audit systems could be improved by giving future junior doctors simple training in audit and computer skills, preferably while they are at medical school, and we recommend that such training become part of the formal curriculum. GERARD STANSBY MARTIN OSBORNE
University Department of Surgery, Royal Free Hospital and School of Medicine, London NW3 2QG I Crombie IK, Davies HTO. Computers in audit: servants or sirens? BMJ 1991;303:403-4. (17 August.) 2 Hamlyn AN. Computers in audit: servants or sirens? BMJ 1991;303:649. (14 September.)
Not research and development SIR, -Dr Paul Walker's call for ensuring adequate dissemination and application of findings by explicit responsibility within the research and development strategy' is all the more timely in view of the present emphasis on guidelines and protocols.2' Before protocols can be implemented and monitored for effectiveness it is necessary to ensure that they reach their intended audience, an important consideration which has not been given due attention in the past. During a recent study in the Northern region we examined the process of dissemination of guidelines for the management of adult patients with a recent head injury. Published guidelines4 were modified in collaboration with neurosurgeons, reproduced on laminated cards by the clinical policy division of the Northern Regional Health Authority, and sent to all hospitals in the region. The personnel officers at the hospitals were asked to distribute the cards by including them in the induction pack given to all junior doctors in appropriate specialties. The guidelines were also promoted by undergraduate and postgraduate lectures and displayed on wall posters in the hospitals. In a postal survey of 163 senior house officers working in the specialties of general surgery, neurosurgery, accident and emergency medicine, and orthopaedic surgery in 1990, 22% of the 131 respondents were not aware of the head injury guidelines and 37% had never possessed a laminated card. In another study to ascertain general practitioners' views on guidelines for referral to an orthopaedic outpatient clinic as recommended by Roland et aP 48 randomly selected general practitioners were surveyed. From the Family Health Services Authority list all general practices were identified and one general practitioner was chosen randomly from each practice. (In the case of a single handed practice the only occupant was chosen.) Of the 36 respondents to date, only 14 had seen Roland et al's paper in the BMJ. None of them had discussed it with their colleagues in the practice. Seventeen general practitioners (47%) would have liked outpatient referral guidelines, and the best mechanism for disseminating guidelines was considered to be postal distribution (15/17, 88%) followed by presenting the guidelines at a seminar (13/17, 76%). Publishing guidelines in a scientific journal was the least preferred option
(12%).
These two examples confirm the need to deal with the problem of dissemination. The process of disseminating information in AIDS health education has rarely been examined6 and may account for the failure of health education to affect sexual behaviour.7 Guidelines which aim to modify physicians' behaviour largely through education (although financial incentives and disincentives have been favoured by third party payers) may fail for similar reasons. In the United States, which has led the world in formulating guidelines with over 1000 guidelines produced by the various professional organisations,8 examination of the dissemination process is considered a priority for the
854
recently established federal Agency for Health Care Policy and Research.9 Similar emphasis is required in the research and development strategy for the United Kingdom. RAJAN MADHOK SANDRA GREEN South Tees Health Authority, Po,ole Hospital, Middlesbrough TS7 ONJ
RICHARD G THOMSON ALAN MORDUE Northern Regional Health Authority, Newcastle upon Tyne 1 Walker P. Not research and development but dissemination and application. BMJ 1991;303:524. (31 August.) 2 Jenkins D. Investigations: getting from guidelines to protocols. BMJ 1991;303:323-4. (10 August.) 3 Gama R, Featherstone S. Investigations: getting from guidelines to protocols. BMJ 1991;303:522-3. (31 August.) 4 Group of Neurosurgeons. Guidelines for the initial management after head injury in adults. BMJ 1984;288:983-5. 5 Roland MO, Porter RW, Mathews JG, Redden JF, Simmonds GW, Bewley B. Improving care: a study of orthopaedic outpatient referrals. BMJ 1991;302:1124-8. (11 May.) 6 Aggleton P. HIV/AIDS education in schools: constraints and possibilities. Health Education Journal 1989;48:167-71. 7 Madhok R. Evaluation of the Health Education Authority's initiative to raise students' awareness of HIV and AIDS [dissertation]. London: Faculty of Public Health Medicine, 1990. 67pp. 8 Bartlett EE, Urich V. Outcomes research and cost-containment. N EngljMed 1991;325:66. 9 Clinton JJ. Agency for Health Care Policy and Research. JAMA 1990;263: 1612.
