Situational awareness in driving, and lessons for surgeons.

It is often said that medicine could learn a lot from aviation. Human and system errors affect all complex organisations including healthcare, and there is increasing awareness of the role of non-technical skills in the safe practice of surgery. Comparisons are often drawn between the way in which the aviation industry learns from errors and the paucity of learning from errors in situational judgement in medical practice. Although many of us travel on planes, very few of us fly them, but most surgeons drive regularly. We review a series of motoring incidents that demonstrate poor situational awareness and judgement, and discuss the incidents, predisposing causes, and their relevance to medical practice. These errors are transferrable to medical practice, and perhaps we can learn from them.

Comparison of primary care doctors and dentists in the referral of oral cancer: a systematic review.

Oral cancer is referred to specialists by both general practitioners (GPs) and dentists, with varying proportions reported in different studies. However, some have noted that dentists more commonly refer oral cancer in the absence of patient-perceived symptoms and may refer at an earlier stage. Unfortunately, approximately half the UK adult population do not receive regular dental care. We have conducted a systematic review of studies that compare GPs and dentists in the referral of oral cancer and have focused on three aspects: the proportion of diagnosed oral cancers, stage on presentation, and delay. Searches of the databases Medline, Embase, Scopus, Google Scholar, Web of Science, and CINAHL, together with additional searches of reference lists, authors, and conference proceedings, found 22 studies from 10 countries, which included a total of 4953 oral cancers. The percentage of medical referrals ranged from 13% to 86%; dental referrals ranged from 15% to 80%. Random-effects meta-analysis indicated a combined relative risk of medical referral to dental referral of 1.36 (95% CI: 0.99 to 1.86). For UK-based studies, the relative risk was also 1.36 (95% CI: 1.05 to 1.76). There was considerable heterogeneity for all studies and for a subgroup of UK studies: I296.4% (95% CI 95.4 to 97.1) and 81.0% (95% CI 63.3 to 90.1), respectively. Several studies showed a lower stage for dentally-referred cancers; the combined risk for dentists and GPs referring early (stages 1 and 2) disease was 1.37 (95% CI: 1.17 to 1.60), and one cause may be the much higher number of cases referred by dentists in the absence of symptoms. No studies showed a significant difference in delay. Oral cancer is referred by both GPs and dentists, typically about 50% and 40%, respectively, although there is a wide range, probably depending on local circumstances. Both groups require skills in oral examination, recognition of lesions, and knowledge of the risk factors. Effectively, regular dental attenders are a select group that is regularly screened for oral cancer, and it is likely that screening is not delivered to those with the highest risk. We suggest that further work is required on how to access high-risk individuals both for possible screening and preventive interventions.

Bismuth toxicity in patients treated with bismuth iodoform paraffin packs.

Bismuth is a heavy metal used in bismuth iodoform paraffin paste (BIPP) antiseptic dressings and in a number of other medical preparations. It can be absorbed systemically and cause toxicity. We report 2 cases of such neurotoxicity after it was used in operations on the jaws.

Occupational exposure to noise in maxillofacial operating theatres: an initial prospective study.

Exposure to excessive noise could impair surgical performance and communication, and lead to long-term hearing loss, but it is only recently that studies on occupational exposure to noise in operating theatres have been published. The aim of this prospective study was to assess mean and peak levels of noise during maxillofacial operations. We found that both were comparable to those in other surgical specialties such as orthopaedics in which power tools are used.

Lethal invasive mucormycosis: case report and recommendations for treatment.

A case of lethal invasive mucormycosis (IM), a rare fungal infection which predominantly affects immunocompromised patients, is reported in a 73-year-old female patient who presented with a cervical abscess. The patient had asthma treated with steroids and had previously undiagnosed diabetes mellitus. Despite surgical treatment and parenteral antibiotic therapy, there was fatal progression of the condition. The pathogenesis, histological appearances and treatment of mucormycosis are discussed, particularly the importance of urgent histological examination of debrided tissue to distinguish this condition from necrotizing fasciitis (NF) earlier than microbiological culture alone would allow, thus permitting the early introduction of appropriate antifungal therapy.

Accidental application of cyanoacrylate to the mouth.

Accidental application of cyanoacrylate adhesives to the eye and ear occurs not infrequently. A case is reported of inadvertent application of such an adhesive to the mouth. This could conceivably have given rise to respiratory embarrassment. The management of the patient is discussed, since such an incident potentially provides an instant, accurately fitting mechanical obstruction which can compromise respiratory function. Clearly the management must be rapid, and it may prove difficult to treat respiratory obstruction caused in this way.

Mental nerve anaesthesia as a result of mandibular metastases of prostatic adenocarcinoma.

Three cases of mental nerve anaesthesia as a result of metastatic deposits from prostatic carcinoma are presented. They were referred to Consultant Oral and Maxillofacial Surgeons by alert GDPs. This highlights the fact that dental surgeons must be aware that systemic illness may manifest in the mouth and appropriate referral is essential.

Granuloma annulare of the supra-orbital region. A case report.

Granuloma annulare (GA) is a relatively infrequent condition affecting the dermis or the subcutaneous tissues. The aetiology of GA is purely speculative, but links with other diseases have been reported since the condition was first described. This paper discusses the usual presentation of GA, typical sites of involvement, and reviews the histology of the subcutaneous lesions of GA. It also reports a case of a 31-year-old patient who presented to an oral surgeon with subcutaneous lesions in the right supra-orbital region. A comparison between this lesion and another histologically similar entity is drawn. The reasoning behind the eventual definitive diagnosis is explained, and a review of the literature found GA affecting the head and neck to be rare.

Impact of dedicated trauma lists on a maxillofacial surgical service.

In 1995, the maxillofacial surgical inpatient services in East Lancashire were centralized in Blackburn Royal Infirmary, and twice-weekly operating lists dedicated to maxillofacial trauma were established. We examined the non-elective workload for three-month periods before and after trauma lists became available to find out the proportion of non-elective operations done out of normal working hours. Although there was an increase in the total number of non-elective patients after centralization, day-time trauma lists allowed a reduction in the proportion of operations performed out of normal working hours. Fewer trauma cases were added to elective lists. Trauma lists allow the unit to comply with the recommendations of both NCEPOD and the Calman report, in that they maximize training opportunities for all staff and facilitate both audit and research.

Improved resuscitation training of senior house officers in oral and maxillofacial surgery.

All healthcare professionals are expected to be competent at cardiopulmonary resuscitation. In a previous study [Br J Oral Maxillofac Surg 1999; 37: 1], senior house officers in oral and maxillofacial surgery (OMFS) expressed dissatisfaction about their training in resuscitation, and we now report the results of a follow-up survey. The amount of training in resuscitation has increased in the 5 years since the initial questionnaire, and 77% of the 73 respondents (n=56) been given such training in the 12 months before the present survey, compared to 48% in the previous study. Fifty-one (70%) now think that they would feel confident if required to resuscitate a patient who had a cardiorespiratory arrest, and this has increased from 47%. Despite this, 70 (96%) of senior house officers in OMFS stated that they wanted further training in cardiopulmonary resuscitation.

Oral manifestations of leukaemia.

Patients with leukaemia can exhibit signs or complain of symptoms in the oral cavity and oropharynx; indeed, these may be the initial presenting complaints of the disease. Septicaemia is common in patients undergoing treatment, and has been reported as having an oral cause in up to 50% of cases. This article reports four patients presenting to dental practitioners with leukaemia, and discusses the management of dental problems in patients with the disease.