Fish oil key in preventing pre-term babies

Taking fish oil supplements can extend pregnancy and reduce complications, according to new research.

While exploring a theory that fish oil might aid brain development in the foetus, South Australian researchers stumbled upon the finding that fish oil extends gestation by an average of two days.

The South Australian Health and Medical Research Institute is now looking to recruit a further 5500 pregnant women to take part in a wider study to test this initial finding.

While the discovery might see reluctant full-term babies requiring come coaxing by induction or caesarean section, it has major implications for preventing pre-term births.

The original study was designed to look at whether omega 3 fats were needed in supplement form during pregnancy to help reduce the risk of post-natal depression and improve developmental outcomes for babies.

Lead researcher, Professor Maria Makrides, said that, “what we found was that it didn’t seem to do that, but the really interesting data we found was that we saw this shift in the mean duration of gestation that resulted in a halving of the number of babies born at less than 34 weeks”.

“It [fish oil] reduced the proportion of births at less than 34 weeks by about 50 per cent – they are the infants that are most likely to need intensive care, and most likely to suffer morbidities of being born pre-term,” Professor Makrides told the Adelaide Advertiser.

“They often can’t breathe properly, and sometimes do have developmental problems as they grow, so the burden on the child, family, and society if often quite large.

“If we are shifting the gestation then this is a really important outcome.”

The study also found that more women required obstetric intervention because their pregnancies were continuing too far beyond term.

The new study will ask women to take a supplement daily, with some women given fish oil and others vegetable oil. Once the women reach 34 weeks gestation they will be taken off the oil.

Professor Makrides said stopping the supplements at 34 weeks will hopefully allow women to get the full benefit of avoiding early prematurity, without extending gestation beyond the expected delivery date.

“This is a safe and cheap potential solution that can easily be applied to everyone,” Professor Makrides said.

Pregnant women interest in taking part of the study can call 08 81617458.

Kirsty Waterford

Transplantation of the heart after circulatory death of the donor: time for a change in law?

Australia has an increasing shortfall in transplantable hearts. Over the past decade, the number of all donors per million population increased from 10.0 in 20051 to 16.1 in 2014.2 However, the number of heart donations per million population over the same period has declined slightly from 3.8 to 3.4, with an annual average of 3.3.3 Procurement of organs has always been conducted according to the dead donor rule — that is, after death of the donor — but this practice is being challenged.

The law defines death in all Australian jurisdictions (eg, in s 41 of the Human Tissue Act 1982 [Vic]) as either “irreversible cessation of all functions of the brain” (brain death) or as “irreversible cessation of circulation of blood in the body” (circulatory death), but it does not define irreversible or how to determine irreversibility (Box). Exceptionally, circulatory death is not defined in Western Australian legislation.

Although the procurement of organs such as livers, kidneys and lungs is permitted after either brain death or circulatory death according to Acts in all jurisdictions, the procurement of hearts has traditionally only been from brain dead donors with functioning hearts. The definition and diagnosis of brain death is not without controversy4,5 and may explain in part why more reliance is being placed on circulatory death, which reduces availability of hearts.6,7 Alternatively, organ procurement from patients after circulatory death may be perceived as more realisable than after brain death. Indeed, circulatory death as the source of solid organs has increased from 10% of 204 donors in 2005 to 28% of 378 donors in 2014.1,2 More total organs have been procured (from 726 to 1193) but the number of hearts has increased only slightly from 72 of 204 donors (35%) to 79 of 378 donors (21%) over the same period.1,2 Only 39 hearts were procured from 189 donors (21%) during the first 6 months of 2015.8

Organ donation and procurement after circulatory death

In the practice of organ donation after circulatory death (DCD), life-sustaining treatment such as mechanical ventilation is commonly withdrawn because of a devastating neurological injury that has not progressed to brain death. The withdrawal of treatment from the donor is staged to facilitate organ transplantation to recipients. The procurement of organs is specified in the Australian national DCD protocol published by the Organ and Tissue Authority9 and enacted through the DonateLife network. It is not declared why the heart is not included in the protocol’s list of organs that may be procured.

