798
Medical kits
on
airliners
StR,—Iread Dr Occleshaw’s (Feb 23, p 494) report on medical kits on airliners with interest. I have lately returned from a visit to the USA and had a similar experience, happily with a more favourable outcome. Several hours after our departure, while over the Atlantic ocean, a request was made for a doctor to make himself or herself known to the cabin staff. A 22-year-old woman with an allergy to nuts was having an anaphylactic reaction to an airline vegetarian lasagne. She had a florid urticarial rash and an unrecordable blood pressure despite self-administration of two doses of adrenaline. Oxygen was given by the cabin staff and I asked for the emergency medical box. This contained several ’Elastoplast’, two ampoules of adrenaline, one of an antihistamine, and a glyceryletrinitrate spray. The drugs were administered with little initial effect and I asked for intravenous fluids or steroids. These were not available, and requests to passengers for injectable steroids yielded a flurry of sleeping tablets and aspirin. The captain diverted the plane to Newfoundland. By the time we arrived the woman’s blood pressure had been restored and she made a full recovery. It is unacceptable that airline carriers are so poorly equipped medically. It is not unreasonable to expect intravenous cannulae, fluids, and steroids as well as equipment for cardiac monitoring and resuscitation, since there are often doctors or other experienced people on board. Department of Haematology, University of Cambridge,
Some women find it hard to attract male partners for whatever reason; others do not lack admirers but fear deep commitment (as symbolised by a genital relationship). Women in either category may understandably wish for a child by donor insemination before it is too late, and it strikes me as implausible to suggest that this represents a covert desire for sexual intercourse via high technology. But it is nonetheless disturbing. Apart from the obvious drawbacks of single parenthood (does not a child need a second parent if only as an insurance against parental death or severe disability?) how will the asexual mother handle adolescent sexuality, especially in a daughter? And will her resolutely single status pose any risk for the development of any normal child? Generally speaking children do not like to be conspicuously different from their peers unless they can fully appreciate the reasons for this, and perhaps not even then. What worries me particularly is the anger of Sue Jennings’ patient at having her decision called into question, if this is how she interpreted further counselling. She ought to understand the need for this in the same way as for most adoptive applicants. And, frankly, I am tired of the argument that no discrimination should be exercised vis-a-vis single women simply because fertile couples can please themselves. This is surely irrelevant from the standpoint of
society. Department of Psychology, George’s Hospital Medical School, University of London,
St
1.
MRC Centre, Cambridge CB2 2QH, UK
MICHAEL HUMPHREY
London SW17 0RE, UK
Humphrey M, Humphrey H, Ainsworth-Smith I. Screening couples for parenthood by donor insemination. Soc Sci Med 1991; 32: 273-78.
DAVID LOMAS
Delivery dates SIR,-Dr Occleshaw’s unhappy experience while endeavouring to
help a fellow passenger during a flight, reminds me of a journey I
made from Delhi to London. Two hours out of Delhi an anxious plea was made by the cabin staff for a doctor to attend a very sick man at the rear of the aircraft. An elderly male had been in acute urinary retention since leaving Bangkok, had not reported his plight to anybody during a fuel stop in Delhi, and was by now desperate. At the time we were flying over Russia with about six hours to go. A stewardess produced the aeroplane’s emergency kit, which I rummaged through without much hope; it contained a footoperated suction apparatus, two sterile size 14 suction catheters, an Ambu bag, and two face masks. The only injectable analgesic was pentazocine. The cabin staff and I were able to lay the man on the floor, with two stewards holding up a blanket for privacy. I gave him an intravenous dose of pentazocine and catheterised his bladder with one of the disposable suction catheters. Of course, the man and the airline staff were all immeasurably grateful. However, although it was possible in this instance to use equipment not designed for the purpose, it might well have proved impossible. In such a case, the pilot would have had to decide whether to return to Delhi or to land somewhere in Russia. An audit of incidents such as this one, and that reported by Occleshaw, by all airlines who operate long-haul services would provide the information to allow both appropriate equipment and drugs to be made available at little expense. Many flights must have doctors and nurses among the passengers but they are relatively helpless without fairly basic equipment. A high proportion of airline passengers are now in the older age group and are those most likely to have medical conditions. Lives could be saved by providing adequate kit, and airlines would avoid the cost of turning back or
landing unexpectedly en route. Department of Anaesthetics, Edinburgh Royal Infirmary, Edinburgh EH3 9YW, UK
ANN WHITFIELD
Virgin births SIR,-As a fellow infertility counsellor I was interested in the "virgin birth syndrome" reported by Sue Jennings (March 2, p 559), which has since received further publicity from a similar case in Birmingham. Most of my work has been with married couples1 although I am occasionally asked to see a single woman.
