Timely diagnosis of convulsive syncope can avert imminent death

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					LETTERS TO THE EDITOR



Med August 2009 pp 323–6). One of the                 the patients contained no indication that        discussed, and we are working on this
(perhaps) unexpected results they included            results of investigations had been               and incorporating other suggestions
in their table (but did not discuss), was the         reviewed before the PTWR. Kendall et al          such as those above.
significant reduction in specialist registrar         (Clin Med December 2009 pp 544–8)
(SpR) diagnosis differences from the                  commend the educational value of a                                               NJ BEECHING
clerking diagnosis (from 35.8% in 2006                structured consultant-led patient handover                                     Consultant physician
down to 24.3% in 2008, odds ratio 0.58                which might encourage the timely review
                                                                                                                                      M CHAPONDA
(0.40–0.83), p 0.002).                                of results, but this would still need to be
                                                                                                                                        Specialist registrar
   It would be interesting to know how this           recorded in the case notes. We suspect
result is accounted for by the authors. Three         that the latter is most likely to occur                                           DS ALMOND
possibilities come to mind. Firstly (the most         during the PTWR.                                                               Consultant physician

favourable interpretation), an improvement               In this issue, Medford noted the small                                    M TAEGTMEYER
in the diagnosis formulation skills of junior         drop in the proportion of diagnoses that                                       Consultant physician
doctors in 2008; secondly (a less desirable           were changed after specialist registrar
                                                                                                                       Royal Liverpool University Hospital
scenario), a significant increase in actual           (SpR) review of patient clerkings per-
SpR clerkings reflecting changes in working           formed by more junior trainees, with no
patterns between 2006 and 2008 and a                  change in the number of diagnoses
                                                                                                       Timely diagnosis of convulsive
shortfall of capacity in clerking junior              altered at consultant review (about 25%
                                                                                                       syncope can avert imminent
doctors (ie below SpR grade); and thirdly             in each year). He wondered if the
                                                                                                       death
(the least favourable scenario), a decrease in        apparent reduction of changes in diag-
quality of the diagnosis formulation skills of        noses made by SpRs was due to                    Editor – Timely diagnosis of convulsive syn-
SpRs in 2008 reflecting possibe changes due           improving diagnostic skills of the junior        cope is crucial to the correct management
to working patterns.                                  trainees, or to a greater proportion of          of underlying causes such as implantable
   The fact that there was no change in the           patients being clerked by SpRs. We found         defibrillator malfunction,1 long QT syn-
difference between consultant diagnosis               that, in 2008, 44.3% of patients were            drome,2 and Brugada syndrome,3 which
and SpR/junior doctor diagnoses in 2008               reviewed by both a consultant and an             may present with self-limiting ventricular
would not support the third or first                  SpR, 45.4% by a consultant alone and             tachyarrhythmia.1–3 Timely identification
scenarios and suggests no decrease (or                6.8% by an SpR alone, compared to                of convulsive syncope becomes a diagnosis
improvement) in the diagnosis formula-                48.2%, 24.7% and 26.2% respectively in           of immediate life-saving importance when
tion skills of both junior doctors and SpRs           2006. This does not directly answer the          ventricular tachyarrhythmia is no longer
over the time of the study. The reduction in          question, but suggests that there were           self-limiting, and the window of opportu-
SpR only reviews is, however, consistent              fewer opportunities for SpRs either to           nity for successful defibrillation is narrow
with the second scenario of increased SPR             review or to clerk patients themselves in        and finite, as was the case in 50% of 14 young
clerkings. This may merit further analysis            2008. We agree with Medford that the             athletes aged 14–17, in whom potentially
as, if confirmed, it will have implications           arrangement of medical on-call and               irreversible exercise-related ‘collapse’ was
for SpR training in the longer term. It is            PTWR should allow middle and senior              associated with convulsive syncope.4 In the
clearly important that SpRs have the                  grade trainees adequate opportunities to         same study, similar brief seizure-like
opportunity to review a significant number            supervise more junior colleagues and to          activity was noted in 13% of 22 older
of cases clerked by their juni
				
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