Expeditious organ procurement may be commenced after death has occurred — defined in Australia as 2–5 minutes after cessation of the donor’s circulation,9 and after 2 minutes in United States.10 The donor’s arrested heart has not usually been procured. However, to increase the availability of hearts, routine procurement after circulatory death is proposed but not yet sanctioned in the current national DCD protocol.9 It is probable that the protocol is under review given that the Organ and Tissue Authority lauded St Vincent’s Hospital in Sydney, where two adults were transplanted with hearts procured after circulatory death in 2014.11 In those cases, the donor hearts were reanimated and kept beating and warm inside a container (ex-vivo Organ Care System, TransMedics) pending transplantation.12

This practice poses ethical,13 legal and medical problems. Foremost of the medical difficulties is the poor condition of the procured heart after it has ceased to circulate blood in the donor. However, the heart can be resuscitated with the aid of extracorporeal techniques, as was performed for the two adult recipients at St Vincent’s Hospital.11,12

Heart transplantations after cardiac death have been performed in three infants in North America14 but were followed by consternation and a medical call for a moratorium on all organ procurement after cardiac death and the accusation that doctors and hospitals were biased towards organ procurement.15 The basis for the opposition was that the infants may not have been dead and possibly were conscious at the time of organ procurement. Of the three infants, one was declared dead 3 minutes after cessation of cardiocirculatory function before the process of organ procurement was initiated, and two were declared dead after 75 seconds.14

Medical interpretation of the legal definition of death

The source of the problem of heart transplantation after circulatory death is the medical interpretation of the legal definition of circulatory death. From a medical point of view, in other contexts, death is not necessarily defined by cessation of the circulation, unless it is of sufficient duration to result in brain death. It is not rare, for example, to be able to resuscitate a victim from a short duration cardiac arrest with complete neurological recovery or to sustain the circulation of a patient for lengthy periods by an extracorporeal circulation with subsequent intrinsic cardiac recovery.

The fact that a transplanted heart can function and sustain life in a recipient must mean that the circulation of the donor is never ceased irreversibly and therefore that the donor of the heart is never dead until his or her heart is removed.

The question is thus posed — how is it possible to procure the heart of a donor under the premise of circulatory death and yet expect it to sustain life in a recipient? Put differently, should the procurement of the heart be a criminal offence in such cases, because its procurement is the cause of death of the donor?

A possible argument to justify heart procurement for transplantation after circulatory death is that legal irreversible cessation of the circulation may be interpreted medically as “will not be resuscitated” rather than “cannot be resuscitated”. However, that interpretation does not appear to be open to the medical profession. From a legal point of view, the meaning of legislation is governed by statute law. In the jurisdiction considered here, it is the Interpretation of Legislation Act 1984 (Vic) and Acts Interpretation Act 1901 (Cwlth) that apply, but these are not helpful in defining “irreversible”.

If a word or phrase is not defined in an Act, resort is made to common law interpretations, which may be described as literal or purposive. The literal interpretation of legislation was defined by Justice Higgins in the High Court of Australia as:

The fundamental rule of interpretation, to which all others are subordinate, is that a statute is to be expounded according to the intent of the Parliament that made it; and that intention has to be found by an examination of the language used in the statute as a whole. The question is, what does the language mean; and when we find what the language means, in its ordinary and natural sense, it is our duty to obey that meaning, even if we think the result would be inconvenient or impolitic or improbable.16

The literal approach may be too restrictive if a word or phrase has more than one meaning. In such instances, legal resort is made to a reputable dictionary — in Australia, usually the Macquarie Dictionary. Since that dictionary defines “irreversible” as “not reversible; that cannot be reversed”, a legal and hence medical interpretation of irreversible cannot logically be “will not be resuscitated”. Doctors cannot simply redefine the meaning of words in legislation to suit their practice.

Notwithstanding that the natural and ordinary meanings of words are the starting points in interpreting Acts,17 a purposive interpretation may be considered when a literal approach produces ambiguity or inconsistency (Acts Interpretation Act, s 15AA). Such an interpretation would be one that best achieves the purpose or object of the Act, whether expressly stated or derived from the content of the Act.

