Brit doctors strike over dangerous work changes

Picture credit: William Perugini / Shutterstock.com

Junior doctors working in British public hospitals are set to go on strike in landmark industrial action following the failure to resolve a dispute over safe working hours and pay rates.

The British Medical Association has announced that a 24-hour strike planned for 12 January will go ahead because it remains at loggerheads with the Government and the National Health Service (NHS) over planned changes it warns will increase doctor fatigue, compromise patient safety and undermine staff retention and recruitment.

During the strike, which has the backing of hundreds of other NHS staff including nurses, health care assistants and porters, junior doctors will provide emergency care only. Similar strike action is planned for 26 January, and junior doctors are threatening full withdrawal of their labour on 10 February if the dispute is not resolved by then.

The action centres on a push by Health Secretary Jeremy Hunt to roster more doctors on the weekend and water down safeguards against excessive hours without offering any extra compensation.

The Minister’s plans were overwhelmingly rejected by junior doctors in November, when 98 per cent voted to strike. The BMA called off a strike planned for late last year and instead organised mediated talks with the Government and the NHS.

But, in a statement issued last week, BMA Council Chair Dr Mark Porter accused the Government of failing to take doctor concerns seriously.

“Throughout this process, the BMA has been clear that it wants to reach agreement on a contract that is good for patients, junior doctors and the NHS,” Dr Porter said. “This is why, despite overwhelming support for industrial action, the BMA instead sought conciliation talks with the Government; talks which were initially rejected and delayed by Jeremy Hunt.

“After weeks of further negotiations, it is clear that the Government is still not taking junior doctors’ concerns seriously.

“We sincerely regret the disruption that industrial action will cause, but junior doctors have been left with no option.

“It is because the Government’s proposals would be bad for patient care as well as junior doctors in the long-term that we are taking this stand.”

The doctors and the Government appear to be close to reaching an agreement on changes to salary arrangements, including basing pay progression on undertaking greater responsibilities and the principle of pay for all work done.

But the two sides are deadlocked on rostering changes.

To fulfil Mr Hunt’s vision for a “seven-day NHS”, the Government wants junior doctors to work to a round-the-clock, seven-day week roster without any additional compensation.

The BMA said junior doctors were willing to work with the Government on ways to realise the Minister’s goal, but “only in a sustainable way that does not make a career in medical practice in the UK less attractive”.

“This is a significant area of disagreement,” the Association said. “The BMA fundamentally rejects the idea that Saturday is a normal working day and should be paid as a weekday.”

Doctors are particularly concerned that the Government is trying to push through rostering changes without sufficient safeguards.

The BMA said patient and doctor safety must be the primary focus, and raised fears that the arrangements sought by Mr Hunt and employers could result in “extremely detrimental rotas for non-resident on-call shifts”, including forcing doctors to work the day after being on-call, without an adequate break.

It said there needed to be limits set on working hours “to ensure that patients are not treated by tired, overworked doctors”. This should include caps on hours worked per shift, the number and type of shifts worked in each rolling seven-day period, and provision for adequate breaks.

The BMA said that in addition to ensuring patient and doctor safety, such safeguards would improve the ability of the NHS to attract and retain staff.

“Ensuring that junior doctors are paid fairly for work they do in unsocial hours will go some way to addressing recruitment problems in specialties that work most intensely across 24 hours,” it said. “This is crucial in order to safeguard the future workforce of the NHS.”

Mr Hunt has condemned the proposed strike, saying it “helps no-one”.

He claimed that the only outstanding area of disagreement was cuts to weekend pay, implying the industrial action was unnecessary.

Adrian Rollins

[Series] Pre-hospital emergency medicine

Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes.

[Comment] Myocardial infarction: rapid ruling out in the emergency room

Patients with symptoms of possible acute coronary syndrome make up a large proportion of people who present to emergency departments, where they undergo lengthy, intensive, and costly assessments.1,2 Yet few are finally diagnosed with an acute coronary syndrome. Improvements in methods to exclude acute coronary syndrome are needed to reliably reassure and safely discharge low-risk patients who can then proceed to further investigations as outpatients. High-sensitivity cardiac troponin assays are reliable and have low thresholds of detection.

Genders experience pain differently, and women have it more

More women than men suffer from chronic pain, described as pain that persists for more than six months. In addition, much of this pain remains undiagnosed or untreated.

As well as the pain associated with menstruation or the bearing of children, waiting rooms of pain physicians, rheumatologists and gastroenterologists show clear majorities of women.

Research has found the only pain conditions more common in men are the relatively infrequent cluster headaches (where strong pain occurs on one side of the head), nerve pain after shingles, ankylosing spondylitis (a form of spinal arthritis) and migraine without perceptual disturbances of light and smell (called “aura”).

