"—that is, without anaesthetic or relaxant. This policy was defended by the view that the patients had never known anything different. However, one day, the medical superintendent came across an article which showed that a third of patients receiving straight electroconvulsive therapy had radiological evidence of vertebral compression fractures. He was appalled and immediately decreed that all patients receiving such therapy should have proper anaesthetic cover.

So, on the next occasion that an anaesthetist arrived, he was confronted, not with the dozen or so patients he had expected, but with 118. Unsurprisingly, he was somewhat put out, but, instead of complaining about lack of resources, he set about solving the problem. He had 10 beds set up in a small ward, and had the patients ushered in in groups of 10. They lay on the beds, and, armed with a 20 ml syringe of thiopentone, he gave each patient 3-4 ml. Of course, he had to draw the plunger back with each patient to be sure that he was in a vein, so there was some mixing of the blood. I was perturbed because two of the patients had general paresis, but he assured me that patients with tertiary syphilis were not infectious. A nurse followed him, giving the scoline, and lastly I came with the ECT machine to give the fit. By the time all that was over, most of the patients were blue, or in some cases black, so a second nurse trundled round with an oxygen cylinder, giving oxygen to the most cyanosed patients.

The session was over in three hours, and all the patients were successfully treated. Nobody died, and, so far as I know, nobody acquired an infection, not even hepatitis. Of course, in those days, AIDS did not exist.

No doubt a present day manager would compliment the anaesthetist on his presence of mind and extreme efficiency.

Woking

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