“I should never have come on this cruise,” she groaned. “It was my husband who wanted us to go. I hate ships and loathe the sea, and now I feel sooo … ill.” This is Stage 1, or mild seasickness—nausea accompanied by self pity and, most importantly, the conviction that it is all someone else’s fault. In Stage 2, moderate seasickness, I am called out in the night to a darkened cabin where, as the ship gently rolls along, …

Routine spinal immobilization for trauma patients has become established in developed countries throughout the world. Cervical spinal injury is, however, relatively rare in trauma patients, and immobilization practice was developed largely without firm supporting evidence. In recent years, published evidence has suggested that spinal immobilization may in some cases be harmful. The purpose of this article is to critically review the evidence and the implications for trauma patient management and outcomes. We searched MEDLINE, the Cochrane Database, Index Medicus and article references with a broad search strategy. Relevant results were analysed and critically reviewed in the context of trauma patient management. Our findings present a growing body of evidence documenting the risks and complications of routine spinal immobilization. There is a possibility that immobilization could be contributing to mortality and morbidity in some patients and this warrants further investigation.

The Ageing Process Even if we did know what we should be selecting for and training in, the value of that knowledge would be limited by the fact that all of us change as we age. Valuable attributes used in initial selection may disappear over time in some surgeons, but not in others.2 For example, it might be felt that motivation and diligence would be considered key attributes when selecting young surgeons for training.3 However, we all know from our own experience that some surgeons continue their passion for surgery long past retirement age, while others burn out early and can then end up a problem to themselves and their surgical colleagues.4

This article reports the lessons learnt from a period of retraining and from discussion with others who have been involved in a similar process. The conclusions are that retraining should only be undertaken once there is full agreement between all parties involved that it is necessary and feasible. There must also be agreement in advance of the criteria which will constitute successful retraining, and the actions which will be taken to ensure the rapid return of the retrainee to the type of practice which is being offered and has been accepted. The process of retraining requires especially close supervision and is very stressful for the retrainee. It is likely that this should only be undertaken in units specially staffed and funded to accommodate this type of work.

If the public are to be assured that surgeons are safe, then there must be some form of competence assessment on which a licence to practice is based. However, the assessment and the licence needs to be both appropriate to the training received by the surgeon and to the requirements of the post they propose to take up. The 'key-concept' described in this paper attempts to address this problem.

The current method for selecting surgeons of the future is neither objective nor relevant to present day needs. An assessment is needed which ranks potential trainees according to aptitude, motivation and diligence, all of which is validated. This task should be a core duty for the Royal Colleges of Surgeons working in close co-operation with surgical specialty associations

Objective: To assess whether a new form of teaching, the ‘donut round’, is as good at imparting factual knowledge as interactive lectures in both the short-term and the long-term. Design: Randomised controlled trial. Setting: University of Oxford Medical School. Participants: 106 fifth year clinical medical students taught half of their A&E/trauma course by donut round and half by lecture. Main outcome measures: The results of multiple choice questions (MCQs) divided according to how the material was taught. Three MCQ papers were set: one at the end of a four-week course, one approximately 10 weeks later and a final exam approximately 17 months after the first. Results: At the first MCQ, the average result for questions taught by donut round was 41.0 (out of 50) and for those taught by conventional lecture was 40.1. At 10 weeks these averages fell to 36.3 and 37.3 and at 17 months they were 38.7 and 38.1, respectively. None of these pairs were significantly different. Ratios were calculated for each candidate by dividing their donut round score by their lecture score. The average ratios for the first, second and third MCQ papers were: 1.029,1.007 and 1.027, respectively, and were not significantly different. The individual ratios of all candidates in all three MCQs were plotted against their equivalent total mark. The calculated linear regression showed a statistically significant advantage of donut rounds over lectures in those candidates who scored a total mark less than 89 (n=260, p=0.02). Conclusions: Donut rounds are at least as good as lectures in imparting factual knowledge and may provide a selective advantage to weaker students

A three-day course was designed to improve the skills of those who provide clinical training to medical students. This long-term follow up of past participants shows a sustained improvement to their skills, especially in terms of involving students in their own learning, and giving them positive feedback.

EDITOR—Pringle, in his review of clinical governance in primary care, says that some underperformance is due to local deprivation and health inequities, some to poor systems of care, and some to under-resourcing.1 Where it is due to an individual, the cause may be a health problem or problems with competency or behaviour.1 As the bandwagon of clinical governance clatters down Mount Worthiness, may I make a small plea for those who suffer because of the job, and in whose interest, and …

Eds Delese Wear, Janet Bickel University of Iowa Press, £36.50, pp 215 ISBN 0 87745 741 7 Rating: ![Graphic][1] ![Graphic][2] The joy of being asked to review a book is that sometimes you end up reading something whose title alone would have convinced you that there were better uses of your time. Jude the Obscure would have approved of the title of this book. Some of the contents are equally woolly. However, there are three chapters that have made me think harder than I have for a long time. “Not difficult in an orthopaedic surgeon,” I hear you say. … [1]: /embed/inline-graphic-1.gif [2]: /embed/inline-graphic-2.gif