SiR,—Sitting here waiting for our third child to be born, we not only support Mr Saunders and Ms Paterson’s suggestion (March 9, p 600) that the expected date of delivery be abandoned in favour ofa range of dates-we have already adopted it. The day that our first child was due to be born we had eleven phonecalls asking where he was. Unfortunately our mostly highly educated friends seem to be statistically illiterate. We felt a great sense of failure that we had not produced the goods and decided thereafter that we would opt for a range rather than a specific date. Thus our next child will be bom "sometime in April". 35 Orlando Road, London SW4 OLD, UK
LIN SMITH RICHARD SMITH
Oral rehydration therapy revisited SiR,—Oral rehydration in acute diarrhoea is well accepted and has prevented many deaths. Inevitably, parenteral rehydration continues to be required. Most authorities recommend the calculation of fluid volumes based on an estimated degree of dehydration, expressed as a percentage of body weight. This mathematical model has served well, but is flawed. The "percent dehydration" is no more than an educated guess ;’ a mathematical model suggests numerical accuracy when in practice neither hydrated weight nor exact losses are known; and additional calculations that are subject to error are required to accommodate further stool losses, maintenance requirements, and the contribution of any oral fluids to the fluid balance. Over the past five years, we have abandoned the "percent dehydration" calculation. Intravenous fluids are given for resuscitation from shock (as defined by impalpable radial pulses or a capillary filling time longer than 4 s), in patients with abdominal distension, severe acidosis and vasoconstriction, encephalopathy, and where there is deterioration or lack of improvement after adequate oral fluids for 2-4 h. After resuscitation with plasma volume expanders where necessary, half-strength Darrow’s solution with 5% dextrose is given at a rate of 10-15 mlJkg per h until oral fluids can be introduced. All other patients are given oral rehydration fluid either by mouth or nasogastric drip at an initial rate of 20-25 ml/kg per hour. In patients with severe diarrhoea, hydration is maintained by means of oral rehydration solution given by nasogastric tube at rates of 5-10 ml/kg per hour, except where very
Medical kits
on
airliners
StR,—Iread Dr Occleshaw’s (Feb 23, p 494) report on medical kits on airliners with interest. I have lately returned from a visit to the USA and had a similar experience, happily with a more favourable outcome. Several hours after our departure, while over the Atlantic ocean, a request was made for a doctor to make himself or herself known to the cabin staff. A 22-year-old woman with an allergy to nuts was having an anaphylactic reaction to an airline vegetarian lasagne. She had a florid urticarial rash and an unrecordable blood pressure despite self-administration of two doses of adrenaline. Oxygen was given by the cabin staff and I asked for the emergency medical box. This contained several ’Elastoplast’, two ampoules of adrenaline, one of an antihistamine, and a glyceryletrinitrate spray. The drugs were administered with little initial effect and I asked for intravenous fluids or steroids. These were not available, and requests to passengers for injectable steroids yielded a flurry of sleeping tablets and aspirin. The captain diverted the plane to Newfoundland. By the time we arrived the woman’s blood pressure had been restored and she made a full recovery. It is unacceptable that airline carriers are so poorly equipped medically. It is not unreasonable to expect intravenous cannulae, fluids, and steroids as well as equipment for cardiac monitoring and resuscitation, since there are often doctors or other experienced people on board. Department of Haematology, University of Cambridge,
Some women find it hard to attract male partners for whatever reason; others do not lack admirers but fear deep commitment (as symbolised by a genital relationship). Women in either category may understandably wish for a child by donor insemination before it is too late, and it strikes me as implausible to suggest that this represents a covert desire for sexual intercourse via high technology. But it is nonetheless disturbing. Apart from the obvious drawbacks of single parenthood (does not a child need a second parent if only as an insurance against parental death or severe disability?) how will the asexual mother handle adolescent sexuality, especially in a daughter? And will her resolutely single status pose any risk for the development of any normal child? Generally speaking children do not like to be conspicuously different from their peers unless they can fully appreciate the reasons for this, and perhaps not even then. What worries me particularly is the anger of Sue Jennings’ patient at having her decision called into question, if this is how she interpreted further counselling. She ought to understand the need for this in the same way as for most adoptive applicants. And, frankly, I am tired of the argument that no discrimination should be exercised vis-a-vis single women simply because fertile couples can please themselves. This is surely irrelevant from the standpoint of
society. Department of Psychology, George’s Hospital Medical School, University of London,
St
1.
