Editor- Johnston et al1 report a system for transmitting medical
images across a system based on personal computers and the internet's
world wide web. The method described is clearly an effective approach for transmitting images of radiographs. However the adoption of this technique will require a significant investment in technology. Such an investment may simply not be affordable for many departments, particularly as it will often be smaller, peripheral units that do not have access to resident specialist advice.

Last year I worked in an A&E department that had no on-site orthopaedic service. A patient presented with a fracture of the lower radius, for which I sought advice from the orthopaedic registrar on-call in the specialist unit 30 miles away in Belfast. As he was unable to view the radiograph of the injury he was uncertain whether internal fixation would be required. Therefore he recommended that until the radiograph was available to them the following morning the patient should be admitted to our surgical ward overnight.

However after discussion we decided on a new approach. I was able to use a pen to trace the outline of the bones by placing a sheet of plain A4 paper over the film on the illuminated X-Ray box.. This provided an accurate drawn image of the fracture, which I then faxed (using the department fax machine) to my colleague in Belfast. Shortly afterwards he phoned me back to say that he could see from the faxed image that the fracture needed internal fixation. Therefore the patient was transferred immediately for this treatment.

I would commend this approach to other departments requiring advice on the management of fractures from non-resident specialists. This technique is simple, easily taught, and is unlikely to require any additional investment in new technology. As such it represents a ‘low-tech’ alternative to the technique described by Johnston et al in their article.

1 Transferring medical images on the world wide web for emergency clinical
management: a case report: David S Johnson BMJ 1998;316:988-989 ( 28 March )

The team at Stanford University who collaborated with the BMJ on the implementation of the new BMJ web site is very pleased with the results on the screen, and is also very much encouraged by the feedback we have received from readers who have filled out the questionnaire on the site.

Generally, one could characterize the feedback in a single word, "more", or perhaps "MORE!". That is, readers like what they see and they want more back content online, and more future services.

This is, as you can imagine, music to a web-developer's ears, since people rarely ask for more of something they found useless in the first place (excepting collectors of cancelled stamps, I suppose).

We look forward to continuing our work, and hope the BMJ's readers will continue their comments.

I read the excellent article about ADRs by Pirmohamed.

It is common practice in Medicine to put patients on combinations of drugs. The vast majority of these combinations of drugs (especially where 3 or more drugs are involved) have never been studied at all, let alone in double-blind trials ( with the exception of Oncology/AIDS treatment, where the toxicity of the drugs demands study); yet it is frequent practice to prescribe these multiple-drug combinations.

It is well accepted in Pharmacology that it is scientifically
impossible to accurately predict the side effects or clinical effects of a
combination of drugs without studying that PARTICULAR
combination of drugs in TEST subjects. Knowledge of the pharmacologic profiles of the individual drugs in question does not in any way
assure accurate prediction of the side effects of combinations of those drugs, especially when they have different mechanisms of action, which is very common because polypharmacy is most often prescribed to patients with "multiple illnesses". Yearly, over 180,000 patients in this country die from identified adverse drug reactions; the number who die as a consequence of polypharmacy is, to my knowledge, unknown.

Is the use of unstudied polypharmacy an example of "scientific" Medicine?

The argument that the prescribing of drugs is the "Art of Medicine" is not valid,
because drugs are developed (indications, dose and administration, etc) and approved through a "scientific" process (double-blind, placebo-controlled studies). The fact that the medicines are often prescribed for "different conditions" is irrelevant (especially to the patient's physiology). The idea that " we are doing the best we can ", a frequent
defense of Polypharmacy, does not in any way uphold a scientific argument in favor of it.
(We are, indeed, trying the best we can, with tools which do not improve at the rate we would wish!) The fact that "there is a limit to how much research can be done" in no way makes the research unnecessary in order to predict the effects of specific combinations of drugs.

Parenthetically, non-conventional systems of health care are often condemned on the basis that they are
"unscientific" or "unstudied". Shouldn't those of us in conventional medicine look at our way of practicing using the same "scrutiny" with which we often condemn "alternative" systems of medicine?

Respectfully,

Charles Sullivan, D.O.

179 Main St suite 403

Waterville, ME
(207)877-0950

dorje@mint.net

"Science progresses, funeral by funeral." - Max Planck