Previous trials of antiplatelet therapy for the prevention of venous thromboembolism have individually been inconclusive, but a meta-analysis of their results indicated reductions in the risks of deep-vein thrombosis and of pulmonary embolism in various high-risk groups. The aim of this large randomised placebo-controlled trial was to confirm or refute these apparent benefits.During 1992-1998, 148 hospitals in Australia, New Zealand, South Africa, Sweden and the UK randomised 13,356 patients undergoing surgery for hip fracture, and 22 hospitals in New Zealand randomised a further 4088 patients undergoing elective arthroplasty. Study treatment was 160 mg daily aspirin or placebo, started preoperatively and continued for 35 days. Patients received any other thromboprophylaxis thought necessary. Follow-up was of mortality and of in-hospital morbidity up to day 35.Among the patients with hip fracture, allocation to aspirin produced proportional reductions in pulmonary embolism of 43% (95% CI 18-60; p=0.002) and in symptomatic deep-vein thrombosis of 29% (3-48; p=0.03). Pulmonary embolism or deep-vein thrombosis was confirmed in 105 (1.6%) of 6679 patients assigned aspirin compared with 165 (2.5%) of 6677 assigned placebo, which represents an absolute reduction of 9 (SE 2) per 1000 and a proportional reduction of 36% (19-50; p=0.0003). Similar proportional effects were seen in all major subgroups, including patients receiving subcutaneous heparin. Aspirin prevented 4 (1) fatal pulmonary emboli per 1000 patients (18 aspirin-group vs 43 placebo-group deaths), representing a proportional reduction of 58% (27-76; p=0.002), with no apparent effect on deaths from any other vascular cause (hazard ratio 1.04 [95% CI 0.86-1.26]) or non-vascular cause (1.01 [0.84-1.23]). Deaths due to bleeding were few (13 aspirin vs 15 placebo), but there was an excess of 6 (3) postoperative transfused bleeding episodes per 1000 patients assigned aspirin (p=0.04). Among elective-arthroplasty patients, rates of venous thromboembolism were lower, but the proportional effects of aspirin were compatible with those among patients with hip fracture.These results, along with those of the previous meta-analysis, show that aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk. Hence, there is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.

Undisplaced fractures of the hip can occasionally be difficult to diagnose on radiographs. We performed MRI scans on 33 patients who had post-traumatic painful hips but negative radiographs. Forty per cent of the patients had sustained a fractured neck of femur, 15 per cent had sustained an intertrochanteric fracture and 11 per cent had sustained other fractures around the hip; in one patient a tumour was demonstrated. No fracture was seen in 30 per cent of the patients scanned. MRI is well tolerated by elderly patients in pain, does not involve ionising radiation and provides early and accurate diagnosis in patients with X-ray negative post-traumatic hip pain.

Trauma care in Britain came in for a battering last week when the BBC's science programme QED screened a drama purporting to show a real life case of medical negligence. Christopher Bulstrode examines the controversy surrounding Cause of Death Mark was just a nice, ordinary lad on a big motorbike that crashed. He was fine when he got to the hospital, apart from a few broken bones, but then things started to go wrong. Within a few days he was in the intensive treatment unit after a cardiac arrest. His brain never recovered, and when they switched off the ventilator the family was left devastated. …

benefit individual patients.24They need to be large enough to allow sufficient statistical power to answer the research questions posed.It is also known that only a small proportion of eligible patients are entered into such trials (for example, only 3-5% of patients with cancer in Britain are included in clinical trials4).Among the many reasons for this lack of accrual is a belief that multicentre trials do not officially recognise the considerable time and effort required by clinicians to identify suitable patients, obtain informed consent, and complete the necessary forms.Incentives to recruit patients into trials are required.We suggest that clinicians' vital contribution to randomised controlled trials should be acknowledged separately at the end of published papers.In large multicentre trials it is often not practical or desirable for all collaborating clinicians to be mentioned as authors of papers.Thus many people's efforts in recruiting patients to trials go unrewarded: they do not have publications to their name, and their research is denied the recognition that, since the publication of the Culyer report,' is now necessary to gain funding.Benefits could be gained if it became standard practice for all published papers to incorporate a list of clinicians who enrolled more than a (trial specific) number of patients into the trial.Not only would this acknowledge the important work of these clinicians in the trial but it would also provide evidence of their participation in research for academic assessment and for their curriculum vitae and provide kudos for the clinicians and their department.

though screening is demonstrably cost effective.4Foremost among the unresolved questions is the ability of physicians to treat bone disease once it is detected.The number ofknowledgeable physicians is increasing, but not enough for them to manage the 100-fold increase in caseload that could result from population screening.Today less than 5% of patients with fracture undergo densitometry, and less than one third of the potential patients with indications (for example, those taking corticosteroids or with malabsorption or hyperparathyroidism) are symptomatic.Barlow and col- leagues note that critics confuse clinical densitometry in patients showing symptoms or indications with screening.'Physicians must become educated about bone disease so that they can manage effectively the increased caseload that will result from justified use of densitometry, and they must not be misled by disingenuous arguments against screening.