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Sir,I read the recent article by Petch1 with much interest. As a specialist registrar training in general medicine, having completed two and a half years of general medical on-call, I can safely say that I now feel competent in the procedure of temporary pacing. I fully recognise that as a senior house officer (SHO) or first-year registrar my previous experience in this technique was inadequate, despite having worked in a large District General Hospital as a ‘cardiology SHO’. However, I cannot agree with your statement that this procedure should no longer be essential to the Calman training requirements in general medicine. Admittedly, central line insertion can be a messy business in inexperienced hands, but once mastered, it is a straightforward and uncomplicated procedure providing that the internal jugular vein is the chosen route of access. Routinely calling upon an anaesthetist or cardiologist for assistance is both impractical and unrealistic. Moreover, the prime concern of the doctor performing the procedure is usually the potential provocation of ventricular arrythmias rather than failure to gain venous access.
The current situation is obviously not ideal but where do we draw the line between specialist and general medical training? Temporary pacing is no more hazardous or difficult than intercostal drain insertion and is probably performed with equal frequency within a District General Hospital. Perhaps the Joint Committee on Higher Medical Training should be concentrating their efforts more on discriminating between procedures which fall wholly within the realm of a particular specialty than on integrating them within the general medicine ‘additional procedure’ requirements (Section 6,Record of specialty training). For example, a gastroenterology specialist registrar seeking dual accreditation, should no more have the ability to perform a bone marrow aspiration than a specialist registrar in haematology an endoscopy.
Finally, in those hospitals lacking on-site facilities for permanent pacing, emergency transfer to a specialist centre often means waiting more than 2–3 days and occasionally up to or over a week (I have first hand experience of this). In such situations one obviously needs to weigh up the benefits of temporary wire insertion with the inherent risks of infection and replacement. More often than not this responsibility lies with a consultant physician with an interest other than cardiology supervising a specialist registrar seeking accreditation in general medicine.
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