undertook the second debridement we advised that primary amputation of the limb should be considered. The patient subsequently underwent nine surgical procedures in an attempt to debride the infected area completely, and he also remained feverish for most of his eight month stay in hospital. Though it was interesting to note all the possible mediators of the pathophysiological processes that affected him, it is worth emphasising that all surgical textbooks are agreed that surgery-that is, the radical removal of all necrotic tissue at the first operation-is crucial to the survival ofthe patient.24 In a proximal infection of a limb amputation may be required. A second look operation should be performed at 24-48 hours to ensure that all necrotic tissue has been adequately cleared.4 In our experience debridement is often done badly, being delegated to less experienced members of the surgical team who compromise their excision because they are concerned how the wound will be closed. We believe that this patient would have had a shorter stay in hospital with less complicated, less expensive postoperative care if he had undergone a primary disarticulation, particularly as the article states that he may yet require amputation. N MERCER D M DAVIES
Department of Plastic Surgerv, Charing Cross Hospital, London W6 8RF
Post-traumatic stress disorders SIR, -Dr Gary Jackson's explicit editorial on posttraumatic stress disorders rightly emphasised the long term nature of this disorder, the relatively high incidence in injured combat veterans, and the very high incidence in prisoners of war, especially those from camps in the Far East during the second world war,' which is recognised by the large number receiving war pensions. The Ex-Services Mental Welfare Society dates back to 1919, when this disorder was recognised under other names. Psychiatry has progressed considerably since then, and phrases like shell shock, cowardice, and poor moral fibre are diagnoses of the past. The services today offer excellent medical care and facilities for this condition and other psychological disorders. The society, however, is further able to help in the continuing care of patients when they are discharged from the services. It has two acute psychiatric convalescent homes in addition to a veterans' home for permanent stay. Our welfare officers visit clients in their homes, and our chief psychiatrist and regional psychiatrists are also available. The society works closely with other service charities that refer patients with psychological problems of all types. For further advice on psychological or associated welfare problems inquiries should be addressed (by either patients or doctors) to the assistant director (welfare), Ex-Services Mental Welfare Society, Broadway House, Wimbledon Broadway, London SW19 1RL. T P LINEHAN
Chief medical adviser, Ex-Services Mental Welfare Society, London SW19 IRL 1 Jackson G. The rise of post-traumatic stress disorders. BMJ
1991;303:533-4. (7 September.)
Gas gangrene SIR,-We read with interest the article on gas gangrene presented by Drs P J Lehner and H Powell. ' We saw the patient reported on, a week after his admission to hospital and his first debridement, with a view to performing skin grafting for the fasciotomy defect on the medial aspect of his leg and thigh. At this consultation it was obvious that dead skin and muscle remained, and when we
I Lehner PJ, Powell H. Gas gangrene. BM7 1991;303:240-2.
(27 July.) 2 Sabiston DC. Essentials of surgery. Philadelphia: W B Saunders, 1987: 159. 3 Kyle J, Hardy JD. Scientific foundations of surgery. London: Heinemann, 1981: 622. 4 Cuscheri A, Giles GR, Moosa AR. Essential surgical practice. London: Wright, 1988: 74-5.
SIR,-The letter from Messrs Mercer and Davies gives us an opportunity to provide an update on the patient's progress. The patient's wound was re-explored after 24 hours to control haemorrhage, and no further necrotic muscle was found. Skin demarcation was not clear, and further observation was required to minimise loss of skin. The plastic surgeons were consulted several days later when the patient's life was out of danger. They advised early surgery. Dead skin was removed and the fasciotomy grafted but no muscle debrided. Six days later the leg was dressed again and an area on the lateral aspect of the lower thigh debrided to remove necrotic muscle. At that stage they advised us to amputate. We decided that there was no clinical indication for amputation. Several visits to the theatre were necessary for superficial tissue to be debrided, but he steadily improved and with the aid of intensive physiotherapy was eventually discharged with a fully healed limb. Arterial, venous, and lymphatic studies all gave normal results, and there was no sensory loss. His disabilities are a foot drop and limited knee movement, but he is now mobile. We agree that radical removal of necrotic tissue is necessary as an emergency and that a second look operation should be performed at 24-48 hours; both of these were done. It is not surprising that a wound of this magnitude required further debridement, and this surgery was not delegated to an inexperienced junior. These subsequent procedures were minor and were required not to remove necrotic muscle but to treat secondary infection. We disagree that a major hindquarter operation was indicated in this young man, either initially or later. The original operation was designed to save his life and subsequent treatment to save his limb. It is well known that good limb function can be obtained, particularly in young patients, after the loss of a large amount of muscle. Our colleagues advised amputation after two weeks, when the patient's condition was substantially improved and
BMJ
VOLUME
303
5
OCTOBER
1991
University Department of Surgery, Royal Free Hospital and School of Medicine, London NW3 2QG I Crombie IK, Davies HTO. Computers in audit: servants or sirens? BMJ 1991;303:403-4. (17 August.) 2 Hamlyn AN. Computers in audit: servants or sirens? BMJ 1991;303:649. (14 September.)
