H-Arzt-System und D-Arzt-Aufgaben

The procedure in place for health insurance-approved doctors and general practitioners and the option of checking assign important tasks in the control and monitoring of treatments paid for by the employers’ liability insurance associations to the doctor in private practice who is qualified for emergency treatment (D[Durchgangs]-Arzt). The trauma doctor in private practice who has not undertaken the training for this qualification (H-Arzt) is only allowed to treat such injured persons as come to his or her practice direct. The contract between doctors and accident insurance payers has no procedure in place for other doctors to refer patients to the H-Arzt. Approximately 86% of injured patients are treated by a D-Arzt, while the remaining patients who need trauma surgery are treated by an H-Arzt or general practitioner. A D-Arzt is obliged to be available on Mondays to Fridays from 08.00 to 18.00 and to provide an on-call service on Saturdays from 08.00 to 13.00; it is permissible for the Saturday hours to be entrusted to an officially approved locum. In future a documented qualification in orthopaedics and trauma surgery will no longer be enough to allow a doctor to work as a D-Arzt; the additional specialist qualification in trauma surgery is also required.     

Helicopter doctors?

All roadside procedures carried out by doctors of the Royal London Hospital Helicopter Emergency Medical Service were recorded. Of 100 injured patients treated consecutively, 68 patients required 73 treatments or procedures that were beyond the current training of the ambulance paramedic in the United Kingdom. Doctors are therefore an essential part of HEMS operations and allow earlier live-saving medical intervention in the prehospital phase of care.     

Substance use disorder in the anaesthetist

Anaesthetists have a higher incidence of substance use disorder when compared with other doctors. This might be due to the ease of access to intravenous opioids, propofol, midazolam, inhalational agents and other anaesthetic drugs. Alcohol use disorder continues to be the most common problem. Unfortunately, the first sign that something is amiss might be the anaesthetist's death from an accidental or deliberate overdose. While there are few accurate data, suicide is presumed to be the cause of death in approximately 6–10% of all anaesthetists. If we are to prevent this, substance use disorder must be recognised early, we should ensure the anaesthetist is supported by their department and hospital management and that the anaesthetist engages fully with treatment. Over 75% of anaesthetists return to full practice if they co-operate fully with the required treatment and supervision.     

Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia? The results of a survey of anesthesia residency program directors

Study ObjectiveTo determine the experience, attitudes, and opinions of program directors regarding the reintroduction of residents in recovery from substance abuse into the clinical practice of anesthesiology.DesignSurvey instrument.SettingAnesthesia residency training programs in the United States.MeasurementsAfter obtaining institutional review board approval, a list of current academic anesthesia residency programs in the United States was compiled. A survey was mailed to 131 program directors along with a self-addressed stamped return envelope to ensure anonymity. Returned surveys were reviewed and data compiled by hand, with categorical variables described as frequency and percentages.Main ResultsA total of 91 (69%) surveys were returned, representing experience with 11,293 residents over the ten-year period from July of 1997 through June of 2007. Fifty-six (62%) program directors reported experience with at least one resident requiring treatment for substance abuse. For residents allowed to continue with anesthesia residency training after treatment, the relapse rate was 29%. For those residents, death was the initial presentation of relapse in 10% of the reported cases. 43% of the program directors surveyed believe residents in recovery from addiction should be allowed to attempt re-entry while 30% believe that residents in recovery from addiction should not.ConclusionsThe practice of allowing residents who have undergone treatment for substance abuse to return to their training program in clinical anesthesia remains highly controversial. They are often lost to follow-up, making it difficult, if not impossible to determine if re-training in a different medical specialty decreases their risk for relapse. A comprehensive assessment of the outcomes associated with alternatives to re-entry into clinical anesthesia training programs is needed.     

Abuse of psychoactive drugs among health professionals

Health care givers suffer problems of abuse of and addiction to substances at a rate similar to or perhaps higher than that of the general population according to available studies, most of which were done in the United States. Anesthesiologists tend to have the highest incidence of addiction. Among the risk factors identified are self-medication, stress at work and easy access to drugs. After alcohol, opiates and benzodiazepines are the drugs most favored. No data are available for Spain on this problem. One recently opened treatment program exists, implemented by the Department of Health of the autonomous government of Catalonia (Spain) in collaboration with the Official College of Physicians of Barcelona. Although the problem is probably not great in Spain, prevention programs should be put in place to identify and act on known risk factors, by controlling and limiting access to drugs, raising awareness among health-care givers of the risks of self-medication, and improving working conditions. The main obstacle to treating such patients is denial, which makes identification of abusers and their adherence to a program difficult. The therapeutic phases are identification, intervention, treatment, return to work and follow-up. Addicts are chronic patients who require follow-up for many years, given that the risk of relapse is always present.     