Everything else – from pelvic pain, irritable bowel syndrome, all other headaches, multiple sclerosis, rheumatoid arthritis, jaw pain, bladder pain syndrome, fibromyalgia, chronic regional pain syndrome to odontalgia (painful teeth) – is more common in women.

Men and women also describe pain differently. Research found women tended to use more descriptive, graphic language with a focus on sensory symptoms. Men were more likely to express anger or swear, but recalled the event more objectively.

Male subjects’ written responses were shorter and less detailed, with potential influences being gender role expectations of pain response, a male reticence to report painful sensations and feelings of embarrassment when reporting a pain experience.

History of thinking about pain

We understand pain in others best when we have real or imagined shared experience. Pain in women is frequently both unable to be visualised (unlike lacerations or other visible injuries) and outside the experience of their health professional.

How to view the female patient with pain that can’t be seen is a problem the Ancient Greeks pondered as early as 400 BC. Faced with a complex range of suffering and complaints in women, Ancient Greek physicians came up with a novel explanation: the “wandering womb”. The womb was believed to move upward in a woman’s body whenever it became hot and dry, searching for cool moist places, and causing stress and damage to her physical and mental well-being.

Hippocrates (460-370 BC) used the term “hysteria”, which derives from the Greek word “hysteros” for “womb”, to describe a wide variety of female emotional and physical conditions. By inference this labelled women in pain as weak, inferior or irrational. Parallel to their inferior social position in Ancient Greece, Aristotle (384-322) used the concept of hysteria in his book, The Nicomachean Ethics, as proof that women were unsuitable for public office.

Genders experience pain differently, and women have it more - Featured Image

There’s a common belief that women have a higher pain threshold so they can give birth, but actually men’s pain threshold is higher.

While such beliefs seem far-fetched today, the diagnosis of “hysteria” continued to be commonly used in European medical practice to describe a wide variety of symptoms in women for the next 2,000 years. Only in 1980 was it removed from the DSM III Manual of Psychiatric Disorders.

Unlike women, historical accounts of men’s pain have been influenced by their ability to withstand injuries incurred in warfare. As English poet William Cowper (1792) noted, incitements including “renown and glory” helped men disregard pain on the battlefield.

Research in pain

In 1977, with concern about the risk that new drugs might have on an undiagnosed pregnancy, the US Food and Drug Administration recommended that all women who were capable of becoming pregnant be excluded from drug trials. The presumption was that pain research in men would be applicable to both genders. While well intentioned, the consequence of this decision has been that the majority of pain research has been undertaken in male humans or male rodents.

This decision has since been reversed, and research into pain differences between the sexes has dramatically increased. While results have at times been conflicting, what we are learning is that females consistently show lower pain thresholds and increased pain following a painful stimulus than males. This doesn’t mean women are weaker than men or their pain isn’t real, but they feel pain more intensely than men.

Pains specifically associated with women, such as menstrual pain, may predispose women to feeling pain more acutely in other areas. Women’s brains produce less endorphin (which inhibits pain) following a pain stimulus than men. Yet when morphine is given to treat pain, it generally works equally well in either gender.

Clearly there is still a lot to learn about gender and pain. Newer thinking suggests that pain in men and women may even occur through entirely different mechanisms and pain pathways.

For example, microglia are cells from the immune system involved in chronic pain. Research in mice has shown that drugs that prevent activation of microglia are effective in reducing pain in male, but not female, mice.

So, the observed differences in ability to withstand acute pain on a battlefield (traditionally associated with males) and ability to withstand the pain of chronic disease (more commonly associated with females) may prove to have a physiological basis.

Every one of our cells knows whether we are male or female and responds accordingly. That there are differences between male and female pain should not be surprising.

This article was originally published on The Conversation. Read the original article. This article is part of a series focusing on Pain. Read other articles in the series here.

Other doctorportal blogs

5 hospital presentations that GPs could help prevent

New research suggests over half a million hospitalisations could be avoided if patients had visited their doctor earlier.

The National Health Performance Authority’s report found there were 22 conditions for which hospitalisation was considered to be potentially preventable.

They found that 600,267 hospitalisations in 2013-14 could have potentially been prevented and five conditions specifically account for almost half (47%) of all potentially preventable hospitalisations.

The five conditions are:

Chronic obstructive pulmonary disease (COPD) –10.4% of potentially preventable hospitalisations.
Diabetes complications – 6.8% of potentially preventable hospitalisations.
Heart failure – 8.9% of potentially preventable hospitalisations.
Cellulitis – 9.7% of potentially preventable hospitalisations.
Kidney and urinary tract infections (UTIs) – 10.4% of potentially preventable hospitalisations.

The report found that among the 300 local areas, age standardised rates of potentially preventable hospitalisations were nine time higher in some areas compared to others, “ranging from 1,406 per 100,000 people in Pennant Hills-Epping (NSW) to 12,705 hospitalisations per 100,000 in Barkly (NT).”