In Victoria, the stated aim of the Human Tissue Act is to make provision for removal of human tissue for transplantation and, among other aims, to provide a definition of death. The purpose of defining death is not declared but s 26 of the Act allows a designated officer and medical officers to remove tissue for transplantation only when the proposed organ donor has fulfilled the definition of death under s 41. In other words, a purpose of the Act is to prevent tissue and organ procurement from a donor who is not dead. Thus, heart procurement for transplantation under the practice of DCD is not possible under either a literal or purposive interpretation of the Act.

A similar problem with the interpretation of legislation has occurred in the United States, where death is defined in the Uniform Determination of Death Act 1982, on which Australian legislation has been modelled. The US Act also defines circulatory death as “irreversible cessation of circulatory and respiratory functions”. In a purposive approach, Bernat18 has proposed that as doctors diagnose death by permanent cessation of circulatory and respiratory functions, this satisfies the requirements of death statutes and does not violate the dead donor rule. Bernat also proposes that “permanence is a perfect surrogate indicator for irreversibility” and thus permits heart donation after DCD. This argument is similarly not sustainable. The Macquarie Dictionary defines “permanent” as “lasting or intended to last indefinitely; remaining unchanged; not temporary; enduring; abiding”. Clearly, a heart that has ceased functioning in a donor and functions later in a recipient has not ceased functioning irreversibly or permanently. Moreover, permanent cessation of the circulation is not the legal definition of death, and the concept, wrong that it is, is similarly not available to doctors to justify heart transplantation after circulatory death.

Another putative justification for heart procurement after DCD is that, whereas the heart may have stopped irreversibly in the donor’s body, it is able to function in that of the recipient. This is also a spurious argument, because the only reason that the heart stops in the donor is the elective, and hence reversible, withdrawal of life-sustaining treatment such as mechanical ventilation. The heart had obviously been functioning well in the donor’s body before its procurement.

Possible solution

This potential problem of heart procurement being the cause of the donor’s death arises because death has been mistakenly defined in the legal sense as cessation of the circulation, without any reference to brain function. A possible alternative would be to retain the present definition of brain death as irreversible cessation of all function of the brain, but to omit the requirement for irreversibility in the definition of circulatory death and to redefine it as cessation of circulatory function with cessation of higher brain function. Under this proposition for the redefinition of circulatory death for the purpose of transplantation, procurement of a heart for the purpose of its transplantation could proceed without legal risk and without risk of retained consciousness of the donor.

Conclusion

Organ transplantation is ethical whether after brain death or circulatory death, and it is proper to maximise organ procurement, but only as permitted by law. We have shown that heart transplantation after DCD does not conform to present statute law. When the way forward is not clear in a medicolegal conundrum such as this one, legislation needs to be refined. Otherwise, as some legal academics have argued,19 procurement of a heart after cardiac death for transplantation under present legislation does not conform to the dead donor rule. This may be a potential criminal offence, an accusation that may need to be made in order to encourage law reform. Alternatively, the dead donor rule, which would arguably be violated in heart transplantation after circulatory death, needs societal, legal and medical debate followed by revision or abandonment.13 Otherwise, Australia’s improving organ donor program is at risk of adverse publicity and damage if doctors, hospitals and our organ procurement agencies are perceived as procuring organs from patients not legally dead.

Australian statute law governing procurement of organs for transplantation

Jurisdiction

Act

Provision

NSW

Human Tissue Act 1983

s 33

Qld

Transplantation and Anatomy Act 1979

s 45(1)

Transplantation and Anatomy Act 1983

s 24(2)

Death (Definition) Act 1983

s 2

Tas

Human Tissue Act 1985

s 27A

Vic

Human Tissue Act 1982

s 41

Human Tissue and Transplant Act 1982∗

s 24(2)

ACT

Transplantation and Anatomy Act 1978

s 45

Transplantation and Anatomy Act 2014

s 23

∗Note: circulatory death is not defined in Western Australian legislation.

Obituary – Dr Patricia Mackay

Dr Patricia Mackay’s outstanding contribution to the Australian community for more than 50 years, particularly her advances in patient safety and surgery, will be remembered following her death earlier this month.

