Since the last issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
letter Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
We read with interest the documented technical tip with regards to this original method of splitting a damp Plaster of Paris cast. We agree that splitting of a cast is frequently required following fracture reduction in order to accommodate swelling. However, we feel that in the acute period a damp plaster should not be split as this is likely to interfere with moulding of the cast, which could result in displacement of the fracture. Also any use of a sharp instrument increases the risk of sharps injuries. We advocate allowing the cast to dry and splitting the cast when the patient is in recovery with an electric plaster saw. These are atraumatic, easy to use and are frequently available in trauma theatres.
Footnotes
Comment on Nuñez V, Arnander M. An effective and easy method of splitting damp Plaster of Paris casts. Ann R Coll Surg Engl 2006; 88: 505. doi: 10.1308/003588406X116864
Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
We thank you for your interest in our technical tip. We disagree with all your objections to our technical tip. You mention concerns that splitting the cast might cause any moulding effect to be lost and a subsequent displacement of the fracture. We only advocate splitting the cast after it has ‘set’ and become relatively stiff – this typically takes 3 to 5 minutes.1 Only after this has occurred do we advocate the splitting process, which does not cause any loss of shape of the cast. You rightly mention worries about sharps injuries. Other authors have advocated using an unprotected scalpel to split a cast with the attendant risk of sharps injury.2 We are also concerned and it is precisely for this reason that we advocate the careful use of protective tubing in our technical tip. Plaster of Paris takes 24–72 hours or so to fully dry out and it is for this reason that manufacturers advocate a period of time before allowing weight bearing on a cast.3 In recovery the plaster is still heavy and damp. In our experience the oscillating saw in recovery is noisy for other patients, sticky, messy and inefficient at splitting the damp plaster, and often terrifying for recovering children. Our technique is rapid, neat and effective and helps prevent delays in a busy trauma list.
References
- 1. Surgical Materials Testing Lab Dressings Datacard – Gypsona.
- 2.McRae R. Practical Fracture Treatment. 4th edition. Edinburgh: Churchill Livingstone; 2002. p. 62. [Google Scholar]
- 3.A Practical Guide to Casting. Hull: Smith & Nephew; 1991. [Google Scholar]
letter Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
The decision to omit aspirin prior to transurethral resection of the prostate (TURP) has been a contentious issue for many years. This is reflected in the varied practice seen among urologists, as highlighted in this paper. Contradicting studies into this peri-operative management have not helped. The only randomised study quoted by Enver in support of continuing aspirin actually showed greater post-operative blood loss when it was used.1 There is abundant evidence that low dose aspirin treatment reduces the risk of thrombo-embolic events in patients with established cardiovascular disease. The worry is that omitting aspirin peri-operatively would increase this risk. Certainly this is borne out in anecdotal reports in the literature,2 and is of increased concern within the context of the hypercoagulable state seen during TURP.3 Efficacy of greenlight photo-vaporisation of the prostate (PVP) has been well established. This modality has comparable figures for improved flow rate and post-operative retention, with improved rates for haemorrhage, post-operative stay and impairment of sexual function. Greenlight PVP is successfully and safely undertaken with patients still on aspirin, as well as clopidogrel. In one study warfarin was safely discontinued two days before and re-instated one day after surgery.4 No patients had clinically significant haematuria, and none suffered clot retention. Enver not only illustrates the lack of clarity in TURP management at present, but also, inadvertently, highlights yet another benefit for greenlight PVP.
Footnotes
Comment on Enver M, Hoh I, Chinegwundoh F. The management of aspirin in transurethral prostatectomy: current practice in the UK. Ann R Coll Surg Engl 2006; 88: 280–283. doi: 10.1308/003588406X95084
References
- 1.Nielson JD. The effect of low dose acetylsalicylic acid on bleeding after transurethral prostatectomy- a prospective randomised, double-blind, placebo-controlled study. Scand J Urol Nephrol. 2000;34:194–98. doi: 10.1080/003655900750016580. [DOI] [PubMed] [Google Scholar]
- 2.Mitchell SM. Hazards of aspirin withdrawl before transurethral prostatectomy. BJU Int. 1999;84:530. doi: 10.1046/j.1464-410x.1999.00237.x. [DOI] [PubMed] [Google Scholar]
- 3.Mumtaz FH. Correspondence. BJU Int. 2000;85:778. [Google Scholar]
- 4.Sandhu JS. Photoselective laser vaporisation prostatectomy in men receiving anticoagulants. J Endourol. 2005;19:1196–98. doi: 10.1089/end.2005.19.1196. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
It is now over thirty years since the publication of Professor DA Kolb's seminal work on adult experiential learning.1 However, far from being dated, its approach to learning through experience remains pertinent, particularly to surgeons. The government's policy statement on Modernising Medical Careers2 has outlined plans to reduce the duration of surgical training for the majority of trainees and in some vanguard areas such as urology, changes have already been implemented. There is certainly no doubt that a degree of change is required to better approximate workforce training with realistic projections of clinical need, yet valid concerns have been raised over the ability to deliver quality surgical training in a shorter time frame by trainers and trainees alike. What is undisputed is that with a move towards shortened surgical training, maximum benefit will need to be gleaned from limited training opportunities.
