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Preference: Emergency Medicine

202

Pertussis control: where to now?

Improving protection against pertussis requires sorting the facts from the artefacts

Pertussis is a disease of significant morbidity and, in infants, mortality. Regrettably, even though there is greater than 20-fold reduction in pertussis burden with immunisation,1 it persists globally as a significant public health problem. For more than two decades, Australia has had the highest reported rates of pertussis in the world.2 In the 1990s, this was driven by the introduction of mandatory reporting by laboratories of positive test results for vaccine-preventable diseases to the National Notifiable Diseases Surveillance System and extensive use of serological tests for diagnosis, primarily in adults.3 Unlike many other countries, all positive test results in Australia are included in national data. Also, testing for pertussis by polymerase chain reaction (PCR) has qualified for reimbursement since 2008, after which a sevenfold increase in testing of children in general practice was documented.4 Pertussis epidemics occurred sequentially across Australia from 2008 to 2012 and, unlike previous epidemics, the highest notification rates were for children under 10 years of age. This raises the question of whether Australia’s “pertussis problem” is related to vaccines with poor effectiveness or is an artefact of testing.

Observational methods are used to measure vaccine effectiveness (VE) (also known as “field efficacy”). The screening method enables estimation of VE if the vaccination status of patients with a case of the disease and population vaccine coverage are known — the more effective the vaccine, the lower the likelihood of patients with a case of the disease having been vaccinated compared with the source population.5 The screening method performs best when about 50% of the population is vaccinated. When vaccine coverage is over 90%, estimates of VE change substantially with small changes in population coverage estimates. In this issue of the Journal, Sheridan and colleagues use the screening method to estimate VE for acellular pertussis vaccine in Queensland children during an epidemic in 2009 and 2010.6 They found that VE for three doses in children aged from 1 to < 4 years was over 80%. However, similar to studies in the United States,7,8 VE fell significantly and progressively in children over 5 years of age, whether they had received four or five doses. It was previously reported that among Queensland children born in 1998, those who had received one or more doses of whole-cell pertussis vaccine were significantly better protected than those who had received only acellular vaccine, especially after 6 years of age.9 A national study, which included Queensland data from 2009, took a different approach — cases were individually matched by birth date to children on the Australian Childhood Immunisation Register and were limited to children younger than 4 years.10 Similar VE estimates were obtained for the first 2 years of life, but, in contrast to findings from the Queensland study, there was a significant and progressive fall in VE between ages 2 years and 4 years (the latter being the age at which children were eligible for the fourth dose).

Importantly, Sheridan et al were also able to evaluate testing patterns by age, showing that the overall number of PCR tests increased in the second year of the Queensland epidemic.6 Also, in children aged over 5 years, although PCR tests were less commonly performed, the results were more commonly positive.6 This is probably due to older children with cough being less likely to present to general practice and less likely to be tested, suggesting that notification rates of pertussis would have been even higher if more testing had been done. Disease severity is also an important consideration: assessing the disease burden from pertussis cases in older children is valuable, and VE is expected to be lower for less severe illness.5 Apart from the requirement for hospitalisation, against which VE was high for children younger than 1 year3 and 1–4 years,10 few data on severity are available. In a recent New South Wales study using linked hospitalisation and pertussis notification data, it was found that only 2% of children over 5 years who had pertussis were hospitalised, but 8% had been taken to an emergency department.11

What conclusions can we draw from these studies? First, the current acellular vaccines are highly effective in preventing severe pertussis, especially in the first 2 years of life, but effectiveness progressively wanes from 2 years after the last dose. Such rapid waning was not expected when the decision to forego the 18-month booster in favour of a booster for adolescents was made in 2003. This decision was based on favourable results from modelling this change using the only available data at the time12 — data which suggested that three doses provided protection up to 7 years of age,13 which contrasts with more recent findings. Australian data showing low levels of population antibody to pertussis toxin preceding the recent epidemic support the idea that the schedule change had a negative impact.14 Second, high levels of laboratory testing inflated Australian case numbers disproportionately to other countries, through identifying more ambulatory cases in children and adults. Third, pertussis vaccine coverage has increased dramatically in Australia since the epidemic in the late 1990s, with better acceptance by parents and doctors of the acellular vaccines compared with more reactogenic whole-cell vaccines. Notably, the national epidemic from 2008 to 2012 was associated with fewer deaths than the late 1990s epidemic, despite much higher numbers of cases.

Where does the future lie for pertussis vaccines in terms of improving disease control, especially death and severe morbidity? A vaccine that effectively reduces transmission and disease is an important objective for herd immunity. In this regard, there is promise from research on live attenuated vaccines,15 and the potential for acellular vaccines with improved adjuvants and less reactogenic whole-cell vaccines, but all are some years away. Immunising mothers during the last 8 weeks of pregnancy with adult-formulated acellular pertussis vaccine could prevent early infant mortality and morbidity. Reinstalling the 18-month booster in the National Immunisation Program could improve control in early childhood, if cost-effectiveness criteria can be met. For all vaccines on the National Immunisation Program, ongoing monitoring of VE is crucial and greater use of Australia’s high-quality data systems can support this, as recommended in the National Immunisation Strategy.16

The help that John does not want

In this fictional scenario, could anything have been done to prevent John’s distress? Who should be involved?

John’s parents, Sue and Neville, thought he’d been doing well for a year or so. His schizophrenia had been under control.

He lives in a “granny flat” under their house; really more of a room with a bathroom and a sliding door to the back yard. They all prefer that he has a separate entrance. Nobody has to see the marijuana he smokes, and there is privacy when his case worker comes to visit.

But now, Sue and Neville are worried. Since an old friend of John’s died, they hardly ever see John outside. All they see is white smoke from his flat. And the television is on loud until very late. Plus, they suspect he has stopped taking his medications.

On Monday morning, Neville phones Kate, John’s caseworker. “I could see him this afternoon. Will he be in?”

“He’s always in. We’ll be here too.”

Kate knocks, slides open the door, and sees John in a T-shirt and tracksuit pants, joint in hand, staring at the television. He doesn’t turn or acknowledge her. Kate moves around him to be in his field of view. “Do you mind if I turn the TV off?” she asks.

“Just turn it down.”

They talk for a while. John seems OK, just a bit slow, with long pauses when he speaks. Then Kate mentions the medications.

“John, are you taking your pills?”

He stares at the silent television. “I don’t want to . . . poison . . . ”

“John, you’ve been good on them for a year. It’s really important.”

“Poison . . . I’m not hurting anybody and they should leave me alone . . . I just want to . . . watch TV. I’m allowed to be sad!”

Kate tries for a while longer, but in the end she leaves it. He’s not harming anybody, and apart from the joints, he’s not harming himself. She goes out from the sweet smoky smell to the fresh air. Sue and Neville meet her out the front and she explains that she can’t force John to receive appropriate health care. Neville looks at the ground and slowly nods. Kate says there will be a case conference on Thursday.

***

But on Wednesday it all goes bad. John has come into the house upstairs carrying a swivel chair above his head. He has a cigarette lighter held in his teeth. He is ranting, and Neville can’t understand what he is saying. He throws the swivel chair and it breaks a coffee table, so Sue and Neville retreat to the bedroom, lock the door and call an ambulance.

Sean, the paramedic, asks for police to be called when he is put on the job. When he arrives at the house the police are there in number and he parks the ambulance behind a police car and van.

