Thursday 22nd February, 2007
"Glasgow's health priorities - where now?"
Dr Burns has long been an advocate for addressing the particular health problems and disparities of the Glasgow population. He has taken these concerns with him in his translation from Glasgow to the Scottish Executive Health Department.
Speaker: Dr Harry Burns
Chief Medical Officer for Scotland
Buffet supper 6.15 for 7.00pm
Ebenezer Duncan Centre, Victoria Infirmary, Glasgow
If you are a member of the Society and you would like to book for the pre-meeting buffet, please email 'Buffet' and your name to: Lesley.O'Donnell@gvic.scot.nhs.uk
20 February, 2007
09 February, 2007
Does everyone have an autistic syndrome? - notes
Comments from Dr D MacIntyre
Professor Gillberg gave a fascinating review of the patterns and aetiology of autistic syndromes, a lot of it based on his own work in the field over a 30 year period. He described four main variants. Classical autistic syndrome is apparent before the age of three. Occasionally there is initial normal development in the infant and then regression but that is the exception. The dominant feature is a lack of reciprocal interaction with others in both social activity and communication. Any interaction with others is on the individual's own terms. This is associated with a restricted development of imagination.
The definition of Asperger's Syndrome seemed a little more difficult. The ICD10 classification requires normal development for the first three years which doesn’t always happen, and requires only three separate symptoms which could lead to a very broad inclusion within the diagnosis. Chris Gillberg following Asperger's original description suggested five of six separate features were required – social impairment e.g. lack of empathy or no friends; a narrow all absorbing specific interest; habits or behaviours which become an abnormal routine or ritual; a speech or language peculiarity e.g. delayed or pedantic speech or poor comprehension of normal conversation implying a lack of awareness of the mental prospective of others – "concrete conversation"; poor non verbal communication; motor clumsiness.
Two other groups – atypical autism or autistic like condition where individuals don’t fill the full criteria for diagnosis; and childhood disintegrative disorder – a condition which appears after three years of age and may be associated with provocative factors.
Recent publicity has suggested an increase in autistic syndromes however Professor Gillberg quoted his own survey from Gothenberg in 1977 which suggested prevalence figures similar to now at 0.7%. Some surveys using a less rigid diagnosis suggest higher prevalence but this may simply reflect a distribution of some features of autism as a continuum within society. This raised the question of whether autism is simply one end of a spectrum of behavioural characteristics – a disorder of empathy. Professor Gillberg preferred to see a variety of different syndromes which have autism as a cardinal feature. In many of these syndromes other developmental or psychiatric features are prominent – mental retardation, epilepsy and other aspects of visual hearing or sensory impairment. This co-morbidity is an important general issue – in the past autism was under diagnosed; now there can be a risk of missing other conditions in the presence of autism – attention deficit, depression, eating or sleep disorders for example. It is likely that the apparent increased prevalence of autism is due to increase awareness and diagnostic substitution.
There is a clear genetic link. Between 10 and 20% of siblings of a proband with classic autism exhibit features of the autistic spectrum – in identical twins this rises to between 60 and 90%. In general first degree relatives have an increase incidence of assorted social or functional disorders. There is some evidence pointing to specific genetic involvement in neurological development. Studies of histological changes in the brain have shown a number of different patterns of damage – varying from specific brain stem and cerebellar or frontal / temporal damage in classic autism to more widespread damage in patients with associated mental retardation. The general concept of aetiology is therefore of genetic predisposition possibly with an environmental insult during development leading to neurochemical damage which results in impaired social and neurocognitive functions leading in turn to the full blown syndrome.
The outcome in autistic syndromes is very variable depending on initial features but in at least 50% there remains major disability. Nonetheless more detailed and early diagnosis does allow interventions giving prospect of improvement. A high rate of secondary psychological problems is a major complicating factor. In future more detailed knowledge of specific subgroups might allow more effective management or treatment options. Greater awareness on the problem and better acceptance of people with autism might also improve their prospects.
