Document x16G8w4wr9k4en2yyqrnkBvJ

-H BRITISH MEDICAL JOURNAL 8 SEPTEMBER 1973 03 543 could record the impress-ions that have led me to think that despite the conclusions quoted above deputizing services probably do not provide the best patient care. The only drutts we were given were morphine, pethidine, adrenaline, aminophyllinc. ergo- metrine, amylobarbitone sodium, A.P.C., and free samples, which were usuallv of the less commonly indicated antibiotics. Many of rhe deputies bought their own supplies of other drugs! rhe rest did without. We were told Blood giving sef to equip ourselves with a sphygmomano meter, auriscope, and ophthalmoscope, but it was not checked whether we had these items and in fact some of the deputies did not. Many patients were upset at not seeing Bung the doctor they Thought they had called, and in the cases of children and the elderly I think che history and examination were made Teat holder more difficult by unfamiliarity. Many were annoyed by having to make several telephone calls. They often rang their own G.P., were told he was off dun1, told to ring another doctor, and when they rang him were re ferred to the deputizing service. Those that Prepored feed had to use public call boxes found this particularly trying. Our service accepted reverse-charge calls, but not all patients knew how to make use of this facility. Many patients I saw were old, chronically sick, living in poor conditions, and relatively inarticulate. Seeing these people for the first time, it was very difficult to decide whether their condition had undergone any recent change or not. It was not .possible to arrange a second visit unless the patient rang again and asked for it. I understand that many services allow a depurv to make a second call, for example, at weekends--but I was told that we could not do this and that if I thought a patient should be seen again, then he should be admitted to hospital. The bung is inserted into the plastic teat holder and both can be easily sterilized by autoclaving. The bung is pierced by a sterile standard blood giving set, which is attached to the feeding tube. A simple bottle holder can be constructed from metal wire.--We are, etc., G. A. FAUX John Wyeth and Brother Ltd., Taplow, Berks Northwick Park Hospital, Harrow, Middlesex H. B. VALMAN From my experience m hospital I have many times wished that I had had access to the records of patients admitted as emergencies. Some patients do not know V Polyvinyl Chloride T-tubea what drugs they take, and in the case of steroids, monoamine oxidase inhibitors, digoxin, and antibiotics this is often im portant. Again, some patients do not know what operations they have had, which may tv of crucial importance if they present with, for example, an acute abdomen.--I am, Wel'h National 5rhool of Medicine, Orei-ie'al Practice Unit. Cardiff D. H. Howe I Williams. B. T-. Dixon. R. A., and Knowelden, 1., British Journal of Preventive and Soda! Medicine, 1973. 27. 136. Prepacked Milk Feeds for Continuous Iniragastrtc Feeding Sir,--In a oaoer describina the use of con tinuous :nir:iv:t'tr:c milk feeds in rn/ants of low wviitri: (2 Setnemlvr ly72. i*. Sir,--The loss of flexibility in a polyvinyl chloride T-tube described by Wing Com mander M. W. Sleight (21 July, p. 171) can indeed occur within 10 days of operation as the following case report demonstrates. A woman underwent elective cholecystectomy in October 1972. Freoperacive cholangiography showed stones in the common bile duct, which were removed via a choledochoromy. The common bite duct was drained with a polyvinyl chloride (Portex) T-tube. The subhepatic area was drained by a right flank, corrugated polyvinyl chloride drain. The initial postoperative course was uneventful, the flank drain being removed on the fifth day. On the ninch postoperative day T-tube cholangiography showed no residual scones and free flow into the duodenum. On the following day the T-tube was removed with difficulty, whereupon the patient complained of severe adbomina! pain and very rapidly developed signs of generalized peritonitis. Urgent laparotomy confirmed the diagnosis of biliary peritonitis. The additional features of interest were the absolute lack of a sd7i ; was