Chronic combat-related PTSD and concurrent substance abuse: Implications for treatment of this frequent “dual diagnosis”

Vietnam combat veterans suffering from post-traumatic stress disorder (PTSD) who had requested treatment through a special VA-sponsored PTSD treatment program were evaluated using the Diagnostic Interview Schedule (DIS). Based on the DIS, 91.12% of the sample had a lifetime diagnosis of substance abuse or dependence and this was, by far, the most frequent co-diagnosis in the sample. The most common reason for patients not completing the treatment program was for use of illegal substances or alcohol while in the program, even though they were aware that to do so meant that they would be either discharged or transferred to another unit. The percentage of other co-diagnoses, and an estimate of currentness for all Axis I diagnoses were also presented on the sample of 102 patients. It was determined that for this population, the symptoms of substance abuse were chronic and were inextricably intertwined with PTSD symptoms and with the initial stressor (combat). Treatment process implications were discussed.     

Appraisal and revalidation: a guide for junior doctors

If you are a doctor and want to practise in the United Kingdom, you need registration with the General Medical Council (GMC) and a license to practise. An annual appraisal is essential to be able to demonstrate fitness to practise for revalidation. However, many doctors do not know this, or the process whereby they can fulfil their obligations to the GMC. Junior doctors in training are able to provide evidence for re-validation through the Annual Review of Competence Progression (ARCP) process. Junior doctors who have taken, or are taking time out, of training posts for a variety of reasons need to be aware of the need to provide evidence of having participated in the appraisal process in order to revalidate. Similarly, junior doctors who are leaving foundation training but not entering another training post, such as clinical teaching fellows, clinical surgical fellows, working overseas or locum doctors, need to be aware of their revalidation responsibilities. The professional regulation of doctors has taken great strides forwards since 2012 when revalidation was launched. The General Medical Council (GMC) framework is based on core guidance for doctors contained within ‘Good Medical Practice’. All licensed doctors in the UK now have to have an annual appraisal and need to demonstrate with supporting information how they meet the values set out in Good Medical Practice. All doctors who wish to hold a licence to practise are legally required to be revalidated every 5 years to prove they are up to date and fit to practise. Revalidation provides the link between core guidance for doctors, Good Medical Practice and regular appraisal.     

Ausrüstung von Notarzteinsatzfahrzeugen

The work of the emergency services has been regulated by law in the different countries of the Federal Republic of Germany. These laws provide the basis for the regular services of emergency doctors. In many places such services have been established. Two different systems have been developed: the stationary system and the “rendez-vous” system. The advantages and the disadvantages of both systems are outlined. In the “rendez-vous”-system the ambulance and the doctor are stationed at different places. The doctor comes with a special car to the place of an emergency. In this car all the essential equipment is provided, which is needed for an effective first aid. The equipment of such a special car is described. The model shall become generally accepted through the German DIN-commission.     

Occupational health and pollution from anaesthetics

The Control of Substances Hazardous to Health Regulations require employers in the United Kingdom to evaluate and control the risks to health for all their employees from exposure to hazardous substances at work. This applies to those working in hospital operating theatres who may be exposed to anaesthetic gas pollution. These legal requirements coupled with continuing concern about the effective localised control of anaesthetic pollution, the potential chemical interactions in the upper atmosphere, as well as the analysis of the prospective study in the United Kingdom on the health of women doctors, have prompted a reassessment of the topic. Some of the original fears are without foundation but the overall conclusion is that we can still not regard anaesthetic pollution as a problem solved.     