Sean goes to the front door and finds it open. John is inside smoking, and refuses to come out. With police help, he is wrestled to the ground, handcuffed and taken outside to a police caged vehicle. After the cage door is closed there is banging from inside, and the van is rocking before it is driven away.

On arrival at the emergency department (ED), John is left in the vehicle while police and paramedics go in to explain the situation. There is a short delay while a space in a resuscitation room is made available and roles are allocated: two staff for each limb, one for the head and a separate doctor and nurse for medication and directions.

John is brought in kicking and ranting. At the code word, he is lifted onto the bed and held down. He fights for his life, certain he will be killed. But there are too many staff. He is injected with 5 mg droperidol through his tracksuit pants into his thigh. He hawks in preparation to spit. A nurse pulls John’s T-shirt over his face in time for a dark wet stain to appear where his mouth is. The T-shirt is swiftly exchanged for an oxygen mask. Now an intravenous cannula goes in and is strapped with brown sticking plaster. A dose of midazolam, and everybody begins to relax.

Later, John is to be transferred again — from the ED to a mental health unit at another site. Patients have to be conscious to be transferred, and after John is allowed to wake up he is restrained, and struggles endlessly.

Neville and Kate have both come in to the ED to try to calm him down, but are unsuccessful.

Neville says, “Kate, if you had just told him he had to, he would have gone with you on Monday. Now he’s tormented. From inside and outside.”

Potentially incapable patients objecting to treatment: doctors’ powers and duties

Occasions of potential involuntary detention of patients who refuse treatment are not limited to dramatic situations involving the police, with such unfortunate outcomes as John’s.1 Consider the following scenarios: in a coronary care unit, a man wants to discharge himself without explanation one day after having a myocardial infarction; in a general practice waiting room, a patient with a serious head injury makes for the door saying he can’t wait; in an emergency department, a young woman wakes up from a presumed overdose and demands to leave. In each of these scenarios, patients are refusing assessment or treatment, but there is reason to suspect that they may lack the capacity to refuse treatment or may suffer from a mental illness.

In this article, we present a clinically oriented guide to scenarios like these, grounded in a previously published detailed legal analysis.2 First, we describe a doctor’s powers when a patient is known to lack decision-making capacity (DMC) or is known to be mentally ill. Next, we suggest that when a person’s DMC or mental state is unknown, the law provides a limited justification to briefly detain a patient when there is a strong reason to suspect that he or she may lack DMC or be mentally ill, and when refusal of treatment may place the patient at risk of serious harm. Third, we review any duty of care that a doctor may have to act in these circumstances.

Legal powers when a patient is known to lack decision-making capacity or be mentally ill

The law places enormous emphasis on a competent adult’s right to self-determination, and an adult patient with “no mental incapacity has an absolute right to choose whether to consent to medical treatment” or refuse it.3 Most medical assessment or treatment of adults with DMC will only be lawful if it is consented to. Detaining a patient against his or her will may constitute false imprisonment.

In the New South Wales case, Hunter and New England Area Health Service v A, Justice McDougall acknowledged that when patients refused treatment, there were sometimes two conflicting interests: the competent patient’s right to autonomy; and the state’s interest in preserving life.4 In attempting to resolve this conflict, McDougall J had regard for Lord Donaldson’s comments from an earlier English case and said, all things being equal, “the individual patient’s right was paramount” but that “if there were doubt as to the individual’s expression of preference, ‘that doubt falls to be resolved in favour of the preservation of life’”.4

Under the law, all adults are presumed to have the capacity to consent to, or refuse, medical treatment unless and until that presumption is rebutted.4 A person lacks DMC to make a particular decision if he or she “is unable to comprehend and retain the information which is material to the decision . . . or is unable to use and weigh the information as part of the process of making the decision”.4 The fact that the decision may seem irrational is not, on its own, sufficient to overturn the presumption of capacity.3

Australian states and territories have guardianship legislation that provides some mechanism for substituted consent once it is clear that the person lacks DMC (Box). These statutes allow patients to be treated in an emergency, without substituted consent, where treatment is considered necessary to save the incompetent person’s life or prevent serious damage to the patient’s health. However, if it is not yet clear that the objecting patient lacks DMC — and incapacity is only suspected — these statutes do not apply.

Every jurisdiction in Australia also has mental health legislation that provides for the detention of people with mental illnesses to allow assessment and treatment (Box). Once patients are detained under these acts they may be given psychiatric treatment and, in some cases, medical treatment without the need for consent. Just as guardianship legislation provides no assistance in the management of a patient if incompetence has not been established, mental health legislation is unhelpful in the management of objecting patients if mental illness is suspected but there has been no opportunity for assessment.

Justification for restraining a patient when incapacity or mental illness is suspected

In some cases the courts have determined that it may be justified to restrain a person when it is unclear whether they lack DMC or suffer from a mental illness. In the 19th century English case, Scott v Wakem, a man with delirium tremens who was consequently likely to have been incompetent, and who had threatened to kill his wife, brought an action against the “medical man” who restrained him.5 The judge commented that, if at the time of the original restraint the person was likely to do mischief to anyone, the doctor would have been justified in restraining him, “not merely at the moment of the original danger, but until there was reasonable grounds to believe that the danger was over”.5

In Watson v Marshall, the Australian High Court considered a case where a former doctor brought an action for false imprisonment against the medical superintendent of a psychiatric hospital.6 The Court referred to Scott v Wakem and other cases7,8 and noted that, in those cases, the lawfulness of an act of restraint depended on the “overriding necessity for the protection of himself or others”.6

In these and several other cases, courts have recognised a justification for the “otherwise unlawful restraint” of a person who may be a danger to themselves and others for the purpose of an examination “by proper persons” or “until the regular and ordinary means can be resorted to”. However, this would apply only in circumstances of “obvious necessity” and “could not be extended to ordinary cases”.9

We feel that these cases provide a basis at common law for lawfully restraining a patient in circumstances where there is suspected incapacity and where the restraint is necessary for the protection of the patient or others. Restraint could be applied only as long as the necessity prevailed or until other means of consent could be resorted to.

Duty of care to provide advice, assess decision-making capacity and detain

Doctors owe a duty of care to their patients to provide advice, care and treatment. The care provided should be of a standard that would be widely accepted by peer professional opinion as competent professional practice. Doctors are also under a duty to provide patients with information that any patient would feel was relevant to the decision at hand and any other information that the doctor should have known would have been important to that particular patient (Box).10 When a patient refuses to wait for a full assessment, there is a duty to at least provide appropriate advice. In the NSW case, Wang v Central Sydney Area Health Service, the court found the health service negligent in failing to provide appropriate advice to a young man with a head injury who decided to leave an emergency department waiting room without waiting to be seen by a doctor.11

A number of cases suggest that there is also a legal duty to assess DMC where there is uncertainty about its presence and where there are potentially serious consequences if treatment is refused. Uncertainty may arise in circumstances where the nature of a particular injury (such as a head injury) or the person’s presentation (such as a reduced level of consciousness) suggests that his or her capacity may be impaired.

