If a trauma patient is tachycardic, should we call for a counsellor?

BACKGROUND: It has been suggested in the literature that raised heart rate in the early period after trauma is associated with the development of post-traumatic psychopathology, but little account has been taken of the potential confounding effect of injury severity. MATERIALS AND METHODS: A cohort of 154 patients, studied as part of a wider investigation of trauma outcomes, was included. Initial heart rate in the accident & emergency department, and injury severity score and new injury severity scores were recorded. Patients completed the General Health Questionnaire (GHQ-28) as a measure of psychopathology at presentation and again at two- and six-month follow-up. RESULTS: There was no relationship between psychopathology at presentation and initial heart rate or injury severity. Raised heart rate was associated with post-traumatic psychopathology at two months but not at six months. When the potential confounding effect of injury severity was controlled for, there was no independent correlation between heart rate and post-traumatic psychopathology. Injury severity score and new injury severity scores were strongly associated with GHQ-28 caseness. CONCLUSION: Post-traumatic tachycardia is not associated with development of psychopathology, but injury severity is. Previous studies that have suggested a link between tachycardia and development of psychopathology are flawed because they have not considered the confounding effect of severity of injury.

Evaluating the effectiveness of a web-based intervention to promote mental wellbeing in women and partners following miscarriage, using a modified patient preference trial design: an external pilot.

This article describes an external pilot study of a modified 'partially randomised patient preference' trial comparing a web-based intervention (designed to promote mental wellbeing) with standard care post-miscarriage. Assessment comprised an online administration of baseline measures with follow-up at 3 months following registration. Baseline data were obtained from 60 women (and seven partners) post-discharge from one of two Early Pregnancy Assessment Units. 'Intention to treat' versus a 'per protocol' sensitivity analysis showed the effects of introducing a 'preference' option post-randomisation, and highlights the benefits compared with a randomised controlled trial design to enable a robust evaluation of the website in promoting mental wellbeing after miscarriage.

Combat-related disorders: a persistent chimera.

Whilst there may be some individuals who genuinely enjoy combat, for most troops it represents many emotional challenges, such as, overcoming fear and being witness to death, suffering and mutilation, as well as having to tolerate extremes of physical discomfort. At present we lack sufficiently valid and reliable methods of screening out those personnel particularly vulnerable to adverse reactions to these challenges. The authorities should aim to provide good training, an appreciative milieu, and a working climate in which those with genuine psychopathology feel confident to admit this, without censure and stigma, and to have access to evidence-based treatments. We should also remember that military life offers much to many men and women, and that surviving physically and psychologically the unavoidable brutalities of combat can often leave a legacy of positive outcomes. We must avoid becoming preoccupied with risk and psychopathology.

The emotional burden of miscarriage for women and their partners: trajectories of anxiety and depression over 13 months.

OBJECTIVE: To identify the trajectories of anxiety and depression in women and in their partners over 13 months after miscarriage. DESIGN: A prospective study with follow up at 6 and 13 months after miscarriage. SETTING: Three Scottish Early Pregnancy Assessment Units. SAMPLE: Of the 1443 eligible individuals approached, 686 (48.3%) consented to participate (432 women; 254 men). Complete data were obtained from 273 women and 133 men at baseline, 6, and 13 months. METHODS: On completion of the management of the index miscarriage, eligible and consenting women and men underwent an initial assessment comprising a semi-structured interview and a standardised self-report questionnaire. The latter was readministered at the follow-up assessments. MAIN OUTCOME MEASURES: The hospital anxiety and depression scale (HADS), a reliable and valid measure of general psychopathology for use in nonpsychiatric samples. RESULTS: Compared with depression, anxiety was overall the greater clinical burden. Over the 13-month period, women reported higher levels of anxiety and depression than men. Over time, a significantly greater level of adjustment was reported by women particularly with regards to the resolution of anxiety symptoms. The effect of time on HADS scores in either gender was similar between subgroups of socio-demographic and clinical factors. CONCLUSIONS: These findings verify that early pregnancy loss represents a significant emotional burden for women, and to some extent for men, especially with regards to anxiety. For many, the detrimental effects of miscarriage are enduring and display a complex course of resolution. These findings are discussed in terms of their clinical implications for early identification and management.

The challenge of preparation for a chemical, biological, radiological or nuclear terrorist attack.

