Minerva

This article originally appeared in BMJ USA

The Washington Post carried two articles on the medical establishment's Dickensian attitude to fatigue among doctors and its impact on medical error (March 23, 27), prompting a spate of letters to the editor (April 10). Doctors' leaders are self deluded about the problem, the articles say, and none more so than one Harvard trained surgeon who claimed: "Surgeons are built differently [to other people] and become impervious to exhaustion." His own frightening schedule included meeting his trainees every Sunday morning at 8:30 am to listen to their grievances. He dismissed complaints about fatigue as "whining." (See the editorial on fatigue in this issue of BMJ USA on p 294.)

http://bmj.com/cgi/content/full/322/7290/808

When the medical authorities in Indiana issued police officers with automatic external defribrillators, they hoped survival would improve for people having cardiac arrests out of hospital. It didn't. A before and after study showed that if the police arrived before the paramedics, they carried out defibrillations flawlessly. Unfortunately they arrived first in only 6.7% of cases (Academic Emergency Medicine 2001;8:324-330). The rest of the time, the police were too busy or too far away to make it in time.

During dangerous floods in early 1997, the residents of Yuba County, California, were advised to evacuate their homes for higher ground. Four fifths of them left, but the remaining fifth stayed behindoften because they didn't want to abandon their pets (American Journal of Epidemiology 2001;153: 659-665)[Abstract/Free Full Text]. A survey six months later found a dose-response relation between the number of pets in a household and the likelihood of their owners refusing to leave.

George Bush will be relieved to hear from a leading Princeton economist that inflated drug costs and manufacturers' profits are not an economic burden on the US health care system (Washington Post 28 March). He recently told a meeting of the Council on the Economic Impact of Health System Change that Americans spend less on prescription drugs than they do on alcohol, tobacco, and admission fees to entertainment. He ended: "You could just as easily say football was the problem."

In the three years since Oregon's Death With Dignity Act legalised physician assisted suicide, only 70 people have taken advantage of it. The main reason is that few doctors are willing to write the lethal prescription, says a doctor from Portland (Medical Journal of Australia 2001;174:353-354)[ISI][Medline]. The federal government and three major health maintenance organisations in Oregon remain queasy about physician assisted suicide and transmit that feeling to many of the state's doctors, who fear antiabortion-style demonstrations if it becomes known that they are helping people to die.

A small randomised trial in obstetrics and gynaecology provides supporting evidence for the well accepted folklore that ginger reduces nausea and vomiting in early pregnancy (Obstetrics & Gynecology 2001;97:577-582)[Abstract/Free Full Text]. Seventy Thai women took either a placebo or a specially made preparation containing about 1 g of ginger for four days. Nausea and vomiting decreased in women taking ginger. No improvements occurred in controls. Ginger cakes or ginger biscuits might work too, though they contain up to 30 times more ginger.

Minerva lives close to a golf links and often observes players as they amble from green to green chatting and enjoying the sunshine. She has never seen any of them stretching, bending, or doing squat thrusts before teeing off so was not surprised to read that golfers rarely warm up properly before a game (British Journal of Sports Medicine 2001;35:125-127)[Abstract/Free Full Text]. Ritualistic air swings are the most popular form of preparation, but they are unlikely to prevent injury or improve performance, write Australian researchers.

Ironically, this month's Western Journal of Medicine (2001;174:282-283) reprints another article from the British Journal of Sports Medicine which concludes that stretching doesn't prevent exercise induced injury either. The author, from McGill University in Canada, reviews the evidence on stretching, which includes a large randomised trial and a systematic review. Neither show any benefit. In fact, the basic science literature reports that even mild stretching can cause muscle damage at the cellular level.

Death rates are rising in older people with asthma, possibly because they aren't getting the inhaled steroids known to save lives in younger people. Researchers in Ontario found that only 40% of people over 65 received inhaled steroids after an acute exacerbation and a spell in hospital (Chest 2001;119:720-725)[Abstract/Free Full Text]. Those least likely to get steroids were over 80, had other illnesses, or were cared for after discharge by a primary care doctor, not a specialist.

View larger version (115K): [in this window] [in a new window]   A 17 year old Asian girl presented to the dermatology department with symmetrical, pigmented horizontal lines on her back. Histological examination showed only chronic eczema. The patient remarked that she had scratched her back with a long bathroom loofah to relieve intractable itching. This had caused postinflammatory pigmentation of the skin overlying her ribs and vertebral prominences, sparing the intervening areas. G A Johnston, specialist registrar, T O Bleiker, specialist registrar, R A C Graham-Brown, consultant, department of dermatology, Leicester Royal Infirmary, Leicester LE1 5WW, UK

Conflict between doctors and managers is well recorded. But today's competitive health care environment has produced a new phenomenon: doctors fighting doctors. Archives of Internal Medicine (2001; 161:801-802)[Free Full Text] likens two doctors pitted against each other to a cockfight: the real players are those on the sidelines rooting for their favourite bird. Winning the contest becomes more important than the state of the birds when it's all over. Birds can, after all, be replaced. And so, presumably, can doctors.

Doctors from Virginia estimate that blood stream infections acquired in hospital represent the eighth leading cause of death in the United States, causing 20 000 to 70 000 deaths each year (Emerging Infectious Diseases 2001;7:174-177)[ISI][Medline]. Two small changes could reduce the death toll substantially, they say: use of central venous catheters impregnated with antibiotics, and rigorous handwashing between patients.