It also found that people in regional and remote areas and from a lower socioeconomic status often have higher rates of potentially preventable hospitalisation.

“This may be due to poorer health among people living in these areas and, potentially, poorer access to health care services provided in the community,” the report suggests.

Authors of the report say focusing on these five conditions can help PHNs target efforts on areas where there can be potential for great improvement.

The RACGP declined to comment on the report.

Latest news:

Flight into danger

Picture: Dr Jenny Stedmon on deplotyment with the Red Cross to the Philippines following Typhoon Haiyan

It was not getting in to Ebola-struck Sierra Leone that most worried Red Cross medico Jenny Stedmon – it was getting out again.

“I flew in on an Air France flight, and the day after I arrived they stopped flying. All borders were shut,” she recalls. “It was a very volatile situation.”

Dr Stedmon, an emergency physician and anaesthetist, was a member of one of the first medical teams deployed by the Red Cross to Sierra Leone as the scale of the west African outbreak – which would eventually claim more than 11,000 lives – started to become clear in mid-2014.

The Brisbane-based anaesthetist, who has worked as a volunteer for the Red Cross for more than 20 years, was among the first medical specialists the humanitarian organisation contacted as it organised its initial response to the unfolding crisis.

A week after getting the call Dr Stedmon, leaving behind a worried husband, found herself immersed in a medical emergency the like of which she had not encountered before through deployments as far afield as Thailand, Yemen, Sudan, East Timor, Nepal and the Philippines.

Before each deployment, the Red Cross sends their volunteers oodles of information, and ensures they have the supplies and equipment they will need when they arrive.

But because nothing like the Ebola outbreak had been encountered before, Dr Stedmon admits all were going in “a little blind”.

The mission was to set up an Ebola treatment centre on the grounds of one of Sierra Leone’s main hospitals to help cope with the flood of cases arriving on a daily basis.

“Everyone was on a learning curve,” Dr Stedmon remembers. “I had never put on personal protective equipment in my life. There was a lot of fear.”

The Red Cross team learned what they could from World Health Organisation workers who had already been in-country for some time, and did what they could.

As an anaesthetist, Dr Stedmon usually works as part of the surgical team. But in emergency situations such as this, people just pitched in where they could provide the greatest help.

In battling Ebola, she found most of her time spent delivering medicines, water and food to the sick: “This was really basic health care delivery”.

After a month working in such a physically and emotionally demanding environment, Dr Stedmon and her colleagues were due to be rotated out.

But getting out of a country isolated by the international community was always going to be a challenge, and so it proved.

Eventually, she was driven across Sierra Leone to the border with Guinea where a waiting canoe carried her and her suitcase across the river. It was a white-knuckle ride, with the humanitarian worker more than a little alarmed by the strong possibility she might drown.

Once across, she was taken to an airfield at “a little place in the middle of nowhere”. Her fellow travellers included a health worker who was the sole survivor of a team massacred by frightened villagers who believed they were spreading Ebola rather than trying to fight it.

The experience caused Dr Stedmon to reflect that, “You never know where the danger is going to come from.”

Though danger is an inescapable part of working in areas afflicted by war or disaster, Dr Stedmon has never been directly attacked.

“I have been lucky so far,” she said. “I have never actively been involved in a violent act [and] I have never been impeded in my work.”

But she has had some good friends who have not been so lucky.

One of her best friends, New Zealand nurse Sheryl Thayer, was among six Red Cross workers assassinated by gunmen in a brutal attack on a field hospital near Grozny in Chechnya in 1996.

Another friend was seriously injured when a land mine blew up the Red Cross vehicle she was riding in near Fallujah in Iraq.

The Red Cross itself takes the safety and security of its staff and volunteers very seriously, Dr Stedmon said.

During her deployment in 2004 to the Yemen civil war, for example, the organisation took care to make sure the field hospital she worked at was away from the front lines, and even though there was “a lot of shooting going on, none [was] near us”.

Similarly, during the Sudan civil war, Dr Stedmon worked at a field hospital set up right on the border with Kenya, and patients were flown in by plane for care for everything from snake and hyena bites to landmine injuries and gunshot wounds.

Through all these deployments, Dr Stedmon has generally found local people and combatants, from whatever side, have respected the Red Cross’s neutrality.

But she is worried that a shift in attitude seems to be underway that could render Red Cross work ever more hazardous.

“I would never say it’s not dangerous…but I get the feeling there is erosion of respect and knowledge of the symbol [going on],” Dr Stedmon said. “Most people are reasonable, but there appears an increasing number of situations where there is no respect.

“It’s probably getting more dangerous to work for the Red Cross than when I started. That is my gut feeling.”

It is why Dr Stedmon is so passionate in her support for the ICRC’s Health care in Danger project, which aims to highlight attacks on health workers and educate combatants about the need to respect Red Cross neutrality.

“The time has come for the medical profession to stand up and say it’s not acceptable. We should be able to treat people in safety.”