Ms B v An NHS Hospital Trust was an English case involving a 43-year-old woman with tetraplegia due to a cervical spine cavernoma, who sought withdrawal of artificial ventilation.12 The judge held that when there was doubt about the DMC of a patient, the doubt should be “resolved as soon as possible”, and that while the issue of capacity was being resolved, the patient should be cared for “in accordance with the judgment of the doctors as to the patient’s best interests”.12 Guidelines set out in another English case suggested that doctors should identify any problem with capacity as soon as possible and assess this as a priority. These guidelines also suggested that if there was “a real doubt as to capacity the issue should be referred for resolution by the Court”.13

In contrast to decisions involving medical illness, the courts have so far declined to find that doctors have a duty to detain a person whom they suspect may have lost DMC or require treatment due to a psychiatric illness.14–16 Nonetheless, the law does not appear to be settled in this area, and it is possible that future cases may find a similar duty exists.

Conclusion

The courts place a high value on personal autonomy. However, autonomy is lost where DMC is lacking and, if this is not recognised, individuals may be deprived of necessary treatment. In cases where there is good reason to suspect that DMC is impaired and treatment refusal may involve significant risk, there is a duty to clarify the situation as soon as possible. Breach of that duty may give rise to a legal action for damages.

The law in this area is not clear, reflecting the reality that situations involving possible loss of DMC and a doctor’s duty to act are often complicated and may require urgent action. The courts have acknowledged this and recommended that doctors act in the best interests of a patient until the ambiguity can be resolved. Using the reasoning we have laid out above, we suggest the following approach when faced with a patient who refuses assessment and attempts to leave the hospital.

If there are no factors to suggest the patient lacks DMC or suffers from a mental illness, or if there are such factors but there is no foreseeable risk of serious harm to self or others, then the person should be given appropriate advice, and his or her decision to leave should be respected.

If, on the other hand, there is:

  • a known factor, such as a serious head injury, which may give rise to a lack of DMC; or recent behaviour such as an overdose which might suggest the presence of mental illness; or a decision to object to assessment or treatment that, in the context, is so unusual or inappropriate as to lead a reasonable person to suspect that the patient’s DMC may be impaired; and

  • a foreseeable risk of serious harm to that person or others; and

  • no less-restrictive way of clarifying the person’s capacity to refuse assessment or prevent the risk;

then, a clinician should detain a person for as long as necessary to minimise the risk and/or until “regular and ordinary means” can be resorted to.

There appears to be a limited legal justification to detain the patient, using the least amount of force possible and certainly no more force than is proportionate to the danger to be avoided. The regular and ordinary means would likely include an assessment, and in the event that the patient is found to lack DMC or suffer from a mental illness, provision of care under the appropriate legislative or common law provisions. In cases where there is genuine doubt that is unable to be resolved, clinicians should consider detaining the patient and seeking direction from the court or an appropriate tribunal.

Relevant state legislation

Providing mechanisms for substituted consent:

  • Guardianship Act 1987 (NSW)

  • Guardianship and Administration Act 2000 (Qld)

  • Guardianship and Administration Act 1993 (SA)

  • Guardianship and Administration Act 1995 (Tas)

  • Guardianship and Administration Act 1986 (Vic)

  • Guardianship and Administration Act 1990 (WA)

  • Guardianship and Management of Property Act 1991 (ACT)

  • Adult Guardianship Act 1998

  • Emergency Medical Operations Act 1973

Providing for the detention of people with mental illnesses:

  • Mental Health (Treatment and Care) Act 1994 (ACT)

  • Mental Health Act 2000 (Qld)

  • Mental Health Act 1986 (Vic)

  • Mental Health Act 1996 (WA)

  • Mental Health Act 2007 (NSW)

  • Mental Health and Related Services Act 1998

  • Mental Health Act 2009 (SA)

  • Mental Health Act 2013 (Tas)

Defining doctors’ standard of care:

  • Civil Liability Act 2002 (NSW), s. 5O(1)

  • Civil Liability Act 2002 (WA), s. 5PB(1)

  • Civil Liability Act 2002 (Tas), s. 22(1)

  • Civil Liability Act 2003 (Qld), s. 22(1)

  • Civil Liability Act 1936 (SA), s. 41(1)

  • Wrongs Act 1958 (Vic)

  • Civil Law (Wrongs) Act 2002 (ACT)*

* The standard of care in the Australian Capital Territory is different
(see s. 42): “a reasonable person in the defendant’s position who was in possession of all information that the defendant either had, or ought reasonably to have had, at the time of the incident”.

Use of Royal Darwin Hospital emergency department by immigration detainees in 2011

Several thousand people arrive in Australia without a visa each year and seek asylum by applying for recognition as refugees. While awaiting processing, these asylum seekers are involuntarily detained by the Australian Government for periods ranging from 1–2 months to several years, and, in 2011, the majority of detainees had been in detention for at least 6 months.1 Previous studies have shown a high burden of physical and psychiatric morbidity — especially mental health problems, self-harm and suicide attempts — in asylum seekers, particularly those held in immigration detention.2–5

Darwin, in the Northern Territory, receives a substantial proportion of the asylum seekers who arrive in Australia and on Christmas Island by boat, and had two major immigration detention facilities in 2011. The first, the Northern Immigration Detention Centre, is a high-security detention centre that houses men, and has a capacity of 456 people. The second, Darwin Airport Lodge, houses families and unaccompanied minors, and has a capacity of 435 people. A third major facility opened in Darwin at Wickham Point in December 2011, and has a capacity of 1500 people. In a 2010 report, the Australian Human Rights Commission raised serious concerns about the provision of health services to immigration detainees in Darwin.6 In a 2013 Auditor-General report, it was shown that about 40% of surveyed immigration detainees in Australia said that their basic health care needs had not been met.7

Despite large numbers of immigration detainees in Darwin, only one public hospital serves their needs — the Royal Darwin Hospital (RDH), a 350-bed teaching hospital with an emergency department (ED) that sees about 65 000 patients per year. We noticed a large burden of morbidity, particularly self-harm, in asylum seekers attending the RDH ED in 2010 and 2011. Since no data quantifying this burden were publicly available, we undertook a retrospective audit of RDH ED attendances by immigration detainees during 2011.

Methods

We retrospectively audited RDH ED attendances during the 2011 calendar year for people identified, using the hospital’s financial coding, as immigration detainees. The number of detainees attending, demographic information, and time and date of attendances were extracted from the hospital’s data warehouse. Clinical information was manually extracted by reviewing the ED clinical database, a custom-built database for prospectively recording details of each episode of care. Broad categorical primary and secondary diagnoses were those recorded by the ED doctor at the time of presentation. The primary diagnosis was defined as the primary reason for attending the ED. The secondary diagnosis, if any, was defined as a coexisting active medical problem that contributed to the ED attendance.

Data were entered into a purpose-built Microsoft Access database and analysed using Stata version 10 (Statacorp). As we did not have access to accurate data on the number of people in immigration detention in Darwin during 2011, we estimated the denominators using data summaries on the number of people in immigration detention that are released every 1–2 months by the Department of Immigration and Citizenship.1 These reports provide detainee numbers for immigration detention centres (IDCs) (eg, the Northern Immigration Detention Centre), but only provide national-level summary data for facilities classified as alternative places of detention (APODs) (eg, Darwin Airport Lodge). We assumed that the proportion of total Australian mainland detainees resident in APODs in Darwin was the same as the proportion of total Australian mainland detainees resident in IDCs in Darwin. Hence we estimated the number of immigration detainees in Darwin in each month of 2011 for which data were available as: NIDC + (NIDC ÷ MIDC × MAPOD). In this calculation, NIDC is the number of detainees in the Northern Immigration Detention Centre, MIDC is the number of detainees in all mainland IDCs combined, and MAPOD is the number of detainees in all mainland APODs combined. The mean of these monthly numbers was calculated as an estimate of the average number of detainees resident in Darwin during 2011.