Terrorism is not a new phenomenon, but, in the contemporary scene, it has established itself in a manner which commands the most serious attention of the authorities. Until relatively recently, the major threat has been through the medium of conventional weaponry and explosives. Their obvious convenience of use and accessibility guarantees that such methods will continue to represent a serious threat. However, over the last few years, terrorists have displayed an enthusiasm for higher levels of carnage, destruction and publicity. This trend leads inexorably to the conclusion that chemical, biological, radiological and nuclear (CBRN) methods will be pursued by terrorist organisations, particularly those which are well organised, are based on immutable ideological principles, and have significant financial backing. Whilst it is important that the authorities and the general public do not risk over-reacting to such a threat (otherwise, they will do the work of the terrorists for them), it would be equally ill-advised to seek comfort in denial. The reality of a CBRN event has to be accepted and, as a consequence, the authorities need to consider (and take seriously) how individuals and the community are likely to react thereto and to identify (and rehearse in a realistic climate) what steps would need to be taken to ameliorate the effects of such an event.

A randomised controlled trial to evaluate the effect of self-administered analgesia on women's experience of outpatient treatment at colposcopy.

OBJECTIVE: To evaluate the effect of self-administered isoflurane and desflurane on women's experience of outpatient treatment at colposcopy. DESIGN: A prospective double-blinded randomised controlled trial. SETTING: A colposcopy clinic serving a regional population. POPULATION: Three hundred and ninety-six women scheduled for treatment of cervical intraepithelial neoplasia (CIN) by large loop excision of the transformation zone (LLETZ). METHODS: Self-administration of trial gas during a LLETZ procedure. One hundred and ninety-eight women were randomised to use isoflurane and desflurane and 198 to use placebo. MAIN OUTCOME MEASURES: Patient satisfaction, pain and anxiety. RESULTS: The mean pain score for cervical surgery was significantly lower for women using isoflurane and desflurane (22.4) than the placebo arm (29.6) (P= 0.003). There was no significant difference between arms in anxiety levels before or after treatment. More women using isoflurane and desflurane (78%) reported 'total helpfulness' of the trial gas than those using placebo (67%) (P= 0.012). A subgroup analysis of trial participants classified as anxious by Hospital Anxiety and Depression Scale (HADS) score at recruitment showed that using isoflurane and desflurane significantly increased total treatment acceptability, helpfulness of the gas and willingness to undergo a similar procedure at six-month follow up. CONCLUSION: Satisfaction with outpatient treatment at colposcopy is generally high. The main effect of isoflurane and desflurane evaluated in this trial was to reduce pain. It appeared to be effective for women with clinically significant anxiety and could be offered as an alternative to general anaesthesia.

Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims.

OBJECTIVES: To investigate the long term psychological sequelae of treating multiple victims of traumatic incidents, such as violent crime and motor vehicle accidents, and to assess staff exposure to violent patients in the emergency department. METHODS: A self administered questionnaire booklet was distributed to all full time and part time staff working within the Johannesburg Hospital Trauma Unit during September 2002. Participation was voluntary. The questionnaire was specifically designed for the study as no relevant, validated questionnaire was found to be suitable. Psychological assessment comprised two standardised measures, the impact of event scale-revised and the Maslach burnout inventory. RESULTS: Thirty eight staff members completed the questionnaire, a response rate of 90%. Over 40% of respondents had been physically assaulted while at work and over 90% had been verbally abused. Staff reported a significant level of post-traumatic symptoms, evaluated by the impact of event scale-revised (median = 17.5, range = 0-88), as a result of critical incidents they had been involved in during the previous six months. At least half of the respondents also reported a "high" degree of professional burnout in the three sub-scales of the Maslach burnout tnventory-that is emotional exhaustion, depersonalisation, and personal accomplishment. CONCLUSIONS: Preventative measures, such as increased availability of formal psychological support, should be considered by all trauma units to protect the long term emotional wellbeing of their staff.

Disturbance of pro-inflammatory cytokines in post-traumatic psychopathology.

BACKGROUND: Post-traumatic psychopathology (PTP) is important to the orthopaedic surgeon as it may complicate the recovery from musculoskeletal injury. PTP is associated with a disturbance of the hypothalamic-pituitary-adrenal axis, and may lead to impaired healing. We have investigated the relationship between PTP and pro-inflammatory markers of the metabolic response to trauma. MATERIALS AND METHODS: A prospective cohort study of 82 patients with musculoskeletal injuries, correlating development of psychopathology (measured by general health questionnaire) and pro-inflammatory markers (CRP, IL-6, sIL-6r, TNF-alpha) two and six months after their injury. RESULTS: Psychological disturbance was found in 39% of patients at two months and 18% at six months. This disturbance was associated with significantly increased levels of IL-6 at two months and of sIL-6r and TNF-alpha at six months. CRP levels were not related to the development of PTP. CONCLUSIONS: The relationship between PTP and disturbances of pro-inflammatory markers needs further exploration, but may explain in part the impaired functional recovery when musculoskeletal trauma is complicated by psychological disturbance.

