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excluded by CT scan, should receive low-dose heparin. For allother stroke patients, external pneumatic compression is

recommended. Neurosurgical and stroke patients who remainbedridden for more than 5 days should receive prophylaxisuntil ambulatory. No studies provide information regarding theuse of gradient compression stockings, physical therapy, orearly ambulation as modes of prophylaxis, either singly or inconjunction with other recommended modalities.

Trauma

The specific risks of bleeding dictate the manner and type ofprophylaxis to be used in the trauma patient. The elderlypatient with a hip fracture is at high risk for thromboemboliccomplications, and clearly requires some form of prophylaxisfor at least 7 days, or until ambulatory. One can choose fromthree effective measures; dextran and low-dose warfarin havethe best documentation for effectiveness, and externalpneumatic compression or pressure gradient elastic stockingsmay be useful alternatives. The efficacy of low-dose warfarin inhip fracture patients is not known.Head injury and acute spinal cord injury patients also require

In England Now

OUR community psychiatric nurses are an intrepid lot-theyhave to be, because they work with the elderly who can, at times,be pretty formidable. Often the difficulties are compoundedbecause it is unclear which member of the houshold ought to bethe patient. As with child psychiatry, it is often not the one whohas actually been referred.

Recently we received an urgent call from the elderlycompanion of Miss X, a new patient on our books. Thecompanion had not seen Miss X that day, her bedroom door waslocked on the inside, and shouting and hammering evoked noresponse. One of our sisters took Bill, a young enrolled nurse onour staff, and set off for the flats in which the couple lived.Sister decided to send Bill to peer in through the bedroomwindow; as the flat was a couple of floors up, he had to clamberalong a narrow ledge from the adjacent sitting-room window.This he did. On looking in he was quite sure the room wasempty, so back he went along the ledge to report to his superior.Sister was unimpressed. It was only too obvious, she explainedpatiently, that Miss X must be lying unconscious behind orunder the bed. He must go back and effect an entry to the room.

Sighing heavily, Bill traversed the ledge once more and, aftermanaging to open the window, slid into the room. It was empty.Bill tried the door and found that, contrary to report, it wasunlocked. He started to step into the little hall, running over inhis mind certain matters on which he intended speaking fairlyfirmly to his superior.At this point the kitchen door opened and out came Miss X,

fully dressed and anything but unconscious. Demands for anexplanation for Bill’s presence in her bedroom were lent acertain cogency by the regular, frequent, and forceful

impingement of a large handbag on any portion of his anatomythat came within range-a handbag which, Bill maintains, wasfilled with concrete. He was able to assure me that there was noneed of a neurological examination; he could confirm that MissX possessed good muscle power and tone and has no signswhatsoever of intention tremor.

Later it transpired that Miss X, though a bit forgetful, wasmentally far better than her companion, who was firmly fixedsomewhere around 1922. The companion remained convinced,however, that Bill had effected a daring rescue of Miss X, andshowed her appreciation at Christmas by giving him a

calendar-two years out of date, it is true, and it was Easter, notChristmas, but the thought was there.

* * *

prophylaxis. To minimise the high risk of bleeding, externalpneumatic compression is the method of choice.For severe musculoskeletal trauma, prophylaxis is indicated

until the patient is ambulatory. Low-dose heparin or dextran iseffective in young patients if initiated early. External pneumaticcompression may be an effective alternative for decreasinglower leg thrombosis, if lower extremity trauma does notpreclude its use. In multisystem trauma, anticoagulants shouldbe used with caution until the types of injuries present havebeen assessed, and initial bleeding controlled.

Medical Conditions

Limited clinical trials support the use of low-dose heparin forpatients with heart failure, acute myocardial infarction, orpulmonary infection to prevent DVT. Although studies do notexist to support extension of these observations to other medicalpatients prescribed bed rest and at risk for thromboembolism,administration of low-dose heparin may be indicated, especiallyas long as other conditions predisposing to DVT co-exist.Where long-term prophylaxis is indicated in chronic high-riskpatients, warfarin therapy is appropriate.

I LEARNED a lot in the RAMC. Amongst other things theexercise of power. This was something I had but smallinclination or opportunity to use, but occasionally it was

necessary. I was posted to a large training unit with strict ordersto improve the efficiency of the medical services therein. It wasearly when I arrived at the medical centre and the waiting areaswas crowded with soldiers awaiting a medical examination ofone kind or another. One RAMC private was trying to organisethe throng, putting name, rank, number, and nature ofexamination onto separate sheets of paper and disposing thevarious categories to different parts of the room. His sole helpwas another RAMC private who was trying to keep the placetidy by brushing the floor, exorting the patients not to smoke,and doing his utmost to keep everyone in their allotted seats.The noise was deafening but all became quiet as I appeared onthe scene. Where was the sergeant and the rest of the staff, Iasked? After some hedging it gradually came out. They werestill abed and not expected to appear for some little time. Theprevious medical officer had, apparently, not been in the habitof arriving too promptly.

It took some effort but eventually I routed them all out, linedthem up, and, without more ado, sent them back to the basehospital. I telephoned the colonel, explained the situation andwas allocated replacements. I returned to the waiting areawhere a deathly silence reigned. I summoned the two privatesThey stood to attention in front of me. "You," I said addressingthe one who had been trying to bring order out of chaos. "Lookat that man." I pointed to his comrade who had been doing hisbest to keep the place clean. "Tell that corporal to get his haircut. Now let’s start this sick parade and I mean at once.

Understood, sergeant?" He understood.

* * *

"Quit while you’re in front" is sound advice. Last Friday inRegent’s Park The Lancet’s band of very amateur roundersplayers rashly ignored it. With less discussion than usual aboutthe rules, and no chance of the weather curtailing matters, thecontest with the BMJ soon ends with a resounding victory forAdam Street. Or so it appears. But with refreshment notavailable until 5-30 it seems ungallant to refuse to carry on.Disaster strikes. Tavistock Square’s star ("We borrowed himfrom the archives", was the cryptic response to an inquiry abouthis eligibility) hits top form and threatens the grassroots activityof a non-editorial couple beyond second base. Worse, the BM7,clearly weaned on "grandmother’s footsteps", masters thesneaky art of tactical running. An inquiry into the identity of thelanceteer who agreed that the two innings should be cumulativebegan on Monday.