In discussion Professor Gillberg was asked about the male preponderance (3:1). He wondered about the normal range of male and female behaviour, about the possibility of some testosterone effect, and about whether certain behaviours might be regarded more readily as abnormal in a boy. In further discussion of prognosis he suggested that very few with classic autism managed gainful employment. In Asperger’s Syndrome this figure might be around 50%. There is no currently useful specific drug treatment though treatment of identified complicating psychological factors is important.
In thanking Professor Gillberg for his address Dr Elaine Morrison, President of the Medical Chirurgical Society reflected the views of the audience that we had heard a fascinating and informative review of the subject from someone who is clearly a world expert speaking from a background of major clinical and research experience.
Professor Gillberg gave a fascinating review of the patterns and aetiology of autistic syndromes, a lot of it based on his own work in the field over a 30 year period. He described four main variants. Classical autistic syndrome is apparent before the age of three. Occasionally there is initial normal development in the infant and then regression but that is the exception. The dominant feature is a lack of reciprocal interaction with others in both social activity and communication. Any interaction with others is on the individual's own terms. This is associated with a restricted development of imagination.
The definition of Asperger's Syndrome seemed a little more difficult. The ICD10 classification requires normal development for the first three years which doesn’t always happen, and requires only three separate symptoms which could lead to a very broad inclusion within the diagnosis. Chris Gillberg following Asperger's original description suggested five of six separate features were required – social impairment e.g. lack of empathy or no friends; a narrow all absorbing specific interest; habits or behaviours which become an abnormal routine or ritual; a speech or language peculiarity e.g. delayed or pedantic speech or poor comprehension of normal conversation implying a lack of awareness of the mental prospective of others – "concrete conversation"; poor non verbal communication; motor clumsiness.
Two other groups – atypical autism or autistic like condition where individuals don’t fill the full criteria for diagnosis; and childhood disintegrative disorder – a condition which appears after three years of age and may be associated with provocative factors.
Recent publicity has suggested an increase in autistic syndromes however Professor Gillberg quoted his own survey from Gothenberg in 1977 which suggested prevalence figures similar to now at 0.7%. Some surveys using a less rigid diagnosis suggest higher prevalence but this may simply reflect a distribution of some features of autism as a continuum within society. This raised the question of whether autism is simply one end of a spectrum of behavioural characteristics – a disorder of empathy. Professor Gillberg preferred to see a variety of different syndromes which have autism as a cardinal feature. In many of these syndromes other developmental or psychiatric features are prominent – mental retardation, epilepsy and other aspects of visual hearing or sensory impairment. This co-morbidity is an important general issue – in the past autism was under diagnosed; now there can be a risk of missing other conditions in the presence of autism – attention deficit, depression, eating or sleep disorders for example. It is likely that the apparent increased prevalence of autism is due to increase awareness and diagnostic substitution.
There is a clear genetic link. Between 10 and 20% of siblings of a proband with classic autism exhibit features of the autistic spectrum – in identical twins this rises to between 60 and 90%. In general first degree relatives have an increase incidence of assorted social or functional disorders. There is some evidence pointing to specific genetic involvement in neurological development. Studies of histological changes in the brain have shown a number of different patterns of damage – varying from specific brain stem and cerebellar or frontal / temporal damage in classic autism to more widespread damage in patients with associated mental retardation. The general concept of aetiology is therefore of genetic predisposition possibly with an environmental insult during development leading to neurochemical damage which results in impaired social and neurocognitive functions leading in turn to the full blown syndrome.
The outcome in autistic syndromes is very variable depending on initial features but in at least 50% there remains major disability. Nonetheless more detailed and early diagnosis does allow interventions giving prospect of improvement. A high rate of secondary psychological problems is a major complicating factor. In future more detailed knowledge of specific subgroups might allow more effective management or treatment options. Greater awareness on the problem and better acceptance of people with autism might also improve their prospects.