Born in New Zealand in a small town south of Dunedin, Dr Mackay started her medical journey at the Otago Medical School. In an interview with Dr Christine Ball in 2008, Dr Mackay said that at medical school she was assigned to undertake a caesarean section by herself, and despite the obstetrician saying she shouldn’t worry about anaesthetic because the baby was dead, the baby turned out to be alive. Dr Mackay said this moment made her career.

Dr Mackay made the move to Australia to take the post-graduate examination. She started as a clinical assistant at the Alfred and Royal Melbourne Hospital. Dr Mackay had a long and proud history at the Royal Melbourne Hospital. She was the first female appointed as Head of Anaesthesia in 1984, a position she held until 1992. Dr Mackay established the first acute pain management unit in Victoria while at the Royal Melbourne Hospital.

She was among a small group of anaesthetists who founded the Australian Patient Safety Foundation and started the Anaesthetic Incident Monitoring Study, a national anonymous collection of incidents with the objective of finding out things that went wrong. The study continues to this day.

Dr Mackay held Secretary and Treasurer positions before taking on the role as President of the Australian Society of Anaesthetists from 1966-1968. She served as chair of the Victorian Consultative Council on Anaesthetic Mortality and Morbidity from 1991 until 2005.

In 1999, the AMA granted a life membership to Dr Mackay, and she was awarded the AMA Women in Medicine Award in 2001. She was also awarded the Australian and New Zealand College of Anaesthetists Medal. In 2008, Dr Mackay was awarded a Medal of the Order of Australia – for service to medicine in the field of clinical anaesthesia, particularly as a contributor to the improvement of quality and safety of patient care, and to the community.

Dr Mackay made remarkable contributions to medicine, especially her efforts in patient safety. She was a wonderful role model for generations of anaesthetists, both male and female, and her passion and dedication to the profession will not be forgotten.

Kirsty Waterford

[Perspectives] Medicine’s uncanny valley: the problem of standardising empathy

A month after my father died of heart failure in a cardiac intensive-care unit in my hometown, I flew back to Baltimore to finish my final year of medical school. Although I was apprehensive about returning to the hospital, I knew that the full schedule would be a welcome distraction. Still, I was surprised how easily I fell back into the old routine of attending morning rounds, admitting patients, writing progress notes, and presenting cases to the head physician.

AMA updates stance on Climate and Health

Following an extensive engagement process with members, the AMA updated its Position Statement on Climate Change and Human Health (Revised 2015), which was last revised in 2008.

The updated Position Statement takes account of the most recent scientific evidence.

AMA President Professor Brian Owler said the AMA Position Statement focuses on the health impacts of climate change, and the need for Australia to plan for the major impacts, which includes reducing greenhouse gas emissions.

“It is the AMA’s view that climate change is a significant worldwide threat to human health that requires urgent action, and that human activity has contributed to climate change,” Professor Owler said.

“The evidence is clear – we cannot sit back and do nothing.

“There are already significant health and social effects of climate change and extreme weather events, and these effects will worsen over time if we do not take action now.

“The AMA believes that the Australian government must show leadership on addressing climate change.

“We are urging the Government to go to the United Nations Climate Change Conference in December in Paris with emission reduction targets that represent Australia’s fair share of global greenhouse gas emissions.

“There is considerable evidence to convince governments around the world to start planning for the major impacts of climate change immediately.

“The world is facing a higher incidence of extreme weather events, the spread of diseases, disrupted supplies of food and water, and threats to livelihoods and security.

“The health effects of climate change include increased heat-related illness and deaths, increased food and water borne diseases, and changing patterns of diseases.

“The incidence of conditions such as malaria, diarrhea, and cardio-respiratory problems is likely to rise.

“Vulnerable people will suffer the most because climate change will have its greatest effect on those who have contributed least to its cause and who have the least resources to cope with it.

“The Lancet has warned that climate change will worsen global health inequity through negative effects on the social determinants of health, and may undermine the last half-century of gains in development and global health,” Professor Owler said.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) states that:

· Australia should adopt mitigation targets within an Australian carbon budget that represents Australia’s fair share of global greenhouse gas emissions, under the principle of common but differential responsibilities.