What it is like to volunteer for the Red Cross

Training:

Three-day basic training course;

Week-long medical course drawing on expertise in areas like war surgery and emergency medicine.

Pre-deployment:

Detailed briefing notes; vaccinations; medical kits

Deployment:

Duration – typically three months, though in intense disaster response situations one month.

Equipment and supplies – apart from personal belongings, everything else supplied.

Support – extensive network of experienced in-country staff look after travel, accommodation, logistics

Costs – Red Cross covers air fares, food and shelter, and provides a per diem

Work absence – Dr Stedman has the support of her employer, Redlands Hospital, and takes unpaid leave for duration of deployment (gives them some scope to employ a locum if needed).

Post-deployment: extensive debriefing

Adrian Rollins

Summer reads

Australian Medicine suggests a selection of books to stimulate and entertain this summer.

Honour, Duty, Courage. By Mohamed Khadra. Penguin Random House; 249 pages; $34.99

What drives doctors with good jobs and loving families to risk life and limb by volunteering to work in some of the most hazardous places in the world? In his latest book, Sydney-based surgeon Mohamed Khadra sets out to answer that question, interviewing dozens of health professionals about their experiences working as volunteers for the Australian Army Medical Corps. He creates two fictionalised characters to recount their stories, and what emerges is a portrait of people imbued with a strong sense of duty (and a penchant for adventure) who are severely tested, physically, mentally and emotionally. Deployed to a forward surgical unit in a war-torn country that could be Rwanda, Afghanistan or Iraq, the book’s two protagonists – emergency surgeon Dr Jack Foster and anaesthetist Dr Thomas McNeal – are confronted with extremes of human depravity and deep ethical dilemma as they cope with a relentless flow of casualties from all sides of the conflict. Khadra gives a sympathetic account of the often harrowing situations such volunteers confront, and how these experiences stay with them long after the deployment ends.

The Gluten Lie: And other myths about what you eat. By Alan Levinovitz. Black Inc; 272 pages; $22.99

For his day job, Alan Levinovitz researches religious myths to find out what they mean and why they are persuasive. With this background and expertise, it is no wonder he has turned his attention to the world of food. Few areas are as prone to fads, half-digested ideas and quackery than what we eat. Flick through any newspaper or magazine, or surf the web, and you will be quickly hit with advice about the latest ‘super-food’, fad diet or poisons lurking in what you eat. In his brightly written and tightly-argued book, Levinovitz seeks to chart how some of the big myths about food of our times have emerged and taken hold, causing many into dietary contortions as they seek to confine themselves to ‘safe’ foods. He examines the science and shows how mass beliefs, in some cases verging on hysteria, about MSG, salt, sugar, grains, meat and gluten have arisen, mostly based on very thin evidence. Unlike diet books, Levinovitz doesn’t dispense advice about what you should eat, but instead asks some hard questions of those who do.

Happiness by design: change what you do, not how you think. By Paul Dolan. Penguin Random House; 235 pages; $16.

For many years, the overriding advice for those seeking to improve their happiness has been to change their mindset. Bookshelves abound with tomes advising people to think their way to a good mood. But Paul Dolan takes a refreshingly different approach. Drawing on the latest research in behavioural economics and brain science, he draws some general conclusions. Climate, for instance, does not exert a major influence on satisfaction. Wherever people live, they acclimate to the weather and get on with other aspects of their lives. He repeats the well-founded observation that volunteering tends to be correlated with a great sense of purpose, while television is associated with a sense of pleasure. So, how do individuals improve their happiness. Following the dictum that attention shapes experience, Dolan advocates identifying the things in life from which you derive joy or contentment, and seeking to make room for more of these experiences. Hardly earth-shattering advice, but powerful in its own way. As a Scientific American reviewer observes, Dolan touches on an important idea: happiness need not be pursued, simply rediscovered. In other words, sources of pleasure and purpose are all around us, if only one knows where to look.

‘Everything presents at extremes…’ – a Solomon Islands experience

Pictgure: Dr Elizabeth Gallagher (second from left) with other staff and volunteers at the National Referral Hospital, Honiara

By Dr Elizabeth Gallagher, specialist obstetrician and gynaecologist, AMA ACT President

The mother lost consciousness just as her baby was born.

The woman was having her child by elective Caesarean when she suffered a massive amniotic fluid embolism and very quickly went into cardiac arrest.

We rapidly swung into resuscitation and, through CPR, defibrillation and large doses of adrenaline, we were able to restore her to unsupported sinus rhythm and spontaneous breathing.

But, with no equipment to support ventilation, treat disseminated intravascular coagulation, renal failure or any of the problems that arise from this catastrophic event, it was always going to be difficult, and she died two-and-a-half hours later.