sugeested that ilie sterile milk should be placed in an autoclaved blood transfusion bottle. Since life* publication of that paper prepacked feeds have been intro duced in many maternity units, milk kitchens have been abolished, and there are no facilities for providing sterile milk in blood transfusion bottles. We have found that continuous intraeastric feeds can be liiven using ore-packed teeJs bv substituting a standard blood iransfusion bottle bung for [he feeding teat 'see fiu.). track u> either drain site and the hole- in (he common bile ducr, which was now considerably larger than the original opening. The common bile duct on this occasion was drained by means of a red rubber T-tube and the abdomen by a red rubber corrugated drain. The postoperative course was uneventful and the patient continued to be well 10 months later. The polyvinyl chloride T-tube on ex amination showed an interesting pattern of change. The Dorn-... of tubing which had remained outside i;u body was still flexible and pliable, the remainder was rigiJ and non-pliablc. The line of demarcation was quite distinct. It is unlikely, therefore, that the action of bile was responsible for the alteration. Similar changes have been ob served in nasogastric tubes, admittedly after a longer period.1 Polyvinyl chloride T-tubes are unsuitable for use because of their failure to promote a fistulous track and also because of the very real danger of damage to the common bile duct during removal. There have been several reports of toxic effects ascribed to substances leached out of polyvinyl chloride.*-* These have led to calls for new safety standards.2 Any standards specification must also consider the purpose for which the plastic is intended.8 It would therefore appear desirable that in addition to the study of the effects of the body on prosthetic materials8 8 the effects of such materials altered by the body on important structures be urgently examined. One such area that immediately comes to mind is the use of polyvinyl chloride tracheostomy tubes and the incidence of tracheal stenosis.*011 --I am, etc., D. J. Bouchier-Hayes St. Vincent's Hospital, Dublin MeUoro, H., Lancet, 1971, 1, 87. - Duke, H. N., and Vane, J. R., Lancer, 1968, 2, 3 Rogers, A. F., and Dunn, P. M., Lancet, 1969, 2, 1246. 4 Jaegar, R. J., and Rubin, R. J., New LneUmd Journal of Medicine, 1972, 287, 1114. \ Little, K., and Parkhousc, J., Lancet, 1962, 2, 857. 8 Lancet, 1968, 2, 34. 1 Lancet, 1973, 1. 28. 8 Little, K., Lancer, 1968. 2. 351 * T293e' C R" Medical Journal, 1973, 3, ,e Guess, W. L., and Stetson, J. B., Journal of the American Medical Association, 1968, 204, 580. *' ^M. J., British Journal of Surgery, 1971, Facial Palsy in Tetanus Sir,--I read with interest the report of a case of facial palsy in tetanus by Drs. M. Mishra and B. N. Sinha (19 August, 1972, p. 475)..They thought that a neuromuscular block may be responsible for such paralysis as only the lower part of the face was in volved in their case. Boudouresques ei al.,1 mentioned that the facial palsy imv be limited to the upper or lower part of the face or a single muscle may be affected. Kaeser ei a/.,2 reported a case of gen eralized tetanus in which 5 mg of D-tubo- curarine intravenously every 20 minutes was used for muscle relaxation. The patient remained tetraplegic after the curare was discontinued and developed severe diarrhoea, hypotension, and bronchopneumonia and subsequently died. On the basts of electro- physiological studies they suspected neuro muscular block bv tetanus toxin as the cause of tetrapk-jia Kaeser and Saner1 reix>rted neuromii'Ciil.ir block in cxjvnmental local tetanus in r.us due io imi-aired presvnaptic release id' acetylcholine. There consider able controversy as to whether the lesion is in the facial nucleus or peripheral nerve or at the neuromuscular junction. A peri pheral nerve lesion was suggested by Wat kins' on the basis of loss of taste on the same side as the facial palsv. Star2ecka5 re ported an incidence of 3-57'.. of facial palsy in their 757 cases. Park'1 reoort-d six cases f5 6". ) of facial paralysis out of 107 cases of tetanus. Farquharson' reported one case (which I saw while working in Brook BFG09218 T I J I 21082001