· Renewable energy presents relative benefits compared to fossil fuels with regard to air pollution and health. Therefore, active transition from fossil fuels to renewable energy sources should be considered.

· Decarbonisation of the economy can potentially result in unemployment and subsequent adverse health impacts. The transition of workers displaced from carbon intensive industries must be effectively managed.

· Regional and national collaboration across all sectors, including a comprehensive and broad-reaching adaptation plan is necessary to reduce the health impacts of climate change. This requires a National Strategy for Health and Climate Change.

· There should be greater education and awareness of the health impacts of climate change, and the public health benefits of mitigation and adaptation.

· Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.

The AMA Federal Council last month passed a policy resolution acknowledging the need for the healthcare sector to reduce its carbon footprint through improved energy efficiency, green building design, alternative energy generation, alternative transport methods, sustainable food sourcing, sustainable waste management, and water conservation.

The AMA Position Statement on Climate Change and Human Health (Revised 2015) is available at position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

John Flannery

[The Lancet Commissions] Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer.

[Comment] Global surgery—going beyond the Commission

In September, 2013, a small group met at the Lancet offices in London to begin planning for a Lancet Commission on Global Surgery. Our aim was to improve access to safe and affordable surgery and anaesthesia care. Our remit, to define the current global surgery landscape, review best practices, and make recommendations. The domains that we were to consider were health systems, workforce, information management, and finance.

Nation pays high price for unnecessary tests, unproven treatments

Cracking down on inefficient and clinically unnecessary practices like over-ordering diagnostic tests, prescribing inappropriate medications and using unproven or speculative treatments could save the health system more than $15 billion a year, a leading epidemiologist has said.

In a provocative speech to the AMA National Conference in which he called for a transformation in the way in care is conceived and delivered, Associate Professor Ian Scott said up to 30 per cent of health spending was wasteful or went on procedures and treatments that were of little benefit or could actually be harmful.

A/Professor Scott, who is director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital, said while some interventions and treatments, like vaccination programs, public health campaigns, chemotherapy, renal dialysis and some cancer screening programs were effective uses of scarce health funds, the pay-off from many other practices was more questionable.

He questioned the bias in the medical profession to provide intensive care, including “heroic interventions”, for very ill patients – 30 per cent of health funds are spent on health care in the last year of life, including $2.4 billion on providing hospital care to the elderly – and suggested a more conservative approach involving a shift in focus away from treatments that do not improve survival beyond six months or enhance quality of life.

One of the oft-cited sources of inefficiency and cost blow-outs in the health system is in the area of diagnosis, including the tendency to over-prescribe diagnostic tests.

Much of this has been attributed to the rise of “defensive medicine”, which MDA National Manager of Medico-legal and Advisory Services, Dr Sara Bird, defined as the ordering of treatments, tests and procedures “primarily to help protect the doctor from liability”, rather than to substantially advance patient diagnosis or treatment.

Dr Bird, who addressed the same AMA National Conference policy session as A/Professor Scott, said that although the incidence of defensive medicine was difficult to measure, evidence suggested it was widespread.

In the United States, 96 per cent of specialists practising in fields at high risk of litigation confessed to practising defensively, including 43 per cent who reported ordering unnecessary diagnostic imaging tests.

Dr Bird said the situation appeared to be similar in the United Kingdom, where almost 80 per cent of hospital-based doctors said they practised defensive medicine, including 60 per cent who admitted ordering unnecessary tests and 55 per cent who said they made unnecessary referrals.

In Australia, research indicates that doctors who have been the subject of legal action are much more likely to practise defensively – 55 per cent ordered more tests and 43 per cent made more referrals than was considered usual.

A/Professor Scott said that in addition to unnecessary tests, often clinicians provided treatments that were of little or no value.

He lauded the National Prescribing Service’s Choosing Wisely initiative, under which so far more than 200 routinely used treatments have been placed under scrutiny.

The Federal Government has also commissioned a review of Medicare Benefit Schedule items, led by Sydney Medical School Dean Professor Bruce Robinson, to scrutinise and assess the appropriateness of more than 5500 listed services.