The study was approved by the Human Research Ethics Committee of the Menzies School of Health Research and Northern Territory Department of Health and Families.

Results

In 2011, there were 770 ED attendances at RDH by 518 individual detainees; the mean (SD) age of these detainees was 27.6 (12.2) years, 112 (21.6%) of them were aged < 18 years, and 413 (79.7%) were male. Iran and Afghanistan were the two most common countries of birth (283 and 90 individuals, respectively), followed by Iraq (63), Indonesia (24), Sri Lanka (14), and other countries (44).

We estimated that there was a mean of 776 individuals living in immigration detention in Darwin during 2011 (monthly range, 561–920 individuals) (Box 1). If we assume there was no population turnover during this time, this would mean that 518 ÷ 776 = 66.8% (95% CI, 63.3%–70.1%) of these people attended the ED at least once in 2011. If we assume the entire population was replaced every month, then the proportion who attended the ED at least once would be 66.8% × 1/12 = 5.6%. Given that the median length of stay by asylum seekers in immigration detention in 2011 was about 9 months,1 we estimate that 66.8% × 9/12 = 50.1% (95% CI, 47.0%–53.2%) of immigration detainees in Darwin attended the RDH ED at least once in 2011. The mean monthly ED attendance rate for detainees was 1.06 attendances per person-year and, based on 9-month length of stay, we estimate that 1035 people passed through Darwin’s immigration detention facilities in 2011.

Detainees’ clinical characteristics

Each patient who presents to the ED has the urgency of his or her condition assessed and is assigned a triage category, from category 1 (needs immediate resuscitation) to category 5 (non-urgent problem). In 2011, the pattern of triage categories for immigration detainees was similar to that for all patients, but hospital admission rates were substantially lower for immigration detainees in all triage categories except category 5, and the differences were significant for categories 2, 3 and 4 (Box 2).

The most common primary reason for attendance was a psychiatric problem; it accounted for 187 (24.3%) of primary diagnoses, of which 138 were for self-harm (Box 3) (15 of these attendances were by children, who were aged 9–17 years). These incidents ranged from minor injuries (eg, superficial cuts and burns) to life-threatening injuries (eg, attempted hanging, lacerated arteries and intentional medication overdose). Including primary and secondary diagnoses, psychiatric problems were diagnosed for 223 attendances (29.0%). The proportion of patients admitted to hospital who were diagnosed with a psychiatric problem was not related to country of birth, but males were more likely to attend for self-harm than females (141/624 [22.6%] v 3/146 [2.1%]; odds ratio, 13.9 [95% CI, 4.4–44.3]).

Infection-related presentations were uncommon. Most presentations were for chronic or non-specific conditions, including musculoskeletal conditions (back pain, myalgia or arthralgia), gastrointestinal conditions (non-specific abdominal pain or diarrhoea), respiratory problems (asthma exacerbations), neurological problems (headaches) and non-cardiac chest pain.

Of 146 ED attendances by children, the most common primary diagnoses were musculoskeletal problems (53, 36.3%), respiratory problems (17, 11.6%) and infectious diseases (14, 9.6%). Psychiatric presentations were less common in children (20, 13.7%) than in adults (203, 32.5%) (P < 0.001).

Of the 518 individuals who attended the ED, 155 attended twice or more during 2011, and 56 attended three or more times. One detainee attended 16 times for asthma. Of the 770 attendances, 309 (40.1%) involved one or more pathology tests, 246 (31.9%) involved plain radiography, 39 (5.1%) involved a computed tomography or magnetic resonance imaging scan, and 23 (3.0%) involved ultrasound. In 162 attendances (21.0%), the patient was referred to one or more inpatient teams for assessment. In 99 attendances (12.9%), the patient required admission to the ED or hospital wards.

Discussion

Although it has been clear for years that there is a large burden of physical and mental illness in immigration detainees, our finding that more than half of immigration detainees in Darwin attended the RHD ED over a 12-month period suggests this problem is worse than previously suspected. This is likely to reflect two main contributing factors: a high burden of morbidity and poor access to primary health care services at detention facilities.

A high burden of morbidity has previously been described in asylum seekers and immigration detainees in Australia3,5 and overseas.2,4,8–10 The primary health care services at Australian immigration detention facilities were described as understaffed and inadequate in a 2010 Australian Human Rights Commission report.6 Our 2011 data support that assessment for three reasons: the number of ED presentations was much higher than one would expect for a population with access to primary care services; there was a high number of repeat ED attendances by some individuals; and, compared with all patients, detainees had a low rate of admission after attendance at the ED.

As we analysed attendance using broad diagnostic categories, it is likely that we underestimated the extent of psychological morbidity. The most common non-psychiatric complaints (myalgias, headaches, non-specific abdominal pain and non-cardiac chest pain) are symptoms that are commonly due to somatisation in people with psychological distress.

The large number of ED attendances by immigration detainees also puts a substantial burden on the RDH ED. The 770 attendances by detainees during 2011 represented over 1% of all ED attendances. Despite generally low acuity in terms of triage category, resource utilisation was high, with significant proportions of patients needing x-rays, blood tests and referrals to inpatient teams. We did not collect data for 2012 or 2013, but we note that the number of RDH ED attendances by immigration detainees appears to have declined since 2011, probably due to increases in primary health care resources in immigration detention facilities in Darwin and a decrease in average length of stay (277 days in November 2011 v 114 days in February 2013).1 We hypothesise that this was also influenced by the Australian Human Rights Commission and Auditor-General reports6,7 and by public advocacy.

Our study has several limitations. The main limitation relates to the difficulty in obtaining clear and accurate data on the number of people in detention in Darwin during 2011. As a result, we estimated denominators by extrapolation of available data; hence we may have underestimated the number of immigration detainees in Darwin and thus overestimated the proportion who attended the ED. However, as the total capacity of the immigration detention facilities in Darwin during most of 2011 was about 900, we believe our estimated average population of 776 reflects the true situation in Darwin in 2011.

We interpreted the lower admission rates for detainees in each triage category to mean that primary health care services at the immigration detention facilities were deficient, because generally people are discharged from hospital when they have a condition that is of low acuity and severity and could be managed adequately in primary care. Alternatively, for non-medical reasons, doctors might have had a higher threshold for admitting detainees to hospital (eg, detainees were being discharged to supervised accommodation). Irrespective of the explanation, the high numbers of ED attendances and repeat attendances support the assertion that primary care services for people living in immigration detention in Darwin in 2011 were deficient.

We collected our data retrospectively, mostly in categorical form, so our results lack detail about individual diagnoses and presentations. However, the data on diagnoses are likely to be accurate because they were coded and recorded prospectively by doctors as a routine part of ED practice. A prospective real-time study would provide more accurate data, and could include a qualitative component, but this would require time and funding that was beyond the scope of our study.

Our data show that there was a high prevalence of unmet health need, particularly relating to psychiatric morbidity, and limited access to primary health care services, for immigration detainees in Darwin in 2011.

