Situational awareness in driving, and lessons for surgeons.

It is often said that medicine could learn a lot from aviation. Human and system errors affect all complex organisations including healthcare, and there is increasing awareness of the role of non-technical skills in the safe practice of surgery. Comparisons are often drawn between the way in which the aviation industry learns from errors and the paucity of learning from errors in situational judgement in medical practice. Although many of us travel on planes, very few of us fly them, but most surgeons drive regularly. We review a series of motoring incidents that demonstrate poor situational awareness and judgement, and discuss the incidents, predisposing causes, and their relevance to medical practice. These errors are transferrable to medical practice, and perhaps we can learn from them.

Comparison of primary care doctors and dentists in the referral of oral cancer: a systematic review.

Oral cancer is referred to specialists by both general practitioners (GPs) and dentists, with varying proportions reported in different studies. However, some have noted that dentists more commonly refer oral cancer in the absence of patient-perceived symptoms and may refer at an earlier stage. Unfortunately, approximately half the UK adult population do not receive regular dental care. We have conducted a systematic review of studies that compare GPs and dentists in the referral of oral cancer and have focused on three aspects: the proportion of diagnosed oral cancers, stage on presentation, and delay. Searches of the databases Medline, Embase, Scopus, Google Scholar, Web of Science, and CINAHL, together with additional searches of reference lists, authors, and conference proceedings, found 22 studies from 10 countries, which included a total of 4953 oral cancers. The percentage of medical referrals ranged from 13% to 86%; dental referrals ranged from 15% to 80%. Random-effects meta-analysis indicated a combined relative risk of medical referral to dental referral of 1.36 (95% CI: 0.99 to 1.86). For UK-based studies, the relative risk was also 1.36 (95% CI: 1.05 to 1.76). There was considerable heterogeneity for all studies and for a subgroup of UK studies: I296.4% (95% CI 95.4 to 97.1) and 81.0% (95% CI 63.3 to 90.1), respectively. Several studies showed a lower stage for dentally-referred cancers; the combined risk for dentists and GPs referring early (stages 1 and 2) disease was 1.37 (95% CI: 1.17 to 1.60), and one cause may be the much higher number of cases referred by dentists in the absence of symptoms. No studies showed a significant difference in delay. Oral cancer is referred by both GPs and dentists, typically about 50% and 40%, respectively, although there is a wide range, probably depending on local circumstances. Both groups require skills in oral examination, recognition of lesions, and knowledge of the risk factors. Effectively, regular dental attenders are a select group that is regularly screened for oral cancer, and it is likely that screening is not delivered to those with the highest risk. We suggest that further work is required on how to access high-risk individuals both for possible screening and preventive interventions.

Occupational exposure to noise in maxillofacial operating theatres: an initial prospective study.

Exposure to excessive noise could impair surgical performance and communication, and lead to long-term hearing loss, but it is only recently that studies on occupational exposure to noise in operating theatres have been published. The aim of this prospective study was to assess mean and peak levels of noise during maxillofacial operations. We found that both were comparable to those in other surgical specialties such as orthopaedics in which power tools are used.

Bismuth toxicity in patients treated with bismuth iodoform paraffin packs.

Bismuth is a heavy metal used in bismuth iodoform paraffin paste (BIPP) antiseptic dressings and in a number of other medical preparations. It can be absorbed systemically and cause toxicity. We report 2 cases of such neurotoxicity after it was used in operations on the jaws.

Wire-free fixation of jaw fractures.

Stainless steel wire is often used in the management of jaw fractures to provide intraoperative or postoperative intermaxillary fixation (IMF). Wiring of the jaws is time-consuming, a second procedure is needed to remove it, and needlestick injuries occur during placement. We report on 151 consecutive patients who had wire-free fixation of jaw fractures, and outline the value of a system of plastic anchorage points applied to individual teeth in both jaws that allows for wire-free IMF when they are linked by elastics (Rapid IMF, Synthes, PA, USA). A total of 150 successive patients had wire-free fixation of 146 mandibular and 5 maxillary fractures. Ninety-eight were hand-held in occlusion, and 52 were treated using Rapid IMF. There were few complications.

Improved resuscitation training of senior house officers in oral and maxillofacial surgery.

All healthcare professionals are expected to be competent at cardiopulmonary resuscitation. In a previous study [Br J Oral Maxillofac Surg 1999; 37: 1], senior house officers in oral and maxillofacial surgery (OMFS) expressed dissatisfaction about their training in resuscitation, and we now report the results of a follow-up survey. The amount of training in resuscitation has increased in the 5 years since the initial questionnaire, and 77% of the 73 respondents (n=56) been given such training in the 12 months before the present survey, compared to 48% in the previous study. Fifty-one (70%) now think that they would feel confident if required to resuscitate a patient who had a cardiorespiratory arrest, and this has increased from 47%. Despite this, 70 (96%) of senior house officers in OMFS stated that they wanted further training in cardiopulmonary resuscitation.

Potentially fatal oro-facial infections: five cautionary tales.

Five cases of oro-facial infection leading to life-threatening complications are reported. Although all had been treated with antibiotics prior to maxillofacial referral, lack of surgical intervention had allowed progressive infection. The importance of resuscitation, supportive therapy, extraction of involved teeth to remove the source of infection and drainage of pus is emphasised

Lethal invasive mucormycosis: case report and recommendations for treatment.

A case of lethal invasive mucormycosis (IM), a rare fungal infection which predominantly affects immunocompromised patients, is reported in a 73-year-old female patient who presented with a cervical abscess. The patient had asthma treated with steroids and had previously undiagnosed diabetes mellitus. Despite surgical treatment and parenteral antibiotic therapy, there was fatal progression of the condition. The pathogenesis, histological appearances and treatment of mucormycosis are discussed, particularly the importance of urgent histological examination of debrided tissue to distinguish this condition from necrotizing fasciitis (NF) earlier than microbiological culture alone would allow, thus permitting the early introduction of appropriate antifungal therapy.

Facial nerve palsy following intra-oral surgery performed with local anaesthesia.

The precise cause of Bell's palsy remains unclear. A variety of mechanisms have been linked to this palsy, including viral re-activation, demyelination, oedema, vasopasm and trauma. A link with dental treatment has been suggested previously, and a series of seven cases of facial nerve palsy following intra-oral surgery are reported. All of the patients had local anaesthetic solution containing adrenaline as the vasoconstrictor administered. There may be under-reporting of this association, as patients with facial nerve palsy are treated by specialists from several disciplines, not only maxillofacial surgeons. An association with local anaesthesia administered to permit dental treatment would have important medicolegal consequences, and perhaps go some way to explaining the pathophysiology of Bell's palsy.