MRC Centre, Cambridge CB2 2QH, UK
MICHAEL HUMPHREY
London SW17 0RE, UK
Humphrey M, Humphrey H, Ainsworth-Smith I. Screening couples for parenthood by donor insemination. Soc Sci Med 1991; 32: 273-78.
DAVID LOMAS
Delivery dates SIR,-Dr Occleshaw’s unhappy experience while endeavouring to
help a fellow passenger during a flight, reminds me of a journey I
made from Delhi to London. Two hours out of Delhi an anxious plea was made by the cabin staff for a doctor to attend a very sick man at the rear of the aircraft. An elderly male had been in acute urinary retention since leaving Bangkok, had not reported his plight to anybody during a fuel stop in Delhi, and was by now desperate. At the time we were flying over Russia with about six hours to go. A stewardess produced the aeroplane’s emergency kit, which I rummaged through without much hope; it contained a footoperated suction apparatus, two sterile size 14 suction catheters, an Ambu bag, and two face masks. The only injectable analgesic was pentazocine. The cabin staff and I were able to lay the man on the floor, with two stewards holding up a blanket for privacy. I gave him an intravenous dose of pentazocine and catheterised his bladder with one of the disposable suction catheters. Of course, the man and the airline staff were all immeasurably grateful. However, although it was possible in this instance to use equipment not designed for the purpose, it might well have proved impossible. In such a case, the pilot would have had to decide whether to return to Delhi or to land somewhere in Russia. An audit of incidents such as this one, and that reported by Occleshaw, by all airlines who operate long-haul services would provide the information to allow both appropriate equipment and drugs to be made available at little expense. Many flights must have doctors and nurses among the passengers but they are relatively helpless without fairly basic equipment. A high proportion of airline passengers are now in the older age group and are those most likely to have medical conditions. Lives could be saved by providing adequate kit, and airlines would avoid the cost of turning back or
landing unexpectedly en route. Department of Anaesthetics, Edinburgh Royal Infirmary, Edinburgh EH3 9YW, UK
ANN WHITFIELD
Virgin births SIR,-As a fellow infertility counsellor I was interested in the "virgin birth syndrome" reported by Sue Jennings (March 2, p 559), which has since received further publicity from a similar case in Birmingham. Most of my work has been with married couples1 although I am occasionally asked to see a single woman.
SiR,—Sitting here waiting for our third child to be born, we not only support Mr Saunders and Ms Paterson’s suggestion (March 9, p 600) that the expected date of delivery be abandoned in favour ofa range of dates-we have already adopted it. The day that our first child was due to be born we had eleven phonecalls asking where he was. Unfortunately our mostly highly educated friends seem to be statistically illiterate. We felt a great sense of failure that we had not produced the goods and decided thereafter that we would opt for a range rather than a specific date. Thus our next child will be bom "sometime in April". 35 Orlando Road, London SW4 OLD, UK
LIN SMITH RICHARD SMITH
Oral rehydration therapy revisited SiR,—Oral rehydration in acute diarrhoea is well accepted and has prevented many deaths. Inevitably, parenteral rehydration continues to be required. Most authorities recommend the calculation of fluid volumes based on an estimated degree of dehydration, expressed as a percentage of body weight. This mathematical model has served well, but is flawed. The "percent dehydration" is no more than an educated guess ;’ a mathematical model suggests numerical accuracy when in practice neither hydrated weight nor exact losses are known; and additional calculations that are subject to error are required to accommodate further stool losses, maintenance requirements, and the contribution of any oral fluids to the fluid balance. Over the past five years, we have abandoned the "percent dehydration" calculation. Intravenous fluids are given for resuscitation from shock (as defined by impalpable radial pulses or a capillary filling time longer than 4 s), in patients with abdominal distension, severe acidosis and vasoconstriction, encephalopathy, and where there is deterioration or lack of improvement after adequate oral fluids for 2-4 h. After resuscitation with plasma volume expanders where necessary, half-strength Darrow’s solution with 5% dextrose is given at a rate of 10-15 mlJkg per h until oral fluids can be introduced. All other patients are given oral rehydration fluid either by mouth or nasogastric drip at an initial rate of 20-25 ml/kg per hour. In patients with severe diarrhoea, hydration is maintained by means of oral rehydration solution given by nasogastric tube at rates of 5-10 ml/kg per hour, except where very