In 450BC Confucius opined: ‘Tell me and I will forget. Show me and I may remember. Involve me and I will understand.’ Kolb uses Levin's cycle of adult experiential learning to explore the mechanics of learning through experience. Much of what is said is intuitive and already practised in the NHS. In the surgical sense the abstract cyclical terms of conceptualisation, experimentation, experience and reflection can be replaced by: revision; ‘pre-brief’; surgery; de-brief. Recently, a colleague worked for a consultant surgeon who adhered to such a method: an operation was earmarked in advance for the trainee, who was required to read up and verbally run through the procedure step by step immediately prior to surgery; the surgical procedure was performed by the trainee under supervision; an informal post-operative debrief was undertaken. The basics are thus revised four times. While this approach may provide a useful revision technique for the experienced trainee, it would particularly lend itself to the post-foundation trainee. Of course there is no substitute for experience. A simple structured approach similar to that outlined above may however maximise learning potential in this age of reduced learning opportunities.
References
- 1.Kolb DA. Toward an applied theory of experiential learning. In: Cooper C, editor. Theories of Group Process. London: John Wiley; 1975. [Google Scholar]
- 2.Department of Health. Modernising Medical Careers. A Response of the Four UK Health Ministers to the Consultation on Unfinished Business: Proposals for Reform of the Senior House Officer Grade. London: DoH; 2003. Feb, [Google Scholar]
letter Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
I would go a stage further than Mr Morrison, June 2006 Bulletin. At the current rate of technological advance and the increased use of invasive techniques for diagnosis and treatment by other specialties, surgeons could eventually become purely technicians. Once a diagnosis has been made with a defined treatment plan, the appropriate surgeon will be called to undertake the necessary procedure, ie he will be a specialist for that particular operation. This would not preclude the post-operative care as part of the responsibility. This is no more than exists in the non-medical sphere and would accord with the direction that medical training is heading: that is, superspecialisation. The term consultant would then not be needed in surgery.
Footnotes
Comment on Morrison MCT. What's in a name? Ann R Coll Surg Engl(Suppl) 2006; 88: 204–205. doi: 10.1308/147363506X106152
letter Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
I am writing to congratulate the Bulletin on publishing a timely piece on the development of the surgical workforce. Unfortunately, the theory so outlined fails to satisfy on a number of points. The biggest blunder contained in the article is the presumption that individuals adapt or evolve on Darwinian principles. Individuals do not biologically evolve: one could live for a thousand years and not biologically evolve one iota. Populations evolve over time, individuals do not. The second blunder is the presumption that evolution would lead to ‘better’ trainees: that is not the case. There is no direction inherent in Darwinian processes. A more subtle mistake is the claim that Darwin provided evidence of ‘survival of the fittest’: this phrase is not Darwin's, rather it is attributed to Herbert Spencer, only being place in The Origin latterly, in the 6th edition. I doubt the rationales of survival of the fittest, or observing morphology provide any basis for choosing surgical success: indeed I believe Hamilton Bailey, early on in his career lost his left index finger. He also suffered latterly from a manic-depressive illness. William Stewart Halstead was addicted to cocaine and subsequently morphine. Both appear to have been successful surgeons. Instead of embracing an overly pessimistic Malthusian outlook, would it not be better to attempt to provide coherent training to all who choose to embark on a surgical career?
Footnotes
Comment on Davis B. Origin of the specialists. Ann R Coll Surg Engl (Suppl) 2006; 88: 234–235. doi: 10.1308/147363506X116223
Ann R Coll Surg Engl. 2007 Mar;89(2):186. doi: 10.1308/003588407X168334
Firstly, I would like to thank Mr Wood for expressing his interest in my light-hearted comparison of medical training with Charles Darwin's theories. He is of course correct that individuals, generally speaking, do not evolve (although, at some point in the course of evolution, an individual member of a species would have to evolve for their progeny to carry forth the change, hence evolving the population). However, Mr Wood's claim that individuals do not adapt along Darwinian principles is frankly wrong, as any individual faced with adversity or an unfamiliar environment will have to adapt in order to maximise their chances of survival. Whether this happens in a day, week, or millennium is irrelevant.
Addressing Mr Wood's second claim of a ‘blunder’, there is no presumption that evolution produces better trainees. The beauty of evolution is its bi-directional nature. However, one can only hope that changes in medical training will be for the better – something that only time will tell.
While the phrase ‘survival of the fittest’ is Herbert Spencer's, it is useful as it provides a simple way for people to summarise Darwin's theories. As for the digitless Hamilton-Bailey, or the psychiatric illness of Halstead, what is to say that these did not favour the propagation of their skills? Unfortunately, their logbooks and audit data are not available for analysis.
Finally, the comment regarding a Malthusian outlook is somewhat strange, given that modern applications of Malthusian theory have centred around population control. Indeed, one can clearly see that this is the entire point of the training reforms. I agree entirely that it would be better to allow all those who wish to train as surgeons to do so. However, I'm sure that Mr Wood understands that in a world with a surplus of surgeons for the available posts, Darwinian theory will prevail.