Not research and development SIR, -Dr Paul Walker's call for ensuring adequate dissemination and application of findings by explicit responsibility within the research and development strategy' is all the more timely in view of the present emphasis on guidelines and protocols.2' Before protocols can be implemented and monitored for effectiveness it is necessary to ensure that they reach their intended audience, an important consideration which has not been given due attention in the past. During a recent study in the Northern region we examined the process of dissemination of guidelines for the management of adult patients with a recent head injury. Published guidelines4 were modified in collaboration with neurosurgeons, reproduced on laminated cards by the clinical policy division of the Northern Regional Health Authority, and sent to all hospitals in the region. The personnel officers at the hospitals were asked to distribute the cards by including them in the induction pack given to all junior doctors in appropriate specialties. The guidelines were also promoted by undergraduate and postgraduate lectures and displayed on wall posters in the hospitals. In a postal survey of 163 senior house officers working in the specialties of general surgery, neurosurgery, accident and emergency medicine, and orthopaedic surgery in 1990, 22% of the 131 respondents were not aware of the head injury guidelines and 37% had never possessed a laminated card. In another study to ascertain general practitioners' views on guidelines for referral to an orthopaedic outpatient clinic as recommended by Roland et aP 48 randomly selected general practitioners were surveyed. From the Family Health Services Authority list all general practices were identified and one general practitioner was chosen randomly from each practice. (In the case of a single handed practice the only occupant was chosen.) Of the 36 respondents to date, only 14 had seen Roland et al's paper in the BMJ. None of them had discussed it with their colleagues in the practice. Seventeen general practitioners (47%) would have liked outpatient referral guidelines, and the best mechanism for disseminating guidelines was considered to be postal distribution (15/17, 88%) followed by presenting the guidelines at a seminar (13/17, 76%). Publishing guidelines in a scientific journal was the least preferred option
(12%).
These two examples confirm the need to deal with the problem of dissemination. The process of disseminating information in AIDS health education has rarely been examined6 and may account for the failure of health education to affect sexual behaviour.7 Guidelines which aim to modify physicians' behaviour largely through education (although financial incentives and disincentives have been favoured by third party payers) may fail for similar reasons. In the United States, which has led the world in formulating guidelines with over 1000 guidelines produced by the various professional organisations,8 examination of the dissemination process is considered a priority for the
854
recently established federal Agency for Health Care Policy and Research.9 Similar emphasis is required in the research and development strategy for the United Kingdom. RAJAN MADHOK SANDRA GREEN South Tees Health Authority, Po,ole Hospital, Middlesbrough TS7 ONJ
RICHARD G THOMSON ALAN MORDUE Northern Regional Health Authority, Newcastle upon Tyne 1 Walker P. Not research and development but dissemination and application. BMJ 1991;303:524. (31 August.) 2 Jenkins D. Investigations: getting from guidelines to protocols. BMJ 1991;303:323-4. (10 August.) 3 Gama R, Featherstone S. Investigations: getting from guidelines to protocols. BMJ 1991;303:522-3. (31 August.) 4 Group of Neurosurgeons. Guidelines for the initial management after head injury in adults. BMJ 1984;288:983-5. 5 Roland MO, Porter RW, Mathews JG, Redden JF, Simmonds GW, Bewley B. Improving care: a study of orthopaedic outpatient referrals. BMJ 1991;302:1124-8. (11 May.) 6 Aggleton P. HIV/AIDS education in schools: constraints and possibilities. Health Education Journal 1989;48:167-71. 7 Madhok R. Evaluation of the Health Education Authority's initiative to raise students' awareness of HIV and AIDS [dissertation]. London: Faculty of Public Health Medicine, 1990. 67pp. 8 Bartlett EE, Urich V. Outcomes research and cost-containment. N EngljMed 1991;325:66. 9 Clinton JJ. Agency for Health Care Policy and Research. JAMA 1990;263: 1612.