In discussion Professor Gillberg was asked about the male preponderance (3:1). He wondered about the normal range of male and female behaviour, about the possibility of some testosterone effect, and about whether certain behaviours might be regarded more readily as abnormal in a boy. In further discussion of prognosis he suggested that very few with classic autism managed gainful employment. In Asperger’s Syndrome this figure might be around 50%. There is no currently useful specific drug treatment though treatment of identified complicating psychological factors is important.
In thanking Professor Gillberg for his address Dr Elaine Morrison, President of the Medical Chirurgical Society reflected the views of the audience that we had heard a fascinating and informative review of the subject from someone who is clearly a world expert speaking from a background of major clinical and research experience.
20 January, 2007
Does everyone have an autistic syndrome?
In the introduction to his book, Mirror Mind, Eric Chen wrote 'How can a non-autistic hear the heart of an autistic child?'
Of course we can't. But one person who approaches closer than most is Christopher Gillberg, Professor of Child and Adolescent Psychiatry at the Universities of Gothenburg and London, and Visiting Professor to the University of Strathclyde.
In his lecture to the joint meeting of the Glasgow Southern Medical Society and Royal Medico-Chirurgical Society of Glasgow, Chris Gillberg poses the question 'Autism – epidemic, endemic or just there?'
The meeting is introduced by Mr David Ritchie, President of the Glasgow Southern Medical Society and vote of thanks proposed by Dr Elaine Morrison, President of the Royal Medico-Chirurgical Society of Glasgow.
Listen again:
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Further reading:
Of course we can't. But one person who approaches closer than most is Christopher Gillberg, Professor of Child and Adolescent Psychiatry at the Universities of Gothenburg and London, and Visiting Professor to the University of Strathclyde.
In his lecture to the joint meeting of the Glasgow Southern Medical Society and Royal Medico-Chirurgical Society of Glasgow, Chris Gillberg poses the question 'Autism – epidemic, endemic or just there?'
The meeting is introduced by Mr David Ritchie, President of the Glasgow Southern Medical Society and vote of thanks proposed by Dr Elaine Morrison, President of the Royal Medico-Chirurgical Society of Glasgow.
Listen again:
Download [ mp3] 45.9Mb
Listen to [streaming audio]
Further reading:
19 December, 2006
Autistic Spectrum Disorder
On Thursday 18th January, Professor Christopher Gillberg addresses the Society on the subject Autism and Asperger's Syndrome.
In the meantime, you can hear the BBC programme on what it is like to be a person with Asperger's, or to live with a child with Autism in the "Am I Normal?" series here ...
In the meantime, you can hear the BBC programme on what it is like to be a person with Asperger's, or to live with a child with Autism in the "Am I Normal?" series here ...
05 December, 2006
Pandemic Influenza - Part 2: The public health doctor and the government planner
Listen to Part 2 of the Pandemic Flu symposium on your mp3 player or computer.
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04 December, 2006
Pandemic Flu symposium - reflections on the meeting by Dr McIntyre
Session 162
November 23rd 2006
Some 40 members of the Society met in the Ebenezer Duncan Centre with the President, Mr David Ritchie, in the chair. The main business of the evening was a
symposium on Pandemic Flu addressed by Dr Graeme O’May of the Regional Virus Laboratory, Dr Mark Cotton, Respiratory Physician, Dr Helene Irvine of the Public Health Department and Dr Colin Robertson currently working with the Scottish Office on Pandemic Flu planning.
Dr O’May described the mechanisms of genetic change in the flu virus - genetic drift by gradual mutation over time or shift by a reassortment of gene segment between avian and human viruses. These changes could produce increased pathogenicity or transmissibility. If both occurred a pandemic flu could arise. He emphasised that the current H5N1 avian virus was indeed bad news for birds but not for humans. He went onto explain laboratory identification of influenza and how this might respond to pandemic flu. PCR on throat and nose swabs can produce a result in a matter of hours. Laboratory resources would be focused on influenza with working arrangements changed to allow continuous testing. If there seemed a risk of pandemic flu spreading there would be particular attention to viral testing in children where flu tends to appear first. Finally he addressed the difficult issue of vaccination – if vaccines are prepared too early the strain may be wrong, if too late vaccine would be ineffective. The current H5 vaccine is in fact not sufficiently immunogenic to be effective.