Sadly, at the National Referral Hospital in Honiara, the capital of the Solomon Islands, this was not an uncommon outcome. Maternal deaths (both direct and indirect) average about one a month, and this was the second amniotic fluid embolism seen at the hospital since the start of the year.

I was in Solomon Islands as part of a team of four Australian practitioners – fellow obstetrician and gynaecologist Dr Tween Low, anaesthetist Dr Nicola Meares, and perioperative nurse and midwife Lesley Stewart – volunteering to help out at the hospital for a couple of weeks in October.

It was the first time I had worked in a developing country, and it was one of the most challenging, and yet satisfying, things I have ever done

Everything from the acuteness of the health problems to the basic facilities and shortages of equipment and medicines that we take for granted made working there a revelation.

The hospital delivers 5000 babies a year and can get very busy. As many as 48 babies can be born in a single 24-hour period.

The hospital has a first stage lounge and a single postnatal ward, but just one shower and toilet to serve more than 20 patients. The gynaecology ward is open plan and, because the hospital doesn’t provide a full meal service or much linen, relatives stay there round-the-clock to do the washing and provide meals.

From the beginning of our stay, it was very clear that providing training and education had to be a priority. I was conscious of the importance of being able to teach skills that were sustainable once we left.

The nature of the emergency gynaecological work, which includes referrals from the outer provinces, is that everything presents at the extremes…and late. Massive fibroids, huge ovarian cysts and, most tragically because there is no screening program, advanced cervical cancers in very young women.

When I first got in touch with doctors at the hospital to arrange my visit, I had visions of helping them run the labour ward and give permanent staff a much-needed break. But what they wanted, and needed, us to do was surgery and teaching.

To say they saved the difficult cases up for us is an understatement. I was challenged at every turn, and even when the surgery was not difficult, the co-morbidities and anaesthetic risks kept Dr Meares on her toes.

In my first two days, the hospital had booked two women – one aged 50 years, the other, 30 – to have radical hysterectomies for late stage one or early stage two cervical cancer. I was told that if I did not operate they would just be sent to palliation, so I did my best, having not seen one since I finished my training more than 12 years ago.

I also reviewed two other woman, a 29-year-old and a 35-year-old, both of whom had at least a clinical stage three cervical cancer and would be for palliation only. This consisted of sending them home and telling them to come back when the pain got too bad.

It really brought home how effective our screening program is in Australia, and how dangerous it would be if we got complacent about it.

We found the post-operative pain relief and care challenged. This was because staffing could be limited overnight and the nurses on duty did not ask the patients whether they felt pain – and the patients would definitely not say anything without being asked.

Doing our rounds in our first two days, we found that none of the post-operative patients had been given any pain relief, even a paracetamol, after leaving theatre.

We conducted some educational sessions with the nursing staff, mindful that the local team would need to continue to implement and use the skills and knowledge we had brought once we left. By the third day, we were pleased to see that our patients were being regularly observed and being offered pain relief – a legacy I hope will continue.

The supply of equipment and medicines was haphazard, and depended on what and when things were delivered. There was apparently a whole container of supplies waiting for weeks for clearance at the dock.

Many items we in Australia would discard after a single use, like surgical drains and suction, were being reused, and many of the disposables that were available were out-of-date – though they were still used without hesitation.

Some things seemed to be in oversupply, while others had simply run out.

The hospital itself needs replacing. Parts date back to World War Two. There were rats in the tea room, a cat in the theatre roof, and mosquitos in the theatre.

The hospital grounds are festooned with drying clothes, alongside discarded and broken equipment – including a load of plastic portacots, in perfect condition, but just not needed on the postnatal ward as the babies shared the bed with their mother.

It brought home how important it is to be careful in considering what equipment to donate.

The ultrasound machine and trolley we were able to donate, thanks to the John James Memorial Foundation Board, proved invaluable, as did the instruction by Dr Low in its use.

The most important question is, were we of help, and was our visit worthwhile?

I think the surgical skills we brought (such as vaginal hysterectomy), and those we were able to pass on, were extremely useful. Teaching local staff how to do a bedside ultrasound will hopefully be a long-lasting legacy. Simple things like being able to check for undiagnosed twins, dating, diagnosing intrauterine deaths, growth-restricted babies and preoperative assessments will be invaluable.

The experience was certainly outside our comfort zone, and it made me really appreciate what a great health system we have in Australia, and what high expectations we have. I want to send a big thank you to the John James Memorial Foundation for making it all possible.

Govt under pressure as hospitals stumble

Mounting evidence that public hospitals are struggling to make headway in meeting key performance benchmarks is increasing the pressure on the Federal Government to agree on a permanent boost to funding as part of any overhaul of Commonwealth-State health arrangements.

Australian Institute of Health and Welfare figures show that the performance of public hospitals is slipping back as massive funding cuts announced in the 2014-15 Federal Budget begin to bite.

