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Of cabbages and kings

Bandolier as you all know has occasional panic attacks ( Bandolier 11 ). This month's has three components, risk management, reading in bed and déjà vu.

Risk management

Risk management is understandably big business for Trusts, who can buy in to a pool insurance policy, but must look after the shop if claims are to be paid. The spectre, reality rather than vision, is that it is risk managers who will decide that certain interventions will be withdrawn from the menu. The reason for withdrawing services will be the prospect of major harm leading to a major claim and a major payout.

This may have most impact on 'discretionary' interventions, that is where the clinician provides what she or he sees as a Rolls-Royce quality service which has a (small) risk of causing major harm. There are alternatives, which do not provide as high quality benefit but do carry a lower risk of harm. An example is providing epidural local anaesthetic for pain relief after major surgery. This carries a 1 in 5000 risk of neurological sequelae [1], a big or a small risk depending on how you look at it. You could just have intramuscular injections of morphine, although these too carry some risk. The risk of neurological sequelae is too low for clinicians to have to mention it to patients, because the usual rule is that if the risk is less than 1% then it does not have be mentioned in consent procedures. Clearly it is a setting in which many clinicians feel that the benefit, high quality pain relief, is well worth this 1 in 5000 risk. Risk management may dictate otherwise.

Reading in bed

Reading in bed may be one of life's great pleasures but Bandolier believes that technological advance is required. How can you lie on your side to read comfortably while wearing reading glasses? Is there a market here for lorgnettes, with right or left -armed versions for those who read on their right or left side respectively? What about book-rests which swivel from the bedside or bedhead? Thank goodness Bandolier does not come with heavy bindings. A copy of the bound Bandolier for the best suggestions.

Evidence-based Kings

The déjà vu comes from the intriguing book on George III by Macalpine and Hunter [2]. The Reverend Thomas Willis handled the coercion and restraint of the King. Appearing before a parliamentary committee he made the claim, which he couldn't substantiate by retrospective audit, that he could cure 9 out of 10 of his patients. Along came Philippe Pinel, founder of the French school of psychiatry, and the man who symbolically and literally took the chains off his patients at the Bicêtre in 1793, to check out this English wizard. Pinel was systematic - "I have for the last 15 years ... consulted all the works which have appeared on it in the English language" - but (as Bandolier often finds) "I have found no secret although all attest their success". He was also aware that self-limited disorders can lead to claims of magic cures - he had lost "faith in pharmaceutic preparations", because "I saw with wonder, the resources of nature when left to herself, or skilfully assisted in her efforts".
The book also has a picture of what is claimed to be the first histogram in medicine, Dr Richard Powell's chart of 1810, showing the number of lunatics by lustrum, or 5 year period; it was used to demonstrate the 'fashionable' increase in mental illness after King George's little trouble. Recommended reading.

References:

  1. Kane RE. Neurologic deficits following epidural or spinal anesthesia. Anesthesia and Analgesia 1981;60:150-161.
  2. Macalpine I, Hunter R. George III and the Mad-Business. London: Pimlico; 1991.





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