Dr Cotton gave an overview of the clinical features of influenza and highlighted some of the differences between epidemic and pandemic flu with the varying virulence of different strains. The 1918 pandemic seemed particularly virulent with the feature found also in other pandemics of a peak of mortality in young adults – 20 times that of epidemic flu. This is likely to be related to primary influenza pneumonia, a disease of rapid onset and progression. The other major distinction from epidemic flu is timing – pandemic could occur at any time of year and seemed to follow a 3 phase pattern over the course of up to a year. However, the severity of the disease could be locally variable. A 1951 epidemic flu outbreak in Liverpool produced a local death rate greater than that of 1918. Dr Cotton emphasised the broad range of non respiratory illness caused by influenza and in particular increased mortality from coronary artery and other vascular disease. There is therefore a inevitable degree of uncertainty of predicting the clinical features of pandemic flu from what we know about epidemic flu and for example recent human cases of H5N1. At one end of the spectrum there is the acute lung injury of influenza pneumonia – at the other end a variety of clinical presentations in the first few days of illness though with a tendency to sudden onset. This led to debate with general practitioners in the audience over the difficulty of initial distinction of influenza from other viral illnesses. Dr Cotton commented that in the context of an influenza outbreak such an illness probably was influenza – in the absence of an outbreak probably not. Assessment of patients at home would usefully use the CURB 65 approach using confusion, high respiratory rate, low blood pressure and aged over 65 as severity markers. In addition availability of pulse oximetry might identify the younger patient progressing to viral pneumonia.
Dr Irvine explained the work in which she had been involved over the previous 6 years in planning for possible scenarios of pandemic flu. This involved a comprehensive structure of groups and committees covering various aspects of medical and social services within the Greater Glasgow area. She was an enthusiastic proponent of planning to improve the effectiveness of response should a pandemic occur. She outlined 3 separate planning scenarios which represented moderate, severe and worst case pandemic events. The moderate corresponded approximately to the 1957 and 1968 pandemics and the severe with 25% of the population affected and 1.5% case fatality ratio was approximately equivalent to 1918. She was dubious about the benefit of planning for the worst case scenario with a 50% incidence and a 2.5% case fatality and perhaps implied that discussions of such scenarios might risk an element of scare mongering. A severe pandemic would mean for Greater Glasgow and Clyde at the peak of infection a weekly toll of 65,000 cases and 970 deaths. The pressure on the Health Service is inevitably increased by an estimate of 2.500 cases and 37 deaths being in Health Service staff leading to a minimum of 12% staff absence. The increased workload applies to both primary care with a doubling of GP consultations and hospital work with a 50% increase in admissions. Discussions of the sort of scenario included comment on differing possible responses from medical staff – those who would find extra work time impossible and others who would rise to the challenge presented by the workload. Dr Irvine also touched on the problem of Tamiflu and the potential difficulties of deciding how a stockpile of antiviral therapy might effectively be used and whether it would in fact make a difference to outcomes.
Finally Dr Robertson addressed broader issues arising from influenza planning. His background is as a Consultant in Emergency Medicine. He had been seconded for a period of some months to work on influenza planning and had been impressed by the extensive work already done in government to look at the implications of a pandemic across various aspects of public life – not just health and social services but maintenance of other services, provision of goods, and law and order. Much of his own work involved raising awareness of the issue particularly in medical groups around the country. There are examples of detailed planning at both international and national level. The global surveillance of influenza viruses is comprehensive and allows the possibility of vaccine development. The response in the Far East with the cull of poultry when H5N1 first arose was impressive. Local responses can be adjusted according to the characteristics of a pandemic outbreak e.g. whether young adults are substantially affected. There was particular planning to deal with young children who are super spreaders of infection presumably because of close contact. Issues of the benefit and drawbacks for example, of school closure arise. Ethical issues which may be posed by pandemic flu are being addressed by a national working party. This already has papers from the WHO addressing ethical challenges for individuals, health service groups and governments. There are inevitably huge uncertainties. In the Health Service these apply to the availability of primary care cover, the capacity of emergency departments, and the availability of High Dependency or Intensive Care facilities. However, there is the possibility of new treatments becoming available, and biological techniques in this area are advancing steadily – the characterisation of the SARS vaccine took 48 days compared to around 8 years for HIV. His final comment was an observation on excellent working relationships within the different health service and government departments involved in this planning.