The proportion of urgent emergency department patients receiving treatment within the recommended time fell back in 2014-15 from 70 per cent to 68 per cent – brining to an end six years of continuous improvement and leaving performance well short of the target of 80 per cent, which was due to be reached two years ago.

The goal for all emergency department visits to be completed within four hours, which was meant to be achieved this year, has also been missed.

The results bear out warnings made by the AMA earlier this year that the Commonwealth’s funding cuts for hospitals would undermine the delivery of care.

Launching the AMA’s annual Public Hospital Report Card in April, President Professor Brian Owler said the Federal Government’s cuts – amounting to $57 billion in the next 10 years – were creating “a huge black hole in public hospital funding”.

“It’s the perfect storm for our public hospital system,” he said. “There’s no way that states and territories can even maintain their current frontline clinical services under that sort of funding regime, let alone build any capacity we actually need to address the shortfalls now.”

Health Minister Sussan Ley rejected the warnings at the time, but the latest evidence of declining performance are likely to make it increasingly difficult for the Government to win State backing for an overhaul of funding arrangements without more money on the table.

Late last week the nation’s leaders were due to discuss a proposal by South Australian Premier Jay Weatherill to increase the goods and services tax to 15 per cent, with the proceeds to go to the Commonwealth. In exchange, the states would be given a guaranteed slice of income tax revenue.

Weak growth in consumer spending has undermined the flow of revenue to the states from the GST, making it increasingly difficult for them to fund fast-growing demand for public hospital services.

Mr Weatherill said giving states a slice of the faster-growing income tax take would enable them to keep funding health.

The states have been ramping up the pressure on the Commonwealth over the impact of its spending cuts.

Queensland Health Minister Cameron Dick told a meeting of the nation’s health ministers last month that the Coalition Government’s cuts would slash $11.8 billion from the State’s hospital system. The Victorian Government has calculated it stands to lose $17.7, while New South Wales has figured a $16.5 billion loss, South Australia $4.6 billion, Western Australia $4.8 billion and Tasmania $1.1 billion.

The big cuts form a challenging backdrop for discussions of reform to Federal-State relations that include proposals for Commonwealth public hospital funding to be replaced by a “hospital benefit payment” that would follow individuals, similar to Medicare.

Government discussions of changes to the private health insurance industry have included reference to option two in the Reform of the Federation Discussion Paper, which proposes a Medicare-style payment for hospital services, regardless of whether they are provided in the public or private system.

Under the arrangement, the price of hospital procedures would be set by an independent body and the Commonwealth would pay a proportion. For patients in the public system, the states would be expected to make up the difference, while in private hospitals the gap would be covered either by insurers or the patients themselves.

States would retain responsibility and operational control of public hospitals, and would be able to commission services from the private sector, while the Commonwealth would discontinue the private health insurance rebate.

Adrian Rollins

Americans shooting themselves in the foot: the epidemiology of podiatric self-inflicted gunshot wounds in the United States

The United States is home to about one third of all firearms worldwide, with 90 guns for every 100 American citizens.1 It is therefore perhaps not surprising that gunshot wounds (GSWs) are among the leading causes of injury in the US.2,3 The statistics indicate that 93% of the wounded are men, 56% are unemployed, and 56% tested positive for drugs or alcohol after the incident.4–6 As the incidence of GSWs is increasing, epidemiological studies that provide insight into their general nature and the circumstances in which they occur are useful for developing preventive education. Further, an understanding of terminal ballistics is important for determining the appropriate clinical management of GSWs.

The extent of injury inflicted by a GSW is determined by the energy of the primary projectile, its dissipation in the tissue, and the generation of secondary projectiles following osseous injury. The kinetic energy of a bullet before impact is equal to half its mass multiplied by its velocity squared; the energy of a projectile thus increases exponentially with its velocity. In order to maximise mass (and minimise energy loss caused by air resistance), bullets are often made with pointed or rounded tips from metals with a high specific gravity, such as lead. The energy transferred to the tissue after impact is the difference in kinetic energy of the bullet as it enters and leaves the tissue. This difference is dependent on the bullet’s diameter on impact and the density of the tissue. The more a bullet deforms or mushrooms on impact, the greater the amount of energy transferred to the tissue.7,8

High-velocity projectiles create large temporary cavities that fill with water vapour, causing tissue damage and wound contamination distal to the primary tract of the bullet. When a bullet collides with a dense object, such as bone, secondary missiles may be generated, the number of which increases with the velocity of the bullet.9 These secondary missiles have less predictable trajectories and often do more soft tissue damage than the primary projectile. The velocity of the bullet is thus a primary determinant of tissue damage.

