Archibald Lang McLean (1885-1922) - Explorer, writer and soldier.

Archibald McLean qualified in Sydney in 1910 and in the following year joined Douglas Mawson's Australasian Antarctic Expedition (1911-1914). He took a full part in the expedition and was forced to stay an extra year when Mawson failed to return to the base before the ship left. During this time he edited the expedition newspaper, The Adelie Blizzard. His writing impressed Mawson who invited him to work on the book about the expedition. This necessitated visiting England to liaise with publishers and promote the book. He was in England when the First World War broke out and he was commissioned in the RAMC and sent to France. He was invalided out of the army in 1916 and returned to Australia where he obtained his MD for his research in the Antarctic. Then he joined the Australian Army Medical Corps and returned to France where he won the Military Cross and he also suffered gassing. During the war, he developed TB and was unwell when he returned to Australia.

Medical comforts during the heroic age of Antarctic exploration.

In the literature of the exploration of the Antarctic in the early 20th century, there are many references to 'medical comforts'. While 'medical comforts' was sometimes used as a euphemism for alcoholic beverages, the term, which originated in the army, covered all foods and drinks used for the treatment and prevention of illness and during convalescence. This article describes the use of medical comforts during the Antarctic expeditions of the so called 'heroic age'. Apart from alcohol, medical comforts included beef extracts, milk extracts and arrowroot. These products were extensively advertised to the medical and nursing professions and to the general public and the Antarctic connection was sometimes used in the advertising. The products were largely devoid of vitamins and their use may have contributed to some of the disease that occurred on these expeditions.

Medical supplies for the expeditions of the heroic age of Antarctic exploration: introduction.

During the heroic age of Antarctic exploration (1895-1922) there were at least 18 expeditions to the Antarctic lasting between 18 and 30 months. This is an introduction to a series of articles about the drugs taken and used in the Antarctic at this time. Most of the information relates to the expeditions of Robert Scott and Ernest Shackleton and the main supplier of medical equipment was Burroughs Wellcome and Co. This article also describes the medical cases that were taken to the Antarctic.

Psychology during the expeditions of the heroic age of Antarctic exploration.

The psychology of Antarctic explorers and groups in Antarctic bases has been much studied in recent years, and current knowledge has been summarized in a review by Palinkas and Suedenfeld (2008). There was no formal psychological research during the heroic age of Antarctic exploration, but a number of the doctors and non-medical personnel on the expeditions were keen observers of the psychological aspects of the expeditions and wrote about them. In this paper, I describe their understanding of the psychology of Antarctic exploration. By comparing this with current knowledge, it is clear that most of what has been found by formal study was known to the explorers of the heroic age.

Psychiatric illness and suicide in the heroic age of Antarctic exploration.

During the heroic age of Antarctic exploration, a number of the early explorers developed psychiatric illness either in the Antarctic or shortly after leaving it. Most of these were psychotic illnesses and stress reactions. At least six explorers committed suicide either in the Antarctic or after their return. These cases are described, and possible reasons for the apparent high incidence of psychiatric disease and suicide are discussed. There are also examples of the possible misuse of psychiatric labels.

'Polar anaemia': cardiac failure during the heroic age of Antarctic exploration.

On the Belgica expedition (1897-1899), Dr F.A. Cook described a disease that he called 'polar anaemia' and on this expedition it affected most of the expedition members and caused one death. The symptoms were shortness of breath, abnormalities of the pulse and oedema (swelling of the legs) and the disease was clearly cardiac failure. During the heroic age of Antarctic exploration a similar disease affected at least eight other expeditions causing five other deaths. This disease was very similar (and probably identical) to a disease affecting (mostly) Scandinavian seamen and called 'ship beri-beri'. Both diseases were almost certainly what is now called wet beri-beri due to thiamine (vitamin B1) deficiency though most sufferers were probably also vitamin C deficient and some may have had both beri-beri and scurvy. It may have been exacerbated by invalid diets. This paper describes the disease and how it was considered and treated at the time.

Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support (ATLS) system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. For each patient, the blood loss was estimated and patients were divided into four groups based on the estimated blood loss corresponding to the ATLS classes of shock. The median and interquartile ranges (IQR) of the heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS) were calculated for each group. RESULTS: The median HR rose from 82 beats per minute (BPM) in estimated class 1 shock to 95 BPM in estimated class 4 shock. The median SBP fell from 135 mm Hg to 120 mm Hg. There was no significant change in RR or GCS. CONCLUSION: With increasing estimated blood loss there is a trend to increasing heart rate and a reduction in SBP but not to the degree suggested by the ATLS classification of shock.

Testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. Patients were divided into groups representing the four ATLS classes of shock, based on heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS). The relationships between variables were examined by classifying the cohort by each recorded variable in turn and deriving the median and interquartile range (IQR) of the remaining three variables. Patients with penetrating trauma and major injuries were examined in sub-group analyses. RESULTS: In blunt trauma patients grouped by HR, the median SBP decreased from 128 mmHg in patients with HR<100 BPM to 114 mmHg in those with HR>140 BPM. The median RR increased from 18 to 22 bpm and the GCS reduced from 15 to 14. The median HR in hypotensive patients was 88 BPM compared to 83 BPM in normotensive patients and the RR was the same. When grouped by RR, the HR increased with increasing RR but there were no changes in SBP. CONCLUSION: In trauma patients there is an inter-relationship between derangements of HR, SBP, RR and GCS but not to the same degree as that suggested by the ATLS classification of shock.