Mr Ritchie in concluding the evening commented on the range of pessimism and optimism encompassed in this topic and thanked the speakers warmly for contributing to an informative and stimulating evening.
November 23rd 2006
Some 40 members of the Society met in the Ebenezer Duncan Centre with the President, Mr David Ritchie, in the chair. The main business of the evening was a
symposium on Pandemic Flu addressed by Dr Graeme O’May of the Regional Virus Laboratory, Dr Mark Cotton, Respiratory Physician, Dr Helene Irvine of the Public Health Department and Dr Colin Robertson currently working with the Scottish Office on Pandemic Flu planning.
Dr O’May described the mechanisms of genetic change in the flu virus - genetic drift by gradual mutation over time or shift by a reassortment of gene segment between avian and human viruses. These changes could produce increased pathogenicity or transmissibility. If both occurred a pandemic flu could arise. He emphasised that the current H5N1 avian virus was indeed bad news for birds but not for humans. He went onto explain laboratory identification of influenza and how this might respond to pandemic flu. PCR on throat and nose swabs can produce a result in a matter of hours. Laboratory resources would be focused on influenza with working arrangements changed to allow continuous testing. If there seemed a risk of pandemic flu spreading there would be particular attention to viral testing in children where flu tends to appear first. Finally he addressed the difficult issue of vaccination – if vaccines are prepared too early the strain may be wrong, if too late vaccine would be ineffective. The current H5 vaccine is in fact not sufficiently immunogenic to be effective.
Dr Cotton gave an overview of the clinical features of influenza and highlighted some of the differences between epidemic and pandemic flu with the varying virulence of different strains. The 1918 pandemic seemed particularly virulent with the feature found also in other pandemics of a peak of mortality in young adults – 20 times that of epidemic flu. This is likely to be related to primary influenza pneumonia, a disease of rapid onset and progression. The other major distinction from epidemic flu is timing – pandemic could occur at any time of year and seemed to follow a 3 phase pattern over the course of up to a year. However, the severity of the disease could be locally variable. A 1951 epidemic flu outbreak in Liverpool produced a local death rate greater than that of 1918. Dr Cotton emphasised the broad range of non respiratory illness caused by influenza and in particular increased mortality from coronary artery and other vascular disease. There is therefore a inevitable degree of uncertainty of predicting the clinical features of pandemic flu from what we know about epidemic flu and for example recent human cases of H5N1. At one end of the spectrum there is the acute lung injury of influenza pneumonia – at the other end a variety of clinical presentations in the first few days of illness though with a tendency to sudden onset. This led to debate with general practitioners in the audience over the difficulty of initial distinction of influenza from other viral illnesses. Dr Cotton commented that in the context of an influenza outbreak such an illness probably was influenza – in the absence of an outbreak probably not. Assessment of patients at home would usefully use the CURB 65 approach using confusion, high respiratory rate, low blood pressure and aged over 65 as severity markers. In addition availability of pulse oximetry might identify the younger patient progressing to viral pneumonia.
