Medicines and Road Traffic Safety

Medicines and Road Traffic Safety

232 Conference Medicines and Road Traffic Safety THE Transport and Road Research Laboratory at Crowthorne the appropriate venue for a recent meetin...

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232

Conference Medicines and Road Traffic

Safety

THE Transport and Road Research Laboratory at Crowthorne the appropriate venue for a recent meeting of the MedicoPharmaceutical Forum. Luminaries from the world of transportation and the top brass of medical and pharmaceutical politics joined forces to answer a few questions concerning medicines and road traffic safety. At the end of two days of sometimes lively interactions there seemed to be only one point of agreement. No-one was sure whether there was a problem at all. Certainly alcohol can be detected in around 40% of fatal road accidents in the United Kingdom, but only in about 6% is there any evidence of the use of medicines. Had the drugs used by the patients impaired their safety or was their safety impaired because of the illness for which the drugs were prescribed? We do not know whether ingestion of medicines is of greater incidence in individuals involved in traffic accidents, and so, at the moment, there is no strong evidence, one way or the other, that therapeutic drugs contribute to road accidents. The illness itself-particularly if it involved personality disorders-could well be the more important issue. Nevertheless, there was no doubt that many drugs impaired performance, and that there were many ways in which the effects could be tested. There was more excitement during this part of the proceedings. There were broadly two views. There were those who felt that the most appropriate way was to build up a profile of the effect of drugs on performance using laboratory tests, and there were those who felt that some form of simulation which could include car handling was essential. Those in favour of simulation received support from the straw poll of medical directors of pharmaceutical companies. They certainly felt that the approach was more useful than laboratory tests. Those whose studies involved the use of cars were, however, not completely united, and, was

Medicine and the Law Failure to Detect

Radiological Signs Oesophagus

of

Ruptured

AFTER the death of an American tourist in Scotland, an inquiry held on Jan 20, 1986, by the Sheriff of Glasgow and Strathkelvin. On May 15, the Sheriff found the following facts

was

proved.



A woman aged 50 vomited at 2 am on Aug 25,1984. At about 4.45 am she vomited again and had severe and persistent pain in the left chest and shoulder. Shortly after 1 pm she was admitted to the accident and emergency department of the Western Infirmary, Glasgow. She was examined by a junior house officer and the senior house officer in medicine. She was in pain but mentally alert. The chest was apparently normal, but there was some tenderness in the thoracic spine. No other abnormal physical signs were detected. The SHO concluded that there was no evidence of oesophageal tear or chest infection. The chest was X-rayed at about 2 pm. The films were examined by the SHO, who discussed them with the junior house officer. The SHO noted a possible mass on the right side of the chest, which he did not consider significant. He was looking for evidence of bone injury and saw none. He diagnosed muscle spasm and, after a pain-killing injection, the patient was discharged. When the patient returned to her hotel, she slept. At about 8 pm, feeling better, she drank some milk and ate a little food. At about 3.30 am her husband awoke to find that she was not breathing. Despite all attempts to resuscitate her, she was pronounced dead at 4.35 am on Aug 26. At necropsy a spontaneous rupture of the oesophagus was found. Food had entered the left mediastinum and caused infection. The

in particular, gymkhana pharmacology may have fallen by the way. The issue "what the pharmaceutical industry needs to know is what package of tests is appropriate for a new drug, and whether this would be acceptable to the licensing authorities" remained unsolved. "Whose responsibility is it to improve road traffic safety in respect of therapeutic drug taking?" occupied the final session of the meeting. The pharmaceutical industry believed that it had contributed as far as it could to the investigation of the effects of drugs on performance. This may well be so, but the Automobile Association felt that there was insufficient information available to the patient. They had produced a very interesting leaflet (All About Impair. ment), though it had received far less publicity than All About Horses on the Highway. One enthusiast (who arrived on a Vanden Plas) was prepared to have his annual subscription raised by k5toto be sure that he received such information in the future. However, though it was the experience of a medically qualified magistrate that unfitness to drive due to drugs was a rare event, it was the medicolegal opinion that doctors should be certain that they warned their patients of possible impairment. Clearly, it must be determined whether traffic safety is compromised by drugs and, if there is a problem, the appropriate means of assessing impairment in individuals relevant to traffic safety must be decided. This can hardly be the responsibility of the pharmaceutical industry. It must surely involve organisations such as the Transport and Road Research Laboratory, and they should be supported by other Government agencies concerned with impaired performance with drugs. If these issues were settled we would know which tools to use. It is only at this point that the pharmaceutical industry can be expected, in collaboration with university departments of clinical pharmacology, to be responsible for determining whether their drugs impair performance, and so indicating their potential to reduce traffic safety. Royal Air Force Institute of Aviation Medicine, Farnborough, Hampshire GU14 6SZ

ANTHONY N. NICHOLSON, Consultant m Aviation Medicine

rupture had probably occurred at the time of the first vomiting some 24 hours before her death. At the time, the SHO had been qualified for just over two years; he had spent a year in neurosurgery and two periods of six months each in medicine and surgery; and he had experience of examining X-rays while working in these departments. He had not worked inaa radiology department. On the day of the patient’s admission, a Saturday, no radiologists were on duty in the radiology department, though at least two radiologists were on call. After the patient’s death, the films were examined by a radiologist. An erect chest radiograph showed two abnormal features-fluid at the base of both lungs and a small quantity of air in the mediastinum on the left side. A radiograph of the thoracic spine showed two crescent-shaped shadows which indicated the presence of air in the mediastinum. A doctor with the level of experience of an SHO would be unlikely to detect these abnormalities. The Sheriff accepted that rupture of the oesophagus carried a high mortality; and it was rarely possible to diagnose the condition immediately after the event. Although a radiologist could have been called to the hospital to examine the radiographs, the availability of a radiologist on call was of limited relevance, since the SHO’s evidence was that he had examined the radiographs himself and he did not consider seekingaa further opinion from a radiologist or from a senior doctor who might be available in the hospital. The SHO said he had not been instructed to seek a second opinion on X-rays. There was no other evidence to suggest that anY instruction to that effect was in force. Unless; therefore, the doctot who examined the films in the first instance recognised that they were in some respect difficult to interpret, or beyond his experience, he would not seek advice from senior medical staff. This situation arose when radiologists were not on duty in the department. a The Sheriff said that "it must be a matter of public concern situation could arise on these occasions whereby the radiographs of

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