The foot has a number of anatomical and biomechanical features that make it unique in terms of GSW injury and management. The function of the foot depends on its ability to painlessly and efficiently transfer the energy generated by the leg muscles into locomotion. Unlike long bone and other joint injuries, low-velocity GSWs to the foot often result in significant morbidity, and are managed in the same manner as high-velocity injuries. The ratio of bone to soft tissue in the foot is high, with a particularly large number of articular surfaces. More than 80% of GSWs to the foot result in osseous injury,10 and such fractures frequently generate secondary projectiles that damage the densely populated neurovascular structures. The resulting inflammation and haemorrhage within the restricted fascial compartments of the foot predispose to compartment syndrome and other complications.

Management includes antibiotic therapy, operative debridement, bone stabilisation, revascularisation and soft tissue coverage. Low-velocity GSWs to the foot have traditionally been treated with intravenous antibiotic therapy for 1–5 days,11–14 followed by operative assessment of soft tissue contamination and irrigation. However, it is now generally accepted that both low- and high-velocity injuries require careful debridement of non-viable soft tissue and non-essential osseous fragments to prevent necrosis and wound infections.13–20 As mentioned earlier, the vast majority of GSWs to the foot involve intra-articular osseous injury. Even low-velocity injuries may require both internal and external percutaneous fixation of fractures to achieve adequate alignment.21 High-velocity injuries are often allowed to heal by secondary intention, while others may require wound closure with myocutaneous flaps, skin grafting or, in extreme cases, amputation.

Until now there has been no large-scale epidemiological examination of the injury characteristics and circumstance of GSWs to the foot. Given the anatomical and biomechanical features of the foot, these GSWs are unique in their presentation, and, while they have been studied on a case-by-case basis,22–24 the overarching trends of self-inflicted GSWs to the foot have not been investigated in a large sample. We undertook a large-scale epidemiological examination of Americans who had shot themselves in the foot.

Methods

Study sample

Using a stratified probability sample of all US hospitals with more than six beds that provide 24-hour accident and emergency services, the National Electronic Injury Surveillance System (NEISS) collected data for the period 1993–2010 as part of the Firearm Injury Surveillance Study. Based on the number of emergency department visits per year, hospitals were stratified as very large, large, medium or small. An additional stratum for children’s hospitals was also used. Between 1993 and 1996, 91 emergency departments were included in the sample. An additional 10 hospitals were added between 1997 and 1999, with two dropouts between 2000 and 2002; 99 hospitals were included in the sampling frame 2002–2010.

Data collection

NEISS, the primary data collection body for the Consumer Product Safety Commission, was responsible for data collection. Data on initial emergency department visits that resulted from non-fatal firearm-related injuries were extracted from the patients’ medical records.

Outcomes

The characteristics of the patients and the conditions in which each sustained self-inflicted GSWs to the foot were the primary outcomes.

Statistical analysis

All statistical analysis was conducted in Stata 12 (StataCorp). Participants were identified as either generic firearm victims or patients who had a self-inflicted GSW to the foot. χ² tests were used to compare the categorical variables of groups; ie, sex, age group, marital status, illicit drug use, involvement in criminal activities, weapon used, location of incident, and diagnosis. Logistic regression was undertaken for sex and marital status (married v not married).

Results

Of the 69 111 reported firearm-related injuries, 667 (1.0%) were self-inflicted GSWs to the foot. Individuals who shot themselves in the foot were typically men (597, 89.6%) aged 15–34 years (345, 51.7%). Incidents generally occurred in the home (381, 51.1%), involved a handgun (208, 31.2%) or BB gun (228, 64.2%) while the individual was neither committing a crime nor under the influence of alcohol. Significant differences between individuals who shot themselves in the foot and those who had other firearm-related injuries with respect to sex (χ² = 3.19, P = 0.048), age group (χ² = 116.39, P < 0.0001), marital status (χ² = 87.18, P < 0.0001), illicit drug use (χ² = 24.49, P < 0.0001), involvement in criminal activities (χ² = 330.79, P < 0.0001), weapon used (χ² = 457.56, P < 0.0001), location of the incident (χ² = 571.16, P < 0.0001) and the physician’s diagnosis (χ² = 273.18, P < 0.0001) were noted (Box 1).

Logistic regression indicated that individuals who shot themselves in the foot were significantly more likely than individuals with other firearm-related injuries to be male (odds ratio [OR], 1.28; 95% CI, 1.0–1.7) and married (OR, 2.6; 95% CI, 2.1–3.4).

Incidences of shooting oneself in the foot were most common in October, November and December (Box 2).

Discussion

Contrary to popular belief, incidents of Americans shooting themselves in the foot are relatively rare; the characteristics of these incidents, however, are unique. When these auto-foot shooters were compared with individuals who had sustained other firearm-related injuries, significant differences were noted in the demographic characteristics of the victim/assailant, weapon of choice, the circumstances of the incident, and the nature of the injury itself.