Dr Irvine explained the work in which she had been involved over the previous 6 years in planning for possible scenarios of pandemic flu. This involved a comprehensive structure of groups and committees covering various aspects of medical and social services within the Greater Glasgow area. She was an enthusiastic proponent of planning to improve the effectiveness of response should a pandemic occur. She outlined 3 separate planning scenarios which represented moderate, severe and worst case pandemic events. The moderate corresponded approximately to the 1957 and 1968 pandemics and the severe with 25% of the population affected and 1.5% case fatality ratio was approximately equivalent to 1918. She was dubious about the benefit of planning for the worst case scenario with a 50% incidence and a 2.5% case fatality and perhaps implied that discussions of such scenarios might risk an element of scare mongering. A severe pandemic would mean for Greater Glasgow and Clyde at the peak of infection a weekly toll of 65,000 cases and 970 deaths. The pressure on the Health Service is inevitably increased by an estimate of 2.500 cases and 37 deaths being in Health Service staff leading to a minimum of 12% staff absence. The increased workload applies to both primary care with a doubling of GP consultations and hospital work with a 50% increase in admissions. Discussions of the sort of scenario included comment on differing possible responses from medical staff – those who would find extra work time impossible and others who would rise to the challenge presented by the workload. Dr Irvine also touched on the problem of Tamiflu and the potential difficulties of deciding how a stockpile of antiviral therapy might effectively be used and whether it would in fact make a difference to outcomes.
Finally Dr Robertson addressed broader issues arising from influenza planning. His background is as a Consultant in Emergency Medicine. He had been seconded for a period of some months to work on influenza planning and had been impressed by the extensive work already done in government to look at the implications of a pandemic across various aspects of public life – not just health and social services but maintenance of other services, provision of goods, and law and order. Much of his own work involved raising awareness of the issue particularly in medical groups around the country. There are examples of detailed planning at both international and national level. The global surveillance of influenza viruses is comprehensive and allows the possibility of vaccine development. The response in the Far East with the cull of poultry when H5N1 first arose was impressive. Local responses can be adjusted according to the characteristics of a pandemic outbreak e.g. whether young adults are substantially affected. There was particular planning to deal with young children who are super spreaders of infection presumably because of close contact. Issues of the benefit and drawbacks for example, of school closure arise. Ethical issues which may be posed by pandemic flu are being addressed by a national working party. This already has papers from the WHO addressing ethical challenges for individuals, health service groups and governments. There are inevitably huge uncertainties. In the Health Service these apply to the availability of primary care cover, the capacity of emergency departments, and the availability of High Dependency or Intensive Care facilities. However, there is the possibility of new treatments becoming available, and biological techniques in this area are advancing steadily – the characterisation of the SARS vaccine took 48 days compared to around 8 years for HIV. His final comment was an observation on excellent working relationships within the different health service and government departments involved in this planning.
Mr Ritchie in concluding the evening commented on the range of pessimism and optimism encompassed in this topic and thanked the speakers warmly for contributing to an informative and stimulating evening.
03 December, 2006
Pandemic Influenza - Part 1: The virologist and the physician
Listen to Part 1 of the Pandemic Flu symposium on your mp3 player or computer.
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Further reading:
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25 October, 2006
Minutes of Glasgow Southern Medical Society - Presidential Address on 12 October 2006
Minutes of Glasgow Southern Medical Society
Presidential Address on 12th October 2006
Dr David Ritchie, Consultant in Accident & Emergency Medicine presented his Presidential Address to 31 members of the audience. He described the situation in Glasgow around 1870s when there were various hospitals in Glasgow for Specialist Problems but no general hospital in the South Side and for that reason Ebenezer Duncan and other members of the society worked to establish a hospital in the Victoria Infirmary site. At that time there were 250,000 people living in the area around the hospital. In the 1800s 30% of deaths were due to infectious diseases such as tuberculosis and there were 170 infant deaths per 1,000 births.
In 1900 there were 860 patients admitted to the hospital in its first year. The Victoria Infirmary now has 600 beds when the Mansionhouse Unit is included. Now the infant mortality rate is in single figures per 1,000 live births.
In Dr Ritchie's work in Accident & Emergency he has found that he can do all the good things of medicine as described by his first boss:
He can do the best for his patients
He can educate, train and inspire juniors
He can do research.
Emergency care has always been part of medical training for all doctors at some time. In an emergency you do your best. There is a painting in the waiting room in Glasgow Royal Infirmary's Gate House which shows people in period costume waiting around 1910 to be seen. The only change noted is the change in the costume.