undertook the second debridement we advised that primary amputation of the limb should be considered. The patient subsequently underwent nine surgical procedures in an attempt to debride the infected area completely, and he also remained feverish for most of his eight month stay in hospital. Though it was interesting to note all the possible mediators of the pathophysiological processes that affected him, it is worth emphasising that all surgical textbooks are agreed that surgery-that is, the radical removal of all necrotic tissue at the first operation-is crucial to the survival ofthe patient.24 In a proximal infection of a limb amputation may be required. A second look operation should be performed at 24-48 hours to ensure that all necrotic tissue has been adequately cleared.4 In our experience debridement is often done badly, being delegated to less experienced members of the surgical team who compromise their excision because they are concerned how the wound will be closed. We believe that this patient would have had a shorter stay in hospital with less complicated, less expensive postoperative care if he had undergone a primary disarticulation, particularly as the article states that he may yet require amputation. N MERCER D M DAVIES
Department of Plastic Surgerv, Charing Cross Hospital, London W6 8RF
Post-traumatic stress disorders SIR, -Dr Gary Jackson's explicit editorial on posttraumatic stress disorders rightly emphasised the long term nature of this disorder, the relatively high incidence in injured combat veterans, and the very high incidence in prisoners of war, especially those from camps in the Far East during the second world war,' which is recognised by the large number receiving war pensions. The Ex-Services Mental Welfare Society dates back to 1919, when this disorder was recognised under other names. Psychiatry has progressed considerably since then, and phrases like shell shock, cowardice, and poor moral fibre are diagnoses of the past. The services today offer excellent medical care and facilities for this condition and other psychological disorders. The society, however, is further able to help in the continuing care of patients when they are discharged from the services. It has two acute psychiatric convalescent homes in addition to a veterans' home for permanent stay. Our welfare officers visit clients in their homes, and our chief psychiatrist and regional psychiatrists are also available. The society works closely with other service charities that refer patients with psychological problems of all types. For further advice on psychological or associated welfare problems inquiries should be addressed (by either patients or doctors) to the assistant director (welfare), Ex-Services Mental Welfare Society, Broadway House, Wimbledon Broadway, London SW19 1RL. T P LINEHAN
Chief medical adviser, Ex-Services Mental Welfare Society, London SW19 IRL 1 Jackson G. The rise of post-traumatic stress disorders. BMJ
1991;303:533-4. (7 September.)
Gas gangrene SIR,-We read with interest the article on gas gangrene presented by Drs P J Lehner and H Powell. ' We saw the patient reported on, a week after his admission to hospital and his first debridement, with a view to performing skin grafting for the fasciotomy defect on the medial aspect of his leg and thigh. At this consultation it was obvious that dead skin and muscle remained, and when we
I Lehner PJ, Powell H. Gas gangrene. BM7 1991;303:240-2.
(27 July.) 2 Sabiston DC. Essentials of surgery. Philadelphia: W B Saunders, 1987: 159. 3 Kyle J, Hardy JD. Scientific foundations of surgery. London: Heinemann, 1981: 622. 4 Cuscheri A, Giles GR, Moosa AR. Essential surgical practice. London: Wright, 1988: 74-5.
SIR,-The letter from Messrs Mercer and Davies gives us an opportunity to provide an update on the patient's progress. The patient's wound was re-explored after 24 hours to control haemorrhage, and no further necrotic muscle was found. Skin demarcation was not clear, and further observation was required to minimise loss of skin. The plastic surgeons were consulted several days later when the patient's life was out of danger. They advised early surgery. Dead skin was removed and the fasciotomy grafted but no muscle debrided. Six days later the leg was dressed again and an area on the lateral aspect of the lower thigh debrided to remove necrotic muscle. At that stage they advised us to amputate. We decided that there was no clinical indication for amputation. Several visits to the theatre were necessary for superficial tissue to be debrided, but he steadily improved and with the aid of intensive physiotherapy was eventually discharged with a fully healed limb. Arterial, venous, and lymphatic studies all gave normal results, and there was no sensory loss. His disabilities are a foot drop and limited knee movement, but he is now mobile. We agree that radical removal of necrotic tissue is necessary as an emergency and that a second look operation should be performed at 24-48 hours; both of these were done. It is not surprising that a wound of this magnitude required further debridement, and this surgery was not delegated to an inexperienced junior. These subsequent procedures were minor and were required not to remove necrotic muscle but to treat secondary infection. We disagree that a major hindquarter operation was indicated in this young man, either initially or later. The original operation was designed to save his life and subsequent treatment to save his limb. It is well known that good limb function can be obtained, particularly in young patients, after the loss of a large amount of muscle. Our colleagues advised amputation after two weeks, when the patient's condition was substantially improved and
BMJ
VOLUME
303
5
OCTOBER
1991