AMA President Professor Brian Owler has cautiously welcomed the reviews.

Professor Owler said that although it was important to rigorously assess the value and appropriateness of procedures and treatments, it was vital the process was not driven primarily a search for savings, and that it had the support and involvement of medical colleges and societies.

A/Professor Scott warned of “indication creep”, where a treatment proved to be of benefit to one group of patients is uncritically applied more broadly , such as cardioverter defibrillators, cardiac resynchronisation pacemakers and transcatheter aortic valves.

He urged a much more considered and cautious approach to the use of new interventions until there was rigorous evaluation of their safety and effectiveness.

A/Professor Scott said told the conference that clinical guidelines should take into account cost-effectiveness in recommending interventions.

He said often less intensive and cheaper management regimes for conditions such as bleeding peptic ulcers and urinary tract infections in children were just as safe and effective as higher-intensity regimens.

A/Professor Scott recommended that analyses of the comparative cost effectiveness be an integral part of the assessment of each new service or intervention.

He told the conference this cost-effectiveness approach should also inform the selection of patients for a particular treatment.

The epidemiologist said interventions should be targeted to those who would derive greatest benefit.

Adrian Rollins

Penetrating neck injury in an isolated medical setting

Clinical record

A 34-year-old man presented to a small rural emergency department at 21:45, arriving by private car from a bush campsite some 45 minutes’ drive away. An empty “stubbie” beer bottle had been recapped and thrown on the fire. It subsequently exploded, showering glass fragments onto surrounding people, one of whom sustained a small penetrating neck injury (PNI) with a piece of glass lodging in his anterior neck.

On arrival at the hospital, the patient had removed the glass and was clutching his neck with paper towels, describing a feeling of blood in the back of his throat, with associated haemoptysis.

He had a Glasgow Coma Scale score of 15, with normal vital signs, and was found to have a 1 cm wound just above his cricoid cartilage slightly to the right of midline. There was minimal active bleeding externally, but air occasionally bubbled from the wound and surgical emphysema was palpable on the right side of his neck. He was most comfortable slightly head down on his right side, and was maintaining O2 saturation of 99% in room air, with no clinical evidence of pneumothorax.

In consultation with Adult Retrieval Victoria, the attending anaesthetic-trained rural general practitioner decided to proceed to rapid sequence intubation (RSI) with an oral endotracheal tube (ETT) before evacuation to a tertiary centre.

With assistance from the nursing staff and a second anaesthetic-trained rural GP, the patient was pre-oxygenated with deep spontaneous breaths and a successful RSI under direct laryngoscopy was performed. For easier insertion, a size 7.5 cuffed ETT was placed. Blood was present on the vocal cords, but the oropharynx was clear.

Mechanical ventilation was carried out initially with a portable unit (Weinmann Medumat Standard-a), on minute volume cycle with a minimum available pressure of 20 cm H2O. Subsequent chest x-ray showed extensive surgical emphysema (Figure) and air mediastinum, at which point he was moved to the operating theatre to allow lower pressure ventilation using an anaesthetic ventilator. The ETT was shifted further down the trachea to tamponade the site of traumatic injury, and reduce bleeding and tissue emphysema.

Assisted ventilation at the hospital continued until 01:38, when the retrieval team arrived by road ambulance some 4 hours later.

He was transferred by road ambulance to the tertiary hospital, arriving at 04:22, where investigation with computed tomography (CT) angiography excluded any vascular injury. A surgical tracheostomy and tracheal repair was undertaken at 12:40 later that day. He spent over 24 hours in the intensive care unit on mechanical ventilation before making a full recovery.

Penetrating neck injury is commonly related to violence in countries such as the United States and South Africa,1 but it is rarer in Australia. This case report highlights the challenges and importance of initial management of a PNI in an isolated medical service, and the importance of health education around campfire safety.