Dr Plant in 1970 perfonrmed a pilot study of how to look after a "Casualty Department". He suggested different levels of departments run by Casualty Surgeons, Senior Doctors or even single handed casualty departments. Casualty was always the poor relation.
Departments have increased in numbers over the years. Originally Medical Students learned to suture in the departments and this clearly did not give patients the best deal. Accident & Emergency does not only deal with trauma. GP, Hospitals and Accident & Emergency Departments often share the same patients. Accident & Emergency is also used for training Paramedics, Nurses and Doctors. Trainees still need to be supervised.
In USA the ATLS system was introduced dealing with advanced trauma and life support. This was started following an air crash in Wyoming where a doctor looked after his family who were passengers in crash and were severely injured. He was concerned about the poor quality at the local hospital and he produced the ATLS system which is now run by the American College of Surgeons. This gives structure to dealing with training in life support courses with training and accreditation.
There is no shortage of people wanting to go into Accident & Emergency Medicine. Dr Ritchie attended a career meeting where the Anaesthetic Department managed to attract two people to their stand and Accident & Emergency attracted forty.
Accident & Emergency is also associated with long hard shifts and there is an early learning curve with structured teaching programmes. Shift work appeals at first and "doing things for people".
Imaging has improved dramatically over the years and thrombolysis if necessary has to be given within 30 mintues and this is only possible in A&E. This may be necessary in the future dealing with strokes. The Victoria A&E already has its blood gas analyser, machines for measuring U+E's and lactate.
In the future there may be a large number of Community Casualty Units for what is described as "minor" cases. Clearly the definition of minor is important and quite difficult.
In the Accident & Emergency Dept 80% of patients are seen by Juniors. In General Practice 80% of patients are seen by fully qualified GP's. The future plan would be for 80% of patients in A&E Departments to be seen by trained doctors.
The Victoria Infirmary looks after 250,000 patients the same number as when the
Victoria Infirmary was started. The Victoria Infirmary is about to to be closed.
The meeting was then laid open to questions. The first question was about how many A&E Depts are needed in Glasgow. In reply Dr Ritchie told us that in USA a trauma centre is based in an area where there are 5,000,000 patients. In Scotland the only area good enough to have a trauma centre is Aberdeen which has all specialites including Surgery, Orthopaedics, Intensive Therapy, Anaesthetics and Accident & Emergency all in the one area. He suggested that three A&E Depts would be necessary in Glasgow, although there are clearly going to be two A&E Depts.
Dr Prakash gave an excellent vote of thanks summarising some of the salient parts of the speech.
The meeting was very well appreciated by the members.
Dr William P McKean
Presidential Address on 12th October 2006
Dr David Ritchie, Consultant in Accident & Emergency Medicine presented his Presidential Address to 31 members of the audience. He described the situation in Glasgow around 1870s when there were various hospitals in Glasgow for Specialist Problems but no general hospital in the South Side and for that reason Ebenezer Duncan and other members of the society worked to establish a hospital in the Victoria Infirmary site. At that time there were 250,000 people living in the area around the hospital. In the 1800s 30% of deaths were due to infectious diseases such as tuberculosis and there were 170 infant deaths per 1,000 births.
In 1900 there were 860 patients admitted to the hospital in its first year. The Victoria Infirmary now has 600 beds when the Mansionhouse Unit is included. Now the infant mortality rate is in single figures per 1,000 live births.
In Dr Ritchie's work in Accident & Emergency he has found that he can do all the good things of medicine as described by his first boss:
He can do the best for his patients
He can educate, train and inspire juniors
He can do research.
Emergency care has always been part of medical training for all doctors at some time. In an emergency you do your best. There is a painting in the waiting room in Glasgow Royal Infirmary's Gate House which shows people in period costume waiting around 1910 to be seen. The only change noted is the change in the costume.
Dr Plant in 1970 perfonrmed a pilot study of how to look after a "Casualty Department". He suggested different levels of departments run by Casualty Surgeons, Senior Doctors or even single handed casualty departments. Casualty was always the poor relation.
