Letters

Endotracheal intubation in trauma patients

Many patients from rural areas who survive major facial trauma owe their good fortune to the physician who first sees the patient, recognizes the potential for airway obstruction and performs pre-emptive endotracheal intubation. That physician is often a GP-anesthetist.

Prior to anesthesia for elective surgery, many anesthetists are in the habit of shortening the endotracheal tube so that it protrudes just beyond the lips, to prevent it kinking or slipping down the right mainstem bronchus. However, this practice should not be carried over into the trauma setting.

In a recent case managed at our institution, a 34-year-old woman presented with facial fractures, lip lacerations and a comminuted fracture of the shaft of femur. She had been intubated when first seen, but the endotracheal tube had been shortened to 23 cm. She underwent a 6-hour surgical procedure in the lateral decubitus position for her femoral injury, during which vigorous fluid therapy was needed. Her facial swelling, already considerable, was made much worse. Her lips began to cover the attachment of the tube to the breathing system, and the circumferential tapes that held the tube in place cut deeply into the cheeks. Direct laryngoscopy was predictably impossible, and an attempt to change the tube over a stylet failed. The patient subsequently required an urgent tracheostomy.

Had the tube been left at its original length, it would have been easy to remove the tapes and re-secure it more loosely to allow for the swelling.

I urge all physicians managing trauma patients to bear this point in mind.

Saifudin Rashiq, MB, FRCPC
Consultant Anesthetist
University of Alberta Hospitals
Edmonton, Alta.

The new journal of rural medicine

The publication of the first issue of the Canadian Journal of Rural Medicine is a milestone for the enlarging network of rural family physicians in our country. As chair of the Department of Family Medicine at McGill University, I am proud that this work has been spearheaded by the group of practitioners in Shawville, Que., which is one of the rural sites for our residents.

There is a need to address the issues related to rural practice at many levels in the continuum of medical education. We are witnessing an increasing trend in undergraduate medical education to incorporate experiences in rural settings as part of the core training. Residency programs in family medicine have the responsibility to ensure that all trainees are prepared for rural practice through core curriculum experiences provided both in urban and rural sites. Faculties of medicine must develop methods to deliver continuing medical education to practitioners in rural regions that will keep them up-to-date with developments in the many areas related to patient care.

This journal provides an opportunity for rural physicians to share and discuss issues that are of common concern. Our department thanks those who have been involved in its development and wishes them success.

Louise Nasmith, MD CM, CCFP, FCFP
Associate Professor and Chair
Department of Family Medicine
McGill University
Montreal, Que.

The new journal of rural medicine

Congratulations on getting the first issue of the Canadian Journal of Rural Medicine into production. It's a really exciting concept and may provide a venue for some lively debate on all of the issues facing rural doctors.

The Rural Ontario Medical Program is always looking for new ways to spark residents' interest in rural medicine. This will be another tool that we can use. Who knows, we might be able to interest residents in contributing articles and perhaps even having their research published. What a great opportunity for family medicine to show its stuff. We look forward to receiving future issues.

Peter Wells, MD
Director
Rural Ontario Medical Program
Collingwood General & Marine Hospital
Collingwood, Ont.

Table of contents: Can J Rural Med 1 (1)