Bioterrorism: preparing for the unthinkable.

Terrorism is not a new concept but our need to prepare for the effects of bioterrorism has achieved a particular urgency. The use of biological agents provides a new set of challenges to professional caregivers, emergency personnel and Governments. These agents are generally not readily identified through the senses, have delayed effects and have the power to generate fear and panic. They are also intended to demonstrate that Governments and other organisations are not able to protect their citizens and members. What evidence there is suggests bioterrorist incidents have the potential to create higher levels of psychopathology than physical injury. Therefore, the authorities must identify and rehearse suitable methods of psychoprophylaxis and intervention.

Assessing the communication skills of doctors in training: reliability and sources of error.

Medical examining bodies now commonly assess candidates' communication skills. However, there are a number of within-case sources of error that can mean examinations have poor reliability and validity. The aims of this study were to determine the main within-case sources of error and to identify the best methods of maximising reliability in highly structured communication skills assessments. Subjects were fifth year medical students at the University of Aberdeen. Subjects were videotaped giving clinical information to standardised patients and relatives toward the end of their fifth year and toward the end of their pre-registration year. Sources of variation, reliability coefficients and the most effective methods of reducing measurement error were calculated using generalisability theory. Systematic differences among subjects' communication skill was the main source of variation in two of the three assessment cases. The implications of the results are discussed.

The Aberdeen Trauma Screening Index: an instrument to predict post-accident psychopathology.

BACKGROUND: A key challenge in trauma care is the prevention of psychopathology. However, no definitive method of identifying individuals at risk of developing psychopathology exists. The Aberdeen Trauma Screening Index (ATSI) is a brief screening tool developed for use in a clinical setting by non-mental health professionals to facilitate the early identification of individuals most at risk of psychopathology 3-months post-accident. METHODS: The ATSI derived from a prospective study of a 150 out of an initial pool of 213 consecutive admissions to the Orthopaedic Trauma Unit and the Accident and Emergency Department of Aberdeen Royal Infirmary. Potential predictors were identified by a comprehensive assessment conducted within 1-week post-accident. Outcome at 3-months post-accident was measured using 'caseness' according to the General Health Questionnaire (GHQ-28). RESULTS: The ATSI is based on a final model comprising only seven variables with a sensitivity of 79% and specificity of 65%. A predictive index score (0-100) was produced to ensure the practical utility of the ATSI in a clinical setting. A ROC curve was constructed to illustrate the relationship between sensitivity and the specificity values with their corresponding threshold scores. On the basis of a prevalence rate of 55% 'caseness', as identified in the present study, a cut-off point of 45 provides the optimal outcome with a sensitivity value of 70% and a specificity value of 71%. CONCLUSIONS: The ATSI can accurately identify those most at risk of developing psychopathology 3-months post-accident in a sample of accidentally injured adult subjects recruited as consecutive admissions to an urban hospital in the North East of Scotland. However, to establish the generalizability of these findings, it is important that the ATSI be validated in both similar and diverse populations.

A waste of time: non-attendance at out-patient clinics in a Scottish NHS Trust.

UNLABELLED: The Patient's Charter states that patients have a responsibility to attend out-patient appointments or to notify the hospital if they are unable to do so. Non-attendance without notification has substantial financial costs for the NHS and may have clinical implications to the non-attender and other patients on the waiting list. OBJECTIVE: To identify reasons for non-attendance of patients for their first appointment after referral. DESIGN: A survey by questionnaire of a random sample of non-attenders of an NHS trust. SETTING: Aberdeen Royal Hospitals NHS Trust. SUBJECTS: Ten per cent of all non-attenders to the Trust out-patient clinics over a twelve month period. RESULTS: One hundred and fifty five (32%) patients contributed to the survey. Cancellations accounted for 22% (34) of missed appointments with factors relating to illness or treatment, being the most common reason (14; 44%). Patients failing to attend without prior notification stated that hospital administrative problems (75; 57%) and personal administrative problems (31; 23%) were the primary reasons. Clinical speciality, day of the week, the month, availability of a telephone or car, and socioeconomic group were not significantly associated with non-attendance. CONCLUSION: The majority of patients show a responsible attitude to attendance at outpatients when appointments were received. Non-attendance was found to be due to a combination of institutional factors (commonly administrative) and patient factors such as forgetting about the appointment.

Caring for others can seriously damage your health.

