Final-year dental students' opinions of their training in medical emergency management

The management of medical emergencies is clearly of vital importance in dental practice. The starting point of training in this area is the undergraduate dental degree programme. The aim of this study was to examine the opinions of final-year dental students at Newcastle School of Dental Sciences in relation to their undergraduate training in medical emergency management. Overall the responses were positive but the need for further practical training in the use of emergency drugs and equipment was highlighted.

Speed and efficiency in walking and wheeling with novel stimulation and bracing systems after spinal cord injury: a case study

To compare various novel and conventional systems for locomotion, a 25-year-old man was studied with motor complete spinal cord injury at the T4/5 level. He used various devices in the community, and changes in speed, physiological cost index (PCI), and oxygen consumption were measured periodically. Speed was fastest with a conventional manual wheelchair (nearly 120 m/min in a 4-min test). Speed was about 30% less, but the PCI was lowest (highest efficiency) using functional electrical stimulation (FES) of the quadriceps and hamstring muscles to propel a novel wheelchair. He walked with knee-ankle-foot orthoses (KAFO) at much lower speed (8.8 m/min) and higher PCI. He walked with an alternating gait using a new stance-control KAFO with FES. The speed was still slow (5 m/min), but he prefers the more normal-looking gait and uses it daily. Walking with FES and ankle-foot orthoses (AFO) was slowest (3.5 m/min) and had the highest PCI. In conclusion, the leg-propelled wheelchair provides a more efficient method of locomotion. A new stance-controlled KAFO with FES may provide a more acceptable walking system, but must be tested on other subjects.

The patient inflating valve in anaesthesia and resuscitation breathing systems

Patient inflating valves combined with self-inflating bags are known to all anaesthetists as resuscitation devices and are familiar as components of draw-over anaesthesia systems. Their variants are also commonplace in transfer and home ventilators. However, the many variations in structure and function have led to difficulties in their optimal use, definition and classification. After reviewing the relevant literature, we defined a patient inflating valve as a one-way valve that closes an exit port to enable lung inflation, also permitting exhalation and spontaneous breathing, the actions being automatic. We present a new classification based on the mechanism of valve opening/closure; namely elastic recoil of a flexible flap/diaphragm, sliding spindle opened by a spring/magnet or a hollow balloon collapsed by external pressure. The evolution of these valves has been driven by the difficulties documented in critical incidents, which we have used along with information from modern International Organization for Standardization standards to identify 13 ideal properties, the top six of which are non-jamming, automatic, no bypass effect, no rebreathing or air entry at patient end, low resistance, robust and easy to service. The Ambu and the Laerdal valves have remained popular due to their simplicity and reliability. Two new alternatives, the Fenton and Diamedica valves, offer the benefits of location away from the patient while retaining a small functional dead space. They also offer the potential for greater use of hybrid continuous flow/draw-over systems that can operate close to atmospheric pressure. The reliable application of positive end-expiratory pressure/continuous positive airway pressure remains a challenge.

Clopidogrel dilemma for orthopaedic surgeons

BACKGROUND

Patients medicated with clopidogrel who require orthopaedic surgery present a particular challenge. Whether in an emergency or elective situation the orthopaedic surgeon must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates.

METHOD

This paper reviews the current published evidence regarding the risks of continuing clopidogrel, the risks of discontinuing clopidogrel and associated considerations such as venous thromboprophylaxis.

RESULTS

Little good quality evidence exists in regard to perioperative clopidogrel for orthopaedic surgery. Available evidence across non-cardiac and cardiac surgery were assessed and presented in regards to current practices, blood loss for orthopaedic operations, risks when continuing clopidogrel, risks of stopping clopidogrel and also the consideration of venous thromboembolism.

CONCLUSIONS

The patients at greatest risk, when discontinuing clopidogrel therapy, are those with drug eluting stents who may be at risk of stent thrombosis. Where possible, efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding. If the risk of bleeding is too high, antiplatelet therapy must be reinstated as soon as considered reasonable after surgery. In addition, patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space. Until more definitive evidence becomes available, this review aims to provide a guide for the orthopaedic surgeon in dealing with the difficult dilemma of the patient on clopidogrel therapy, recommending that orthopaedic surgeons take a team approach to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible.

Oro-antral fistulae and fractured tuberosities

This paper, in discussing oro-antral fistulae and fractured tuberosities, aims to guide the dentist through the assessment and reduction of risk when removing maxillary molar teeth that are closely related to the maxillary sinus. However, complications are inevitable and the management of these will also be discussed.