The initial management of a PNI in a patient with a patent airway and who is haemodynamically stable with no signs of vascular injury is generally now considered to involve CT vascular imaging and selective surgical management.2,3 In an isolated medical facility without access to these services, management options are more limited. Initial treatment involves management of actual and potential airway complications together with stabilisation of vascular injury and resultant haemorrhage, with a plan for early evacuation to an appropriate tertiary facility for definitive care.

Our patient was haemodynamically stable and clinically had no obvious evidence of a significant vascular injury. The penetrating glass fragment was described as small, although not seen by the medical staff as the patient had removed it before arrival. The ongoing haemoptysis and palpable surgical emphysema suggested airway injury, and potential risks associated with haematoma formation and airway obstruction during transport led to the decision to perform rapid sequence endotracheal intubation. This is thought to be the safest initial airway management when anatomical structures are preserved,2,4 although definitive surgical airway management would be required at the tertiary centre.

Incorrect ETT placement, inadequate seal, or excessive ventilator pressure, may lead to acute deterioration where tracheal injury exists. This is particularly important in a remote medical setting, where considerable delay can occur before transport to an appropriate tertiary care facility, which could have become a critical issue in our case had the patient not been haemodynamically stable.

Despite standard transport immobilisation protocols, the literature recommends that cervical spine immobilisation is not required unless focal neurological deficits are present.2 Penetrating neck injuries (particularly stabbing) rarely cause spinal cord injury,5 and cervical collars can impede airway visualisation or evidence of other injuries. Our patient had no clinical evidence of spinal cord injury and no mechanism of injury to suggest one, so a cervical collar was not applied, making it easier to intubate as well as to monitor and assess the injury site.

Many outdoor recreation activities involving campfires occur in isolated environments, with limited access to medical and emergency services. In such situations, burns are an increasing concern,6 either from falls or exploding containers.7 This case demonstrates the additional risk of projectiles from exploding containers irresponsibly placed into fires. Although common sense dictates that it is risky to throw sealed containers into open fires, anecdotally it is often done when alcohol consumption is combined with open fires in a relaxed bush environment.

This case suggests that appropriate initial management of PNIs in an isolated rural setting can include careful endotracheal intubation until later surgical management with a definitive surgical airway. In addition, it reinforces the public health message that responsible behaviour reduces risk — particularly when setting an example and providing health education messages to the next generation. This case was unusual, but the clinical and public health lessons it provides are perhaps generalisable.

Lessons from practice

Management of penetrating neck injury in an isolated setting involves stabilisation and endotracheal intubation.
Cervical spine immobilisation is not required with penetrating neck injury unless focal neurological deficits are present.
Rapid sequence intubation is a useful skill for general practitioners to have when working in a rural setting.

X-ray of the patient’s neck and upper chest after initial intubation

Red arrow: surgical emphysema. Black arrow: tip of endotracheal tube.

Death due to intravenous use of α-pyrrolidinopentiophenone

To the Editor: Sellors and colleagues report a fatality where urine drug testing (UDT) failed to detect the drug of overdose detected on the coronial blood assay.1 This highlights how clinical care may be handicapped by older testing technology.

Historically, UDT was used for forensic and occupational safety testing. Medicare subsidises UDT that relies on an immunoassay and on standards designed for forensic and occupational safety purposes. The target substances and cut-off values are potentially inappropriate for contemporary use. When prescribing opioid analgesia for chronic pain,2 palliative care or emergency care, physicians need to know whether psychoactive substance use is complicating presentations or whether there may be drug diversion.3 Limitations of UDT include failure to detect buprenorphine, fentanyl, oxycodone (except at very high levels), anabolic steroids, synthetic cannabinoids and most designer and emerging drugs.1,2

Clinicians who wish to test for the presence of specific substances using refined and state-of-the-art technology such as mass spectrophotometry may find that laboratories are unwilling to assist because of the high cost of infrastructure, including highly trained personnel and expensive equipment. Where available, the effort and costs associated with the detection of novel substances is prohibitively expensive. Currently, these confirmatory tests are not subsidised by Medicare. Thus the costs of these tests may be passed on to consumers, who may be unwilling to pay for them.

The case described by Sellors et al presents a timely opportunity for a review of the UDT Medicare subsidy so that it can adequately support diagnosis and improve clinical outcomes.