1 Estimated immigration detainee population and numbers and rates of ED attendance by month, Darwin, 2011

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Mean

Total

Estimated population

873

912

890

920

853

nd

695

nd

666

561

616

nd

776

1035*

Number of ED attendances

88

76

72

70

61

51

47

50

65

65

63

62

—

770

Number of individuals who attended ED at least once

64

48

51

47

46

31

25

36

45

43

38

44

—

518†

ED attendance rate‡

1.21

1.00

0.97

0.91

0.86

nd

0.81

nd

1.17

1.39

1.23

nd

1.06

—

ED = emergency department. nd = not determined (insufficient data). * Estimated total number of people who passed through Darwin’s immigration detention facilities in 2011, based on 9-month median length of stay. † Total number of unique individuals (ie, individuals were not counted more than once if they attended the ED more than once in the same or subsequent months). ‡ Attendances per person-year (number of ED attendances ÷ estimated population × 12).

2 Hospital admission rates according to triage category for immigration detainees and all patients who attended the Royal Darwin Hospital emergency department in 2011

Immigration
detainees
(n = 770)

All patients
(n = 63 327)

P*

Triage category 1

9 (1.2%)

547 (0.9%)

Admitted to hospital

4 (44.4%)

395 (72.2%)

0.06

Triage category 2

83 (10.8%)

5 400 (8.5%)

Admitted to hospital

20 (24.1%)

2 808 (52.0%)

< 0.001

Triage category 3

228 (29.6%)

16 808 (26.5%)

Admitted to hospital

39 (17.1%)

6 958 (41.4%)

< 0.001

Triage category 4

428 (55.6%)

37 606 (59.4%)

Admitted to hospital

35 (8.2%)

5 603 (14.9%)

< 0.001

Triage category 5

22 (2.9%)

2 966 (4.7%)

Admitted to hospital

1 (4.5%)

163 (5.5%)

0.83

* P values compare admission rates for immigration detainees in each triage category with admission rates for all patients in each triage category and were calculated using the χ2 test.

3 Primary and secondary diagnoses for 770 Royal Darwin Hospital emergency department attendances by immigration detainees in 2011

Primary
diagnosis (n = 770)

Secondary diagnosis (n = 113)

Psychiatric problem, including self-harm

187 (24.3%)

46

Self-harm

138 (17.9%)

6

Musculoskeletal condition

178 (23.1%)

33

Gastrointestinal or genitourinary condition

117 (15.2%)

8

Respiratory problem

70 (9.1%)

5

Neurological problem

59 (7.7%)

5

Cardiovascular problem

57 (7.4%)

4

Infectious disease

33 (4.3%)

2

Obstetric or gynaecological problem

16 (2.1%)

0

Dental problem

10 (1.3%)

0

Eye problem

8 (1.0%)

0

Other

35 (4.5%)

10

O come, all ye faithful: a study on church syncope

… willing rather to be absent from the body, and to be present with the Lord (2 Cor 5:8)

Since historical times, fainting in church has been anecdotally common. Up to 40% of calls to emergency medical services on a Sunday morning may be associated with “church syncope”.1 Church syncope is often listed as a subtype of syncope among medical presentations, yet apart from circumstantial cases2 and one case report of syncope in the church choir,3 the epidemiology of church syncope has not been reported in the medical literature.

The church is considered a sacred place, with sanctity sometimes derived from the location where it is built — where a miracle or martyrdom allegedly took place or a holy person was buried, or by the location of a holy item placed within the church. Associated with this sanctity is the concept of sanctuary from intentional physical harm (eg, fugitives were immune to arrest in a church under English law from the fourth to the 17th century). Along the same lines, improved health outcomes and wellbeing from spirituality and the sanctity of the church have also been reported.4,5

Our aim was to investigate the incidence of patients presenting to a major metropolitan hospital after experiencing church syncope. A further aim was to determine whether syncope in this sacred location is associated with improved outcomes. We hypothesised that patients presenting to the emergency department (ED) with church syncope would have similar short-term (at hospital discharge) outcomes as those presenting with syncope experienced at other locations (ie, that the sanctity of the church is associated with no additional sanctuary).

Methods

We conducted a retrospective matched cohort study at the Alfred Hospital, an adult major referral hospital in central Melbourne, Victoria. The hospital receives over 50 000 emergency presentations each year. There are 73 churches within the central business district of Melbourne and surrounding 5 km radius. Approval was obtained for this study from the Alfred Hospital Research and Ethics Committee.

We searched the Emergency and Trauma Centre database for presentations during a 4-year period from July 2009 to June 2013. Medical records were extracted for all presentations with the word “church” documented in the ambulance description, description of triage, place of incident, or discharge description. Two investigators (A J T and E F) independently reviewed medical records through an explicit chart review. Patients with church syncope were identified as cases, and data on demographic and clinical characteristics, management and hospital outcomes were extracted.

Patients who presented to the ED during the same period with “syncope”, “collapse” or “faint” were identified as possible controls. Cases were matched to controls by age (corrected to the nearest 5-year age group) and San Francisco Syncope Score (SFSS).6 The SFSS (Box 1) was developed to identify patients at risk of serious outcomes (death, myocardial infarction, arrhythmia, pulmonary embolism, stroke, subarachnoid haemorrhage, significant haemorrhage or any condition causing a return ED visit and hospitalisation for a related event) within 30 days of presentation. To minimise bias due to seasonal variance, control patients for cases were selected as the next chronologically presenting patients who matched selection criteria.

Statistical analysis

Admission to hospital was the primary outcome measure. The prevalence of the primary outcome among the control group was estimated to be 0.50. With a chosen power of 0.8, α of 0.05, correlation coefficient for outcome between cases and matched controls (phi) of 0.2, and odds ratio of 3.0, the optimal number of controls was determined to be two per case.7 Mortality at hospital discharge, intensive care or coronary care unit admission, and length of stay in hospital were secondary outcome measures.

Normally distributed continuous variables are reported as means with standard deviations, and ordinal or skewed variables are reported as medians with interquartile ranges (IQRs). The association between categorical variables is described using odds ratios (ORs) with 95% confidence intervals. We calculated the statistical significance of odds ratios using the Mantel–Haenszel method for matched data. Variables showing an association with admission to hospital (P < 0.1) were entered into a conditional logistic regression model to determine independent associations with admission to hospital. Statistical significance was defined as P < 0.05.

Results

During the study period, 46 patients presented to the ED after an incident related to a church. After review, 15 of these were excluded: seven patients presented after a fall in church or church grounds without syncope, three patients experienced symptoms (chest pain and nausea) in church without syncope, two patients presented after episodes of self-harm in church, two patients developed back pain while sitting on church benches, and (as the search term also matched partial words), one patient was a visitor, without syncope, from Christchurch, New Zealand. This left 31 patients in the study, who were compared with 62 control patients. Demographic and presenting clinical features of patients are shown in Box 2. The mean age of patients was 79.3 years in the case group and 79.7 years in the control group, and the median SFSS for each group was 0 (IQR, 0–1), demonstrating successful matching. Discharge diagnoses of patients presenting with church syncope are shown in Box 3.

