The Medical journal of Australia
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Review
Withdrawing and withholding treatment in intensive care. Part 1. Social and ethical dimensions.
Intensive care is an expensive resource. The medical profession has been criticised for applying technology indiscriminately and at vast expense to a relatively small group of patients. ⋯ The appropriate response of doctors to these problems is to provide leadership in promoting public awareness and debate of the effects of rationing, and to provide rational allocation of therapy to individual patients. The major issues involving resource allocation in society and to individuals are discussed.
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From July 1978 to March 1989, 1703 foreign medical graduates who entered Australia as immigrants took the examinations of the Australian Medical Examining Council (AMEC) and its successor since 1986, the Australian Medical Council (AMC). Of these, 821 (48.2%) passed the multiple choice question examinations and, of these, 627 (76.3%) passed the clinical examinations. The overall pass rate was 36.8%. ⋯ The high failure rate in the AMC examinations has led to immigrant-activated political pressure for bridging courses and other concessions. If, as a result, the majority of the immigrants were to pass the AMC examinations and so enter general practice, medical immigration will increase at an even faster rate than it has since 1984, with significant changes in the medical workforce. Some reforms which might avert this are suggested.
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In the period 1972 to 1989, 92 sports men and women were treated for stress fracture. Symptoms included localized bony pain aggravated by activity. Physical examination demonstrated point tenderness and pain on loading the bone. ⋯ Radiographs showed evidence in only 49% of fractures. Bone scanning, on the other hand, was found to be very accurate and indicative immediately. Therefore, patients with a clinical history of stress fracture and a normal radiograph should undergo a bone scan.
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This paper presents a case of Irukandji syndrome (envenomation by the jellyfish, Carukia barnesi) with pulmonary oedema and hypokinetic cardiac failure. This case highlights the need for victims (and operators of tours venturing into the waters of North Queensland) to treat even apparently innocuous stings with vinegar and to avoid freshwater bathing and rubbing of stings immediately after such incidents. It also reinforces the use of phentolamine to treat the symptoms of catecholamine release associated with the syndrome. This patient required inotropic support and further underlines the need for practitioners to be aware that the syndrome can have severe sequelae and that central venous monitoring and inotropic management should be available when treating Irukandji stings.