View from the emergency department trolley: fractured olecranon.

The experience of a patient with a fractured olecranon is described.

The Derriford twelve commandments of emergency medicine: a model for good practice in a changing world, or a survival guide for new medical staff.

Time is a precious commodity and with more junior doctors coming through our departments for shorter periods of time it has been useful to lay down some ground rules to facilitate their induction. These are presented in the form of the twelve commandments of emergency medicine.

The incidence of neurogenic shock in patients with isolated spinal cord injury in the emergency department.

BACKGROUND: Spinal cord injury (SCI) is recognised to cause hypotension and bradycardia (neurogenic shock). Previous studies have shown that the incidence of this in the emergency department (ED) may be low. However these studies are relatively small and have included a mix of blunt and penetrating injuries with measurements taken over different time frames. The aim was to use a large database to determine the incidence of neurogenic shock in patients with isolated spinal cord injuries. METHODS: The Trauma Audit and Research Network (TARN) collects data on patients attending participating hospitals in England and Wales. The database between 1989 and 2003 was searched for patients aged over 16 who had sustained an isolated spinal cord injury. The heart rate (HR) and systolic blood pressure (SBP) on arrival at the ED were determined as was the number and percentage of patients who had both a SBP<100mm Hg and a HR<80 beats per minute (BPM) (the classic appearance of neurogenic shock). RESULTS: Four hundred and ninety patients had sustained an isolated spinal cord injury (SCI) with no other injury with an abbreviated injury scale (AIS) of greater than 2. The incidence of neurogenic shock in cervical cord injuries was 19.3% (95% CI 14.8-23.7%). The incidence in thoracic and lumbar cord injuries was 7% (3-11.1%) and 3% (0-8.85%). CONCLUSIONS: Fewer than 20% of patients with a cervical cord injury have the classical appearance of neurogenic shock when they arrive in the emergency department. It is uncommon in patients with lower cord injuries. The heart rate and blood pressure changes in patients with a SCI may develop over time and we hypothesise that patients arrive in the ED before neurogenic shock has become manifest.

Ocular injuries in patients with major trauma.

AIM: To study the epidemiology of ocular injuries in patients with major trauma in the UK, determining the incidence and causes of ocular injuries, and their association with facial fractures. METHODS: A retrospective analysis of the Trauma Audit Research Network database from 1989 to 2004, looking at data from 39,073 patients with major trauma. RESULTS: Of the 39,073 patients with major trauma, 905 (2.3%) patients had associated ocular injuries and 4082 (10.4%) patients had a facial fracture (zygoma, orbit or maxilla). The risk of an eye injury for a patient with a facial fracture is 6.7 times as that for a patient with no facial fracture (95%, confidence interval 5.9 to 7.6). Of the patients with major trauma and an eye injury, 75.1% were men, and the median age was 31 years. 57.3% of ocular injuries were due to road traffic accidents (RTAs). CONCLUSION: The incidence of ocular injuries in patients with major trauma is low, but considerable association was found between eye injuries and facial fractures. Young adults have the highest incidence of ocular injury. RTAs are the leading cause of ocular injuries in patients with major trauma. It is vital that all patients with major trauma are examined specifically for an ocular injury.

Case of the month: Lesson of the week: don't forget scombroid.

We describe five cases of scombroid that presented as one incident. We discuss the aetiology, clinical features, differential diagnosis and treatment of this condition.

The effect of working hours on outcome from major trauma.

OBJECTIVE: To determine whether being admitted with major trauma to an emergency department outside rather than within working hours results in an adverse outcome. METHODS: The data were collected from hospitals in England and Wales participating in the Trauma Audit and Research Network (TARN). Data from the TARN database were used. Admission time and discharge status were cross matched, and this was repeated while controlling for Injury Severity Score (ISS) values. Logistic regression was carried out, calculating the effects of Revised Trauma Score (RTS), ISS, age, and time of admission on outcome from major trauma. This allowed observed versus expected mortality rates (Ws) scores to be compared within and outside working hours. As much of the RTS data were missing, this was repeated using the Glasgow Coma Score instead of RTS. RESULTS: In total, 5.2% of people admitted "out of hours" died, compared with 5.3% of people within working hours, and 12.2% of people admitted outside working hours had an ISS score greater than 15, compared with 10.1% admitted within working hours. Outcome in cases with comparable ISS values were very similar (31.1% of cases with ISS >15 died out of hours, compared with 33.5% inside working hours.) The subgroup of data with missing RTS values had a significantly increased risk of death. Therefore, GCS was used to calculate severity adjusted odds of death instead of RTS. However, with either model, Ws scores were identical (both 0%) within and outside working hours. CONCLUSIONS: Out of hours admission does not in itself have an adverse effect on outcome from major trauma.