Seven patients with church syncope (22.6%) were admitted to hospital, a significantly lower proportion than among control patients (29; 46.8%) (Mantel–Haenszel analysis for matched pairs, P = 0.02). Results of the testing for a univariate association of demographic and clinical variables with admission to hospital are listed in Box 4. After multivariable analysis using conditional logistic regression, there was no statistically significant independent association of church as the location for syncope with admission to hospital (OR, 0.4; 95% CI, 0.1–1.1; P = 0.06). Systolic blood pressure on presentation to the ED was the only included variable to have a statistically significant association with admission to hospital (OR, 1.0; 95% CI, 1.0–1.1).

There were no deaths in either group. Four patients with church syncope (12.9%) and seven control patients (11.3%) were admitted to an intensive care or coronary care unit (Mantel–Haenszel analysis for matched pairs, P = 0.8). Among admitted patients, the median length of stay for both groups was 1 day (IQR, 1–2 days). Two patients with church syncope underwent insertion of a permanent pacemaker, whereas five patients in the control group underwent other surgical procedures.

Discussion

This study, the first to analyse short-term outcomes of patients with church syncope, found that the incidence of patients presenting to hospital with church syncope was substantially lower than has been anecdotally reported. When compared with patients with similar risk profiles experiencing syncope at locations other than a church, a significantly lower proportion of patients with church syncope were admitted to hospital. However, after adjusting for age, SFSS, presence of diabetes mellitus, abnormality on electrocardiogram and presenting systolic blood pressure, church as a location for syncope was not significantly associated with admission to hospital. The sanctity of a church to provide sanctuary against hospital admission after syncope therefore remains unproven.

The patients with church syncope had better outcomes than those previously reported for patients presenting to the ED with syncope (occurring in any location). Reported adverse event rates for patients presenting with syncope range from 6.1% to 11.5%,6,8 with short-term mortality rates of 1.5 to 1.9%.9–11 Rather than divine influence, the better outcomes seen in patients experiencing syncope at church were most likely related to selection bias of a relatively less unwell group of patients. Factors that are likely to be associated with syncope in church include prolonged morning activities while fasting; being stationary in an often warm, enclosed and crowded environment with limited ventilation; or being emotionally charged in the setting of prayers — all of which are more likely to be associated with benign medical conditions.

Beneficial effects of the church on health outcomes may also be gleaned from studies that have correlated church attendance with positive health care practices. Health benefits of church attendance have been reported to include improved rates of mammography, blood pressure measurements and dental visits, and improved social integration and attendance at cancer prevention services.11–14 However, these claims, although multiple, have been refuted in systematic reviews of the literature.15

Although this study found no significant association between church as a location and short-term outcomes among patients with syncope, multiple limitations must be acknowledged. Although this is the largest reported case series on the topic that we are aware of, it was a retrospective review involving a relatively small number of patients. The inclusion criteria were based on history recorded by prehospital and triage staff, and patients with variants of syncope, such as presyncope, vertigo and dizziness, may have been included. The structured data form used in the explicit chart review did not include information on many variables that may be important in the evaluation of syncope, such as medication use, routine blood testing, orthostatic vital signs and carotid massage. The validity of the SFSS in determining risk for adverse events has been previously questioned9 and may have led to disproportionate matching of patients. Assessment and management of patients were considered to be of uniform level, with no adjustment made for seniority of attending clinicians.

In conclusion, the incidence of patients with church syncope presenting to the ED was low. Outcomes were generally favourable, but the church did not appear to offer any additional sanctuary when clinical risk profiles were considered.

1 San Francisco Syncope Score6

Indication

  • Syncope evaluation

    • Evaluate short-term risk of serious outcome

    • May reduce syncope hospitalisation rate

Criteria

  • History of congestive heart failure

  • Haematocrit level < 30%

  • Abnormal electrocardiogram

  • History of shortness of breath

  • Systolic blood pressure < 90 mmHg at triage

Interpretation

  • Positive with any one of the above criteria

2 Demographic and clinical characteristics of patients*

Church syncope
(n = 31)

Other syncope
(n = 62)

Age (years),† mean (SD)

79.3 (6.8)

79.7 (6.7)

Male

9 (29.0%)

15 (24.2%)

Religion

Anglican

5 (16.1%)

7 (11.3%)

Greek Orthodox

7 (22.6%)

5 (8.1%)

Roman Catholic

8 (25.8%)

10 (16.1%)

Uniting

3 (9.7%)

9 (14.5%)

Other

3 (9.7%)

10 (16.1%)

Not specified

5 (16.1%)

21 (33.9%)

History of congestive heart failure

3 (9.7%)

7 (11.3%)

Haematocrit level, mean (SD)

37% (4%)

36% (5%)

Abnormal electrocardiogram

16 (51.6%)

39 (62.9%)

History of shortness of breath

5 (16.1%)

9 (14.5%)

Systolic blood pressure (mmHg), mean (SD)

129.9 (18.5)

140.6 (26.8)

San Francisco Syncope Score, median (IQR)†

0 (0–1)

0 (0–1)

Temperature (°C), mean (SD)

36.2 (0.3)

36.3 (0.5)

Absence of symptoms preceding syncope

3 (9.7%)

12 (19.4%)

Diabetes mellitus

3 (9.7%)

10 (16.1%)

Trauma resulting from syncope

0

12 (19.4%)

* Figures are number (%) of patients unless otherwise specified. † Matched variables.

3 Discharge diagnoses of patients presenting with church syncope

Diagnosis

Patients
(n = 31)

Vasovagal syncope

14

No specific diagnosis

5

Acute coronary syndrome

3

Arrhythmia

3

Dehydration

2

Benign positional vertigo

1

Bradycardia secondary to medication

1

Urinary tract infection

1

Autonomic instability

1

4 Unadjusted odds ratios for admission to hospital

Variable

Odds ratio (95% CI)

Male

0.7 (0.2–2.9)

Haematocrit

0.3 (0.0–8.0 × 104)

History of congestive heart failure

0.8 (0.1–4.2)

Abnormal electrocardiogram

1.5 (0.4–5.2)

History of shortness of breath

0.8 (0.2–3.6)

Systolic blood pressure*

1.0 (1.0–1.1)

Temperature

0.4 (0.1–1.4)

Absence of symptoms preceding syncope

1.4 (0.3–6.0)

Diabetes mellitus*

4.0 (0.8–20.9)

Trauma resulting from syncope

1.0 (0.3–4.3)

* Variables entered into the multivariable regression model, along with church as the location for syncope.

The effect of a gold coin fine on C-reactive protein test ordering in a tertiary referral emergency department

Testing for C-reactive protein (CRP), an acute-phase reactant, is used in investigations for patients who present to emergency departments (EDs). It has been assessed for such roles as identifying bacteraemia in febrile patients,1–4 evaluating patients with an acute abdomen,5,6 and diagnosing patients with possible osteomyelitis or septic arthritis.7 However, such studies have not shown the CRP test to be useful for any of these indications, or indeed for most conditions for which patients present to EDs. Despite this paucity of evidence, CRP tests continue to be ordered as part of the work-up for patients presenting to EDs.

Nepean Hospital is a tertiary referral hospital that serves the western suburbs of Sydney in New South Wales, Australia. About 60 000 patients attend its ED each year. The ED has a 20% paediatric caseload and a 36% admission rate.

