Since the July issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2006 Sep;88(5):453. doi: 10.1308/003588406X117124
letter Ann R Coll Surg Engl. 2006 Sep;88(5):453. doi: 10.1308/003588406X117124
Making a definite diagnosis in patients with acute right iliac fossa pain is difficult, particularly in female patients. Delayed appendicectomy can lead to increased appendicular perforation with associated morbidity while rushing into surgery in doubtful cases paradoxically leads to increased negative appendicectomy rates. Active observation has been widely practised among other things, in an attempt to reduce negative appendicectomy rates. This article, which reflects this practice, nevertheless omits to mention certain important aspects.
Diagnosis of appendicitis was based on history, clinical findings and baseline investigations including full blood count. A total of 112 patients underwent appendicectomy within 24 hours. The basis on which this was done has not been clearly stated. History and clinical examination are not always dependable. Did they analyse leucocyte count and C-reactive protein? If so, what were the findings?
The authors also fail to mention the criteria on which 111 patients were actively observed. Out of this group 42 patients had appendicectomy, of which 20 had ultrasound diagnosis of appendicitis. The reason for operating on the other 22 patients is not clearly mentioned.
One would expect that findings and reasons for appendicectomy in a total of 158 out of 300 patients would be more clearly stated in a study of this nature.
Footnotes
Ann R Coll Surg Engl. 2006 Sep;88(5):453. doi: 10.1308/003588406X117124
The indication for operating on patients in this study was primarily based on clinical examination and, where appropriate, clinical re-examination. The tests that were carried out were used as an adjunct to the decision making process.
letter Ann R Coll Surg Engl. 2006 Sep;88(5):453. doi: 10.1308/003588406X117124
I read with interest this rather emotive article by Mauffrey. It is important to point out that the survey from the ‘large London A&E department’ stating that the management of up to one in ten patients was considered to be poor was published in 1992, a long time before the current changes to SHO work practices and the four-hour rule were introduced.1 This case could have happened yesterday or 15 years ago. The author has not shown any association between the four-hour period or the change in SHO training and a possible reduction in patient care.
What has changed in the last 14 years is a move towards providing ‘quality’ healthcare. At least we are now recognising that sometimes we get things wrong and are moving towards finding solutions. If Mauffrey feels that the changes to SHO training and the four-hour rule are reducing the level of patient care in emergency departments then let's see the evidence; emotive rhetoric will not force change. Certainly, he has failed to demonstrate that the changes ‘will certainly increase negligence and malpractice’ – a rather dangerous assumption to make.
Footnotes
Comment on Mauffrey C. Is patient care affected by the recent changes in junior doctors' training? Ann R Coll Surg Engl 2006; 88: 58–60. doi: 10.1308/147363506X93698
Reference
- 1.Miller E. Quality assurance in Guy's Hospital accident and emergency department. Health Trends. 1992;24:38–40. [PubMed] [Google Scholar]
Ann R Coll Surg Engl. 2006 Sep;88(5):453. doi: 10.1308/003588406X117124
I thank Mr O'Leary for his comment on my article. As he may have noted when reading the article in its entirety, it is a discussion of a case report with a brief review of the literature rather then an original study with a statistical analysis of data to determine and quantify the degree of change in patient care. The title of the article might have misled you and I do apologise for this.
The reference to the survey from a large London accident and emergency department that I quote in my introduction is indeed from 19921 but it acts as a background and is certainly not there to illustrate the recent changes in training. Of course this case report could have happened 15 years ago but as you will note in my conclusion the point of my article is to encourage junior doctors to avoid these unfortunate events by performing a good history taking and physical examination and documenting the findings appropriately in the notes.
Reference
- 1.Miller E. Quality assurance in Guy's Hospital accident and emergency department. Health Trends. 1992;24:38–40. [PubMed] [Google Scholar]