To care for others is a privilege and a source of personal and job satisfaction. However, caregivers must also consider the implications of their work for their own health and welfare.

Psychiatric sequelae and psychosocial adjustment following ocular trauma: a retrospective pilot study.

AIMS: To identify the prevalence of psychiatric and adjustment problems after ocular trauma and those factors related to a poor outcome. METHODS: 47 patients were assessed by structured interview, of whom 45 satisfactorily completed three standardised self report measures of psychological functioning, subjective distress, and social adjustment. RESULTS: 33% of patients displayed psychiatric "caseness". A number of features of the victim consistently resulted in poor outcome including a psychiatric history and peritraumatic dissociation. CONCLUSION: These preliminary findings suggest ocular trauma is associated with psychomorbidity and problems of adjustment. The improved management of such patients would benefit from a more detailed analysis by means of a longitudinal study involving larger samples.

C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder: a pilot study.

BACKGROUND: it has been reported that psychological stress in humans is associated with a derangement of biological homeostasis. This pilot study aimed to examine the inflammatory response to post-traumatic stress disorder (PTSD) through measurements of the serum levels of the receptor to interleukin 6 (sIL-6r) and C-reactive protein (CRP), in relation to measures of psychological disturbance. METHODS: 15 patients with established PTSD and eight control patients with musculoskeletal injuries were studied at least three months after their index trauma. All completed revised impact of events scale (RIES), Davidson's trauma scale (DTS) and the general health questionnaire (GHQ), and gave blood samples that were assayed for CRP and sIL-6r. Statistical analysis was by the Mann-Whitney U-Wilcoxon rank sum tests. RESULTS: positive relationships were found between sIL-6r and the RIES intrusion score (P=0.026), and between CRP and DTS intrusion scores (P=0.016), GHQ depression (P=0.028), and RIES intrusion (P=0.044) in the case group. DISCUSSION: we have demonstrated a relationship between post-traumatic psychological and biological disturbance, which provides the basis for further research on the effects of psychological disturbance on physical recovery after injury.

Ambulance personnel and critical incidents: impact of accident and emergency work on mental health and emotional well-being.

BACKGROUND: The association between mental health and occupational factors among ambulance personnel has not been thoroughly investigated in the UK. AIMS: To identify the prevalence of psychopathology among ambulance personnel and its relationship to personality and exposure to critical incidents. METHOD: Data were gathered from ambulance personnel by means of an anonymous questionnaire and standardised measures. RESULTS: Approximately a third of the sample reported high levels of general psychopathology, burnout and posttraumatic symptoms. Burnout was associated with less job satisfaction, longer time in service, less recovery time between incidents, and more frequent exposure to incidents. Burnout and GHQ-28 caseness were more likely in those who had experienced a particularly disturbing incident in the previous 6 months. Concerns about confidentiality and career prospects deter staff from seeking personal help. CONCLUSIONS: The mental health and emotional well-being of ambulance personnel appear to be compromised by accident and emergency work.

Nairobi terrorist bombing: the personal experience of a mental health adviser.

This is a personal account of the author's involvement as an adviser in the wake of the Nairobi terrorist bombing in 1998. Much has been written in the literature about the problems for and reactions of first responders, emergency personnel and those who provide care for victims of trauma. Less is known about the role of the specialist adviser. The author describes the terrorist incident, how the Kenyans responded to it and his own role. He also highlights important learning points, dilemmas and challenges which an adviser might encounter.

Suicide by patients: questionnaire study of its effect on consultant psychiatrists.

OBJECTIVE: To identify the effect of patients' suicide on consultant psychiatrists in Scotland. DESIGN: Confidential coded postal questionnaire survey. PARTICIPANTS: Of 315 eligible consultant psychiatrists, 247 (78%) contributed. SETTING: Scotland. MAIN OUTCOME MEASURES: Experience of patient suicide; the features and impact of "most distressing" suicide and what helped them to deal with it. RESULTS: 167 (68%) consultants had had a patient commit suicide under their care. Fifty four (33%) reported being affected personally in terms of low mood, poor sleep, or irritability. Changes in professional practice were described by 69 (42%) of the psychiatrists-for example, a more structured approach to the management of patients at risk and increased use of mental health legislation. Twenty four (15%) doctors considered taking early retirement because of a patient's suicide. Colleagues and family or friends were the best sources of help, and team and critical incident reviews were also useful. CONCLUSIONS: Suicide by patients has a substantial emotional and professional effect on consultant psychiatrists. Support from colleagues is helpful, and professional reviews provide opportunities for learning and improved management of suicide and its aftermath.