This study resulted from an audit of pathology test ordering in the Nepean Hospital ED. The aim of the audit was to determine what and how many tests were being ordered, the cost to the department and who was being billed for the tests. Also examined was how pathology testing was affecting our National Emergency Access Target (NEAT) times. To our horror, we discovered that about 25% of patients presenting to the ED had a CRP test as part of their work-up. This included patients who presented with problems that were likely to be non-infective, such as chest pain. A rough back-of-the-napkin calculation suggested that we could afford a new bedside ultrasound machine every year with the money spent on CRP tests ordered in the ED. Also, we found that it took up to 2 hours to get the CRP test result, putting our NEAT performance at risk. Furthermore, we noted that there is evidence that interventions aimed at reducing CRP test ordering are effective in an ED setting.8 We felt it was time to act, to reduce ordering of CRP tests in the Nepean Hospital ED.

The objective of this study was to assess the effect of an education campaign centring on a gold coin fine for CRP test ordering in the ED.

Methods

An education campaign on CRP testing was conducted at the Nepean Hospital ED to coincide with Jeans for Genes Day on 2 August 2013. This day was characterised by an informal atmosphere, including much wearing of jeans, various morning and afternoon teas, and gold coin donations. “No CRP Day” was run simultaneously with Jeans for Genes Day at the Nepean Hospital ED. Education was commenced running up to the day, with email discussions about the utility and potential indications of CRP testing. Also discussed was the cost of CRP testing to the ED, what we could spend the money on otherwise, and how CRP tests were affecting our NEAT performance.

A CRP jar was used, akin to a swear jar in that anyone ordering a CRP test had to put a gold coin in the jar as penance. This money was slated to be donated to the Children’s Medical Research Institute as part of Jeans for Genes Day. Education continued, centring on the CRP jar, with the jar being shaken loudly in front of anyone ordering a CRP test. The jar was left in the ED for the remainder of the month as visual reminder of the campaign.

A retrospective audit of CRP ordering was performed. The date of the intervention was defined as 2 August 2013, the control period was 1–31 July 2013 and the study period was 2–31 August 2013. The number of CRP tests ordered by medical staff working in the ED was collected for each period. A comparison of independent proportions was performed using VassarStats (http://vassarstats.net).

Results

There were 5219 presentations in the control period and 5497 in the study period. In the control period, 1290 CRP tests were ordered, that is in 24.7% of presentations. In the study period, 394 CRPs tests were ordered, that is in 7.2% of presentations. This represented an absolute reduction in the rate of CRP test ordering of 17.6% (95% CI, 16.2%–18.9%; P < 0.001).

Discussion

After No CRP Day, there was a significant reduction in the number of CRP tests ordered in the Nepean Hospital ED, beyond what was expected when the study was designed. It is possible that medical staff in the ED knew that CRP testing is not useful in the work-up for most patients and that they needed “permission” not to order CRP tests. Once they had this permission, they were very happy not to order CRP tests, thus producing the massive fall in ordering.

A significant finding of this study was the proportion of presentations for which CRP tests were performed as part of the clinical work-up before the intervention: almost one-quarter of ED presentations. It is possible that there had been little thought behind pathology test ordering during the control period, akin to a scattergun approach. This is despite many clinical pathways being available for use in the ED, none of them advising the use of CRP testing.

Post-hoc discussions with medical students suggested that, in medical school, the CRP test was not taught as being an important part of a clinical work-up. Similar post-hoc discussions with senior, post-fellowship medical staff suggested that the CRP test was not widely regarded as an important test, with a few exceptions relative to craft group. It seemed then that the main group “championing” the use of CRP testing was the registrar and trainee cohort of medical staff. Medical graduates, as interns, became exposed to the use of the CRP test as a standard test for the work-up of patients in their medical practice, saw CRP testing as an entrenched part of practice, and transitioned into registrars teaching the concept of CRP testing as standard practice to future cohorts of medical graduates. Then it seems that once registrars completed their training and became specialists, the need for CRP testing became less important. Thus, like a virus requiring an endemic host population, it seems that the idea of CRP testing as an important part of a standard work-up is endemic to the hospital registrar population.

A limitation of this study is that only numbers of CRP tests ordered were examined, not the effects on patient outcomes or length of stay. Also, the study did not assess whether CRP testing was indicated in each patient for whom it was ordered, so it is not possible to comment on the appropriateness of individual CRP tests. Hence there is no reason to advocate that CRP tests should never be ordered for patients who present to an ED.

The number of CRP tests ordered after the intervention seemed to still be high compared with the number of CRP tests claimed to be ordered by ED medical staff (zero!). This might be because CRPs were “added on”, by inpatient teams, to pathology tests ordered by ED staff while patients were still in the ED or after patients were transferred to a ward. There was no way to control for this phenomenon in the study.

Very little money was generated for Jeans for Genes Day beyond what was raised by nursing staff at morning and afternoon teas, and a lot less than the expected $394. This was probably more related to the propriety of the test orderers rather than a failure of the concept of the CRP jar.

Think before you insert an intravenous catheter

To the Editor: Peripheral intravenous catheter (PIVC) infection has been highlighted by one of
us (R L S) and colleagues as an important, costly and dangerous complication of PIVCs.1 Infection prevention programs often employ multifaceted interventions and, in the case of PIVC, much debate has been directed towards aseptic insertion
and appropriate dwell times, but little attention has been directed to whether the PIVC is required.2

The concept of the “idle IV” catheter was introduced over 20 years ago,3 yet at our tertiary hospital emergency department (ED), we found that half of PIVCs inserted were unused. In 43% of patients admitted to the hospital, the PIVC remained unused at 72 hours.4 Patients presenting with obstetric, gynaecological and neurological symptoms were significantly more likely to have an unused PIVC.4

Focus group testing revealed that it had become a culture within our ED to insert a PIVC in most patients “just in case”. We have started a program encouraging staff to think before they insert an IV catheter, and to “just say no to the ‘just in case’ PIVC”. Our study did not examine harm caused by unused PIVCs, but the potential benefits of such a program include reduction in infections, phlebitis, patient discomfort and financial cost (24 cents for venepuncture compared with $4.37 for PIVC equipment).1

To address the potentially preventable, iatrogenic complication of infected PIVCs, a sometimes-neglected point of intervention is for clinicians to decide whether the PIVC is actually required in the first place.

Mazda6 Touring Diesel – wisdom, intelligence and harmony

Mazda has been making motor vehicles in Japan since 1931.

Its predecessor, the Toyo Kogyo Company, had made machine tools from 1920 until 1931 when its first vehicle, the Mazdago, ran off the production line.

It was a three-wheeled autorickshaw with handle-bars and a one cylinder air-cooled engine.

During the Second World War, Toyo Kogyo made armaments, most notably the Type 99 Arisaka infantry rifle.

By the 1960s, Mazda was investing heavily in the development of Wankel rotary engines, and is now the sole world manufacturer.

The first Mazda sedan that took my eye was the Bertone-styled Mazda 1500 in 1966.

My father had considered buying the 1500, but bought a locally-made HR Holden instead.

It had only been a generation since the Second World War. Japanese cars were yet to be trusted and there were un-founded doubts about reliability.

A friend bought a Mazda Capella in the 1970s and, in 1980, I almost bought a Mazda 626, but opted for a Chrysler Sigma with a larger engine and less longevity.

Many 626s followed in the 1980s, and in 1983 the Mazda 626 was the Wheels magazine Car Of The Year.

Ford even manufactured a variant of the 626 in Australia, the Telstar.