Rolle des beratendes Arztes

The doctors retained by the employers’ liability insurance companies are an important factor in communication between legally required accident insurance companies, service providers and insured persons. A doctor retained to do this work on a part-time basis as a second occupation can be a specialist in emergency medicine with many years of experience in hospital and private practice, a partner in a joint practice or a doctor employed in a hospital with appropriate arrangements for cover. On the one hand, this guarantees the doctor’s financial independence, while in addition s/he is also in a position to assess individual cases by drawing on hands-on experience. Discussions with those responsible for working on the files, checks on the expert reports and also the invoices and help in the provision of specific aftertreatment and planning of the patients’ reintegration make up an essential part of the work. Increasingly, a doctor retained by the employers’ liability insurance companies is also required to act as a mediator to help avoid the escalation of any conflicts. Sometimes s/he is also required to stand up specifically for patients’ rights! Doctors working in this way are assessed daily by patients, colleagues and administrators. As seen from this paper, their work will remain essential in the future for successful treatment approved by employers’ liability insurance companies.     

Competence assurance — Who cares?

The provision of clinical care in the United Kingdom now requires the acquisition of a licence to practise from the regulatory authority. A review process-revalidation has been put in place to ensure that standards of care are maintained by the medical workforce, and that all doctors remain up-to-date and fit for purpose so that this licence can be retained. This article outlines how this new statutory requirement pertains to paediatric surgery and highlights those areas where adjudication of competence remains imprecise and where progress in this process of revalidation needs to be made.     

The presence and impact of traumatic brain injury among clients in treatment for co-occurring mental illness and substance abuse

Objectives: To compare diagnostic and treatment-related differences between persons participating in treatment for dually diagnosed substance use disorders and severe mental illness who have or do not have a history of traumatic brain injury (TBI).

Design: Prospective cohort.

Interventions: Not applicable.

Primary measures: Demographic information, diagnostic data, pre-treatment status, treatment participation and staff assessment of functioning.

Results: Seventy-two percent of participants in treatment for dually diagnosed substance use disorders and severe mental illness reported a history of at least one TBI. Participants with TBI had greater morbidity as reflected in more complex psychiatric diagnoses and greater likelihood of being diagnosed with an Axis II personality disorder. Participants with a TBI showed tendencies toward earlier onset of substance use and worse current functioning. Both a greater number of injuries and earlier age at first TBI showed some indications of being associated with worse morbidity.

Conclusions: Individuals dually diagnosed with substance use disorders and severe mental illness may have a high rate of TBI, which in turn could contribute to important clinical and treatment differences. Results also suggested the need for validated methods of identifying aspects of a prior history of TBI that provide more information than presence/absence.     

Performance-related pay for hospital consultants

In the United Kingdom there about 300,000 people who earn at least pounds 100,000 per year. These people represent just 1% of U.K. workers. Hospital consultants are in this exclusive earning group, and so they should be. Following a new pay deal in 2003, which enabled consultants to achieve a record average NHS salary of pounds 110,000 in 2006, there is growing momentum to introduce a system of performance-related pay. Such a system could work. Many believe this would create the necessary leverage to get the consultant body to work with the managers to create a robust NHS that is fit for purpose and can compete healthily against alternative providers in an open marketplace. The resolve to achieve this has never been stronger. The NHS has always been dogged by status and power divides between the different groups of workers. The time has come to make some headway with breaking down these divides and get on with running a business. Let's hope the NHS can transform into a place where managers and doctors trust each other and work better together. This would give the 1.3 million people that work in the NHS the best chance of creating a successful business that cares for ill people. The financial and professional rewards will follow.     

One approach to the return to residency for anesthesia residents recovering from opioid addiction

STUDY OBJECTIVE: There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur. DESIGN: 5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia. SETTING: Academic anesthesia practice in a large teaching hospital. RESULTS: Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists. CONCLUSIONS: The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.     

Return to activities after breast reduction

BackgroundUncertainty exists in the medical literature about recommendations for return to work or driving after breast reduction surgery.MethodsA survey was sent to 138 plastic surgeons in the United Kingdom enquiring about their recommended timing of return to work or driving a car depending of level of activity. Data was evaluated with univariate ANOVA test and a p < 0.05 significance level.ResultsOut of 73 surgeons who responded, 13% did not give any specific advice regards to return to work and 30% for return to driving. The remainder suggested to return to work and driving after about 19 days each.ConclusionsBased on this consensus of opinion of plastic surgeons with an interest in breast surgery it appears reasonable to suggest a recovery period of approximately 3 weeks subject to individual variations. Further evidence is needed to comment on the interaction of wound healing and pain and return to driving and work.     