Departments have increased in numbers over the years. Originally Medical Students learned to suture in the departments and this clearly did not give patients the best deal. Accident & Emergency does not only deal with trauma. GP, Hospitals and Accident & Emergency Departments often share the same patients. Accident & Emergency is also used for training Paramedics, Nurses and Doctors. Trainees still need to be supervised.
In USA the ATLS system was introduced dealing with advanced trauma and life support. This was started following an air crash in Wyoming where a doctor looked after his family who were passengers in crash and were severely injured. He was concerned about the poor quality at the local hospital and he produced the ATLS system which is now run by the American College of Surgeons. This gives structure to dealing with training in life support courses with training and accreditation.
There is no shortage of people wanting to go into Accident & Emergency Medicine. Dr Ritchie attended a career meeting where the Anaesthetic Department managed to attract two people to their stand and Accident & Emergency attracted forty.
Accident & Emergency is also associated with long hard shifts and there is an early learning curve with structured teaching programmes. Shift work appeals at first and "doing things for people".
Imaging has improved dramatically over the years and thrombolysis if necessary has to be given within 30 mintues and this is only possible in A&E. This may be necessary in the future dealing with strokes. The Victoria A&E already has its blood gas analyser, machines for measuring U+E's and lactate.
In the future there may be a large number of Community Casualty Units for what is described as "minor" cases. Clearly the definition of minor is important and quite difficult.
In the Accident & Emergency Dept 80% of patients are seen by Juniors. In General Practice 80% of patients are seen by fully qualified GP's. The future plan would be for 80% of patients in A&E Departments to be seen by trained doctors.
The Victoria Infirmary looks after 250,000 patients the same number as when the
Victoria Infirmary was started. The Victoria Infirmary is about to to be closed.
The meeting was then laid open to questions. The first question was about how many A&E Depts are needed in Glasgow. In reply Dr Ritchie told us that in USA a trauma centre is based in an area where there are 5,000,000 patients. In Scotland the only area good enough to have a trauma centre is Aberdeen which has all specialites including Surgery, Orthopaedics, Intensive Therapy, Anaesthetics and Accident & Emergency all in the one area. He suggested that three A&E Depts would be necessary in Glasgow, although there are clearly going to be two A&E Depts.
Dr Prakash gave an excellent vote of thanks summarising some of the salient parts of the speech.
The meeting was very well appreciated by the members.
Dr William P McKean
23 October, 2006
Presidential Address - Mr David Ritchie
Listen to Mr David Ritchie's Presidential Address on your mp3 player or computer.
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Further reading:
tags:
medicine
emergency medicine
Listen again:
Download [ mp3] 40.4Mb
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Further reading:
tags:
medicine
emergency medicine
05 October, 2006
Notice of meeting: Presidential Address - 'Casualty to Accident and Emergency'
Thursday 12th October, 2006
"Casualty to Accident and Emergency"
David Ritchie reflects on the raw reality of A&E life and on how on earth he got there. How did ‘Casualty’ develop from a Cinderella extra into ‘Accident and Emergency’ as the central focus of the acute sector?
Mr David Ritchie
Consultant in Accident and Emergency, Victoria Infirmary
Buffet supper 6.15 for 7.00pm
Ebenezer Duncan Centre, Victoria Infirmary, Glasgow
If you are a member of the Society and you would like to book for the pre-meeting buffet, please email 'Buffet' and your name to: Lesley.O'Donnell@gvic.scot.nhs.uk
"Casualty to Accident and Emergency"
David Ritchie reflects on the raw reality of A&E life and on how on earth he got there. How did ‘Casualty’ develop from a Cinderella extra into ‘Accident and Emergency’ as the central focus of the acute sector?
Mr David Ritchie
Consultant in Accident and Emergency, Victoria Infirmary
Buffet supper 6.15 for 7.00pm
Ebenezer Duncan Centre, Victoria Infirmary, Glasgow
If you are a member of the Society and you would like to book for the pre-meeting buffet, please email 'Buffet' and your name to: Lesley.O'Donnell@gvic.scot.nhs.uk
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