There are several limitations that must be acknowledged in the interpretation of these data. The study included only individuals who presented to US emergency departments with non-fatal firearm-related injuries, so that our comparisons cannot be generalised to the broader population. The primary source of most data was the individual who had shot themselves in the foot; while data about the injury were provided by health care professionals, information about the incident itself may be subject to self-report biases. A social desirability bias may have caused under-reporting of self-inflicted wounds, as individuals who shoot themselves in the foot may not be entirely forthcoming about the nature and cause of their injuries.

Never-married men between the ages of 15 and 34 years were the most common perpetrators of self-inflicted GSWs to the foot. Due to the disproportionate number of males who possess firearms, it is to be expected that the prevalence of these injuries would be higher among men. Of interest, however, was the strength of the relationship between being married and shooting oneself in the foot when compared with the odds of other firearms-related injuries and non-married self-saboteurs. These results are consistent with anecdotal reports from disgruntled spouses and depictions of married men in the mainstream media, such as sitcoms and reality television programs. However, due to the nature of our data, evidence-based generalisations to the broader American population cannot conclusively be made.

Shooting oneself in the foot was extremely uncommon during the commission of a crime or while under the influence of drugs; only five individuals shot themselves in the foot while committing a crime. Given that inhibitions are reduced and cognitive capacity diminished by drug use, it is a somewhat counterintuitive finding that the association of illicit drug use with shooting one’s foot was not stronger. An investigation into the relationship between alcohol use and self-inflicted podiatric injuries is an area for future research, given the ease of access to alcohol and the prevalence of alcohol use in other firearm-related injuries.

There was a strong positive correlation between the month of the year and the number of self-inflicted GSWs to the foot; a disproportionate number of incidents occurred in October, November and December. It is notable that these trends were much stronger than for other firearm-related incidents, with a relatively constant number of these incidents throughout the year.

The epidemiology of firearm-related podiatric trauma has been neglected until now; to our knowledge, ours is the first large-scale epidemiological investigation of GSWs to the foot or of self-inflicted GSWs to the foot. Given the anatomical and biomechanical features of the foot, the nature of the wounds caused by GSWs is unique. A major epidemiological study is required to examine overarching trends in the circumstances and scenarios in which these events occur. Although it may not be possible to prevent Americans from shooting themselves in the foot, large-scale investigations of the nature of these incidents provides invaluable information for those at greatest risk. Particular caution must be taken during the festive season if one is to avoid being caught under the missing toe.

Box 1 –
Characteristics of self-inflicted gunshot wounds to the foot

		Self-inflicted gunshot wounds to the foot		Other firearm-related injuries		P*
		Number	Percentage	Number	Percentage	P*

Number^†		667	1.0%	68 444	99.0%
Demographics
Sex (male)		597	89.6%	59 562	87.0%	0.048
Age	0–14 years	158	23.7%	7 691	11.2%	< 0.0001
	15–34 years	345	51.7%	45 286	66.2%
	35–54 years	134	20.1%	12 109	17.7%
	≥ 55 years	30	4.5%	2 843	4.2%
Marital status	Married	103	24.0%	6 117	11.6%	< 0.0001
	Never married	154	35.9%	26 826	51.0%
	Divorced or separated	21	4.9%	1 262	2.4%
	Other	8	1.6%	635	1.2%
	Not stated	143	33.3%	17 760	33.8%
The incident
Drugs involved		11	1.7%	1 644	2.4%	< 0.0001
Crime involved		5	1.0%	11 680	17.1%	< 0.0001
Weapon	Handgun	208	31.2%	19 002	27.8%	< 0.0001
	Rifle	80	12.0%	3 169	4.6%
	Shotgun	60	9.0%	2 697	3.9%
	BB gun	228	64.2%	10 094	14.8%
	Unknown	91	13.6%	33 482	48.9%
Location	Home	381	57.1%	14 661	21.4%	< 0.0001
	Farm	5	0.8%	109	0.2%
	Apartment or condominium	1	0.2%	75	0.1%
	Street or highway	12	1.8%	14 049	20.5%
	Other public area	24	3.6%	7 500	11.0%
	Mobile home	1	0.2%	112	0.2%
	School	1	1.0%	276	0.4%
	Recreational area	18	18.0%	1 140	1.7%
	Unknown	224	33.6%	30 473	44.5%
The injury
Diagnosis	Amputation	2	0.3%	128	0.2%	< 0.0001
	Contusion or abrasion	7	1.1%	3 936	5.8%
	Foreign body	164	24.6%	7 289	10.7%
	Fracture	75	11.2%	3 738	5.5%
	Laceration	25	3.8%	7 818	11.4%
	Puncture	265	39.7%	24 317	35.5%
	Avulsion	1	0.2%	99	0.1%
	Other	128	19.2%	16 680	24.4%

∗Self-inflicted wounds v other firearm-related wounds. †Number of injuries and percentage of all firearm-related injuries. All other percentages in the table are column percentages.

Box 2 –
Gunshot wounds in the United States, by month; expressed as a percentage of all foot- or non-foot-related incidents