A prescription for the rogue doctor: part I--begin with diagnosis

Among the most serious problems a doctor can have may be those which are the result of a defect of character or a flaw in ethics. Under these circumstances, unacceptable behavior patterns may arise. Examples of unacceptable patterns of behavior include dishonesty, intentionally harming a patient, sexual harassment, and substance abuse. For years, doctors who have these patterns have been handled with kid gloves by those who educate, train, and supervise professionals in the healthcare industry. Counseling, coaching, training, supervising, transfers to less critical disciplines, disciplinary warnings, and offering opportunities to resign have been the typical protocols. Traditionally, outright firing of residents and doctors has been relatively taboo and too radical for the medical profession. Why has this been the case? Reasons may include unwillingness to get involved or to deal with the stress of disciplining a colleague, an unwillingness which often is grounded in fears of retaliation. In a litigious society, fears of slander lawsuits, for example, may be all-too-real. However, the implied paternalism and the practice of protecting doctors' careers by preserving their professional status as practicing doctors have become increasingly problematic. Aside from the fact that it is unethical, allowing problem doctors to continue to practice medicine may have an adverse impact on the well-being of patients and therefore may represent an enormous legal liability for organizations that employ them. In this first of a two-part series, problems that now exist and implementation of a performance management system as a starting point for removing rogues from the system are discussed. A subsequent paper will detail how such a system operates.     

Kobrabiss, (k)ein sonntäglicher Notfall

Exotic snake bite patients are a rarity for most European emergency doctors. The demands are extreme and very challenging for the emergency surgeon, who has only limited diagnostic resources and whose knowledge about the toxicology of snake poisoning is often insufficient. He is primarily dependent upon his senses for diagnosis. Most important is the treatment of the acute symptomatic. Basically the doctor must assess the patient immediately and prepare himself for the possible changes which can result from the actions of the toxin. In emergency medicine it is essential to evaluate the patient frequently. In addition, the well-known algorithms can be used at any time. The principal points include frequent evaluations to avoid hypoxia and hypovolemia caused by systemic anaphylaxis and hemorrhage. Early intubation can be life-saving. The transfer to an intensive care unit is an important factor determining the patient's survival. As soon as possible antivenin should be made available. The following case report describes the case of a private reptile breeder, who handled exotic snakes and was bitten by a Cobra.     

Combat exposure and the etiology of postdischarge substance abuse problems among Vietnam veterans

This study finds a highly significant (p<0.0002) relationship between combat exposure and problems with drugs or drinking too much following discharge from the Armed Forces among a large (N=1,176) national random probability sample of Vietnam veterans. Exposure to heavy combat more than doubled a typical Vietnam veteran's risk of reporting a postdischarge substance abuse problem, as compared to what would have been expected had he served, but seen no combat, in Vietnam. Employing an ordinary least-squares multiple regression model, this study also found a highly significant relationship (p<0.0001) between the self-report of a postdischarge substance abuse problem and age at assignment to Vietnam. These findings support the residual stress theory proposed by Figley (1978), as opposed to the stress evaporation hypothesis advanced by Borus (1973). Providing empirical support for the psychoanalytic construct of normal developmental lines advanced by Anna Freud (1965) and Erikson (1968), this study posits that younger Vietnam combat veterans, having achieved less developmental stability and personality integration than relatively older veterans, were therefore at greater risk for the subsequent emergence of substance abuse problems as a result of their exposure to combat.     

Acute delirium and poor compliance in total hip arthroplasty patients with substance abuse disorders

From the joint registry of 2831 primary total hip arthroplasties (2351 patients) performed between 1998 and 2003, we identified 15 patients (16 hips) who had a documented history of substance abuse disorders at the time of the index surgery. The patients included 13 men (14 hips) and 2 women (2 hips), with the mean age of 49 years (range, 29-65 years). On the basis of the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 13 patients had alcohol abuse disorders, 1 had amphetamine abuse disorder, and 1 had heroin abuse disorder. We found high rates of postoperative substance withdrawal delirium and psychosis (46%), late complication (25%), and lost to follow-up (27%) in these patients. Because patients with substance abuse disorders have unexpected perioperative psychotic episodes, poor compliance, and a tendency to not follow medical advice after surgery and show early discontinuation of follow-up, we suggest that surgeons should work with other medical professionals and carefully perform total hip arthroplasty in such patients.