My partner owned a Telstar TX5 Ghia with an electronic dashboard, but it still wasn’t exactly a Mazda.

In 2003, Mazda changed their numbering system and released the Mazda6, which is the subject of this month’s road test.

Having never actually owned a Mazda myself, I desperately wanted to like this car, as I had pencilled it onto my shopping list.

I liked the way it looked, from the front.

I liked the quality of the finish and the goodies inside.

Everything was going great until I turned the key (sorry, keyless start), if you know what I mean.

I just didn’t like the way it sounded.

Having been spoilt by the quietness of Mercedes, BMW and VW diesels, in ascending order, I was a little surprised by how noisy the motor was, or at least how noisy it seemed compared to the formidably quieter competition.

There is no shortage of go from the diesel Mazda6, with 129kW of power and 420Nm of torque.

It takes off well from a standing start and, like all diesels, it doesn’t lose momentum on hill climbs.

Back in the traffic, the i-Stop feature shuts the engine down when stopped.

While i-Stop saves fuel, it is a little disconcerting at first.

With no motor running it’s more like being parked at the traffic lights, but as soon as you take your foot off the brake pedal the motor fires up and away you go.

Going diesel in a Mazda6 comes at a $3000 price premium over the SkyActiv petrol version.

Power only drops by 7 per cent by going from petrol-powered to diesel-powered, but torque is up by a whopping 68 per cent, making the diesel feel like it has two more cylinders.

Fuel consumption overall is 18 per cent better in the oil-burner.

Even the Mazda6 base model is comprehensively equipped with keyless starting, dual-zone climate control, paddle shifter gear change, emergency brake assist, rain-sensing wipers and satellite navigation.

Going up-market to the top shelf Atenza adds leather seats, 19-inch wheels, radar cruise control, blind spot monitoring, lane departure warning, a sun-roof and Bi-Xenon headlights that turn around corners.

A wagon is $1300 more than a sedan.

Overall, I can see why the Mazda 6 is a favourite among conservative bowls club members. It’s a quality product at an affordable price.

If my hearing keeps on deteriorating I soon won’t notice the clatter from the motor, and some diesel aficionados even like that sound.

Would I buy a Mazda6?

Well, maybe.

It’s still on my list.

Mazda6 Diesel Atenza Wagon

For: Build quality, reliability and retained value.

Against: Sounds like a diesel.

This car would suit: Volvo drivers and older doctors, like myself.

Specifications:

                2.2 litre 16 valve 4 cylinder diesel

129 kW power @ 4,500 rpm

420 Nm torque @ 2,000 rpm

6 speed automatic transmission

5.4 l/100 km (combined)

$55,000 on the road Qld, Vic and NT

$55,500 on the road where IQ’s are higher

Fast facts:

Only 4 per cent of passenger vehicles sold in Australia are diesel-powered.

The Mazda6 diesel is not currently sold in the USA.

The name “Mazda” is taken from the Zoroastrian god of wisdom, intelligence and harmony.

 

Safe motoring,

Doctor Clive Fraser

Email: doctorclivefraser@hotmail.com

NBOMe — a very different kettle of fish . . .

To the Editor: We are concerned that recent media reports about a
17-year-old Sydney boy who died after allegedly consuming 25B- or 25I-NBOMe might lead to an increase
in the incidence of NBOMe toxicity among patients presenting to emergency departments. NBOMe was reported to be available online
for as little as $1.50 per tablet.1 The subsequent media interest is likely to have increased public awareness of the availability of the NBOMe series of drugs; and increased awareness
of psychoactive substances through media reporting is associated with their increased initial uptake.2 It is possible that the increased awareness of this cheap LSD (lysergic acid diethylamide)-like drug will prompt some individuals to buy NBOMe tablets and sell them as LSD in order to make a significant profit.

The NBOMe series are analogues
of the 2C series of psychedelic phenethylamine drugs that include
an N-methoxybenzyl (hence, “NBOMe”) substituent that
has significant effects on their pharmacological activity. NBOMe drugs have been characterised
in in-vitro receptor studies as remarkably potent agonists of the
5-HT2A and 5-HT2C receptors,3 which may account for the powerful psychedelic effects at very low
doses that have been reported by users.4 Unlike LSD, however, the NBOMe drugs have significant sympathomimetic effects and can lead to acute toxicity, in addition to the behavioural hazards associated
with LSD use.4 This problem is compounded by up to six “effective” doses of an NBOMe drug being sold in a single tablet. Our observations of online marketplaces indicate that NBOMe tablets are available for purchase in Australia containing 1200 μg, yet as little as 200–1000 μg may be considered an effective sublingual dose.5

The treatment of a patient presenting with LSD intoxication typically involves supportive care
and rarely requires pharmacological intervention other than sedation. Individuals presenting to emergency departments with acute NBOMe toxicity might experience cardiovascular complications, agitation, seizures, hyperthermia, metabolic acidosis, organ failure
and death.5 Therefore, we would encourage medical and paramedical personnel involved in managing patients presenting with symptoms
of psychosis who are presumed to
be under the influence of illicit drugs to consider the diagnosis of an inadvertent NBOMe-type drug overdose, which mandates a higher level of care than they might otherwise assume is needed. Appropriate treatment might include aggressive cooling, pharmacological intervention and other high-level resuscitative measures.

High-sensitivity troponin in marathon runners

To the Editor: In 2009, we reported on increases in the level of cardiac troponin (using the TnI-Ultra troponin I assay [Siemens Healthcare Diagnostics]) among runners in the Perth marathon.1 Of the 88 runners enrolled, raised troponin levels were seen in 28 participants (32%). The independent predictors were weight loss and an increase in creatinine levels.

Recently, high-sensitivity fifth-generation troponin assays have become available for evaluation pending United States Food and Drug Administration approval. After obtaining approval from the Royal Perth Hospital ethics committee, stored blood samples were reanalysed to compare with our original results. The assay used was the Architect STAT High Sensitive Troponin-I (Abbott Diagnostics). The sex-specific cut-points supplied by the manufacturer for the assay were 16 ng/L for females and 34 ng/L for males.

In repeating our original analysis, we found that 70 (80%) had an elevated troponin level, similar to the findings of another study using the hs-cTnT assay, in which 86% of runners had a raised troponin level.2 Repetition of the statistical model used in our original study revealed no variable that was predictive of an elevated troponin level. A Bland–Altman plot showed that the new assay is identical to the old method, but is more sensitive. This suggested that the cut-points have changed. By recalibrating the old cut-points, we found that cut-points of ≥ 80 ng/L for females and ≥ 70 ng/L for males resulted in a model that produced the same predictor variables that we reported originally. The area under the receiver operating characteristic curve for this model was 0.79 (95% CI, 0.63–0.84).

High-sensitivity troponin assays can detect myocardial damage with increasing sensitivity, but are less specific. Using high-sensitivity troponin assays with a single cut-off to assess possible acute coronary syndrome (ACS) will result in more patients being incorrectly classified as having an ACS, with the associated unnecessary use of resources.3 Recognition of this led to the definition of acute myocardial infarction requiring the detection of a rise and/or fall above the cut-off together with evidence of ischaemia (either as clinical symptoms, electrocardiogram changes or imaging evidence that there is loss of viable myocardium).4 Our results support the call by Scott and colleagues for clarification about the real-world effects of this assay and the need to interpret high-sensitivity troponin assay results with caution.3