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DUNNING : GANGRENOUS EFFECTS O F COLD 883 these were rare events, as his type of work did not attract much outside interest. As an illustration of his attitude, there was an occasion when a visiting surgical club proposed to spend a day in the hospital to watch the work in the operating theatres. The staff therefore arranged a programme of demonstration operations, but Gibbs refused to take part. He explained that to be watched by a group of surgeons might quite easily upset his judgement and interfere with his technique, to the great detriment of his patient. Furthermore, he believed it wrong for the rest of the surgical staff to take any part in this sort of publicity.As could be expected, he was a very skilled user of the cystoscope, both of the earliest models with poor light, small field, and inverted image, and of the subsequent greatly improved instruments; but it was, perhaps, in his masterly method of handling the then very common urethral strictures that his great manipulative ability and experience were best displayed. Cases where all previous attempts by others to pass a bougie had failed always seemed to yield to the many little 'tricks' which Gibbs would demonstrate to students and housemen. It might result only in the passage of a filiform bougie as a start to further dilatation, but this was practical knowledge for which they would be very grateful when they themselves were called upon to deal with similar cases.For many years he controlled the prosectors of the R.C.S., and here his precise knowledge of anatomy was of great value to the prosectors themselves and also to the examiners, who used the specimens thus provided.There can be no doubt that Gibbs was unique in his ability to convey information in the didactic manner so well suited to the state of surgical knowledge at the time. He is still regarded by the older generation of Charing Cross men as having been the finest teacher they knew.N. C. L.

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AimsHealthcare triage for those subject to section 136 powers (MHA 1983/2007) remains challenging. Camden and Islington NHS Foundation Trust opened a dedicated Health-Based Place of Safety (HBPOS) in 2020, situated separately from an emergency department (ED). There was concern that this may lead to physical health problems going unrecognised. We aimed to design a simple, efficient algorithm to be used by non-medically-trained staff to identify those who are subject to s.136 powers who would benefit from medical clearance before being admitted to the HBPOSMethodWe chaired a consensus meeting with nursing staff, police and emergency medicine consultants when designing the algorithm. Case notes of those presenting under s.136 to the POS over 1 calendar-month in 2019 were reviewed, and the proportion of those who the algorithm would have diverted for medical clearance was calculated. We then reviewed the proportion of cases sent for medical clearance during a single calendar month in 2020, after the HBPOS had opened, to see whether there was a significant difference.Result37 patients were admitted to the ED-based POS in July 2019, of which 36 records were analysed. 9 patients (25%) were referred for medical clearance, with 2 (6%) requiring medical admission. 8.6% were identified as needing medical clearance when the algorithm was applied retrospectively (positive predictive value 66%, negative predictive value = 79%).Review of records over 1 calendar-month after the HBPOS was established showed 30.6% of patients had been diverted for medical clearance prior to entering the HBPOS. Of the 65 patients, 1 (2%) required transfer to ED within 48 hours of entry. No statistical difference in the proportion of patients sent for medical clearance was observed since the formation of the HBPOS away from the ED (Chi-squared = 0.549, p = 0.458), suggesting the algorithm successfully identified those patients who needed medical clearance prior to admission.We observed high rates of intoxication amongst those admitted (30–40%).ConclusionThe algorithm showed high specificity and negative predictive value, allowing for a degree of confidence when admitting those deemed at low-risk of physical deterioration, though it does not eliminate the need for clinical judgement. Interpretation of the results is complicated by the COVID19 pandemic in 2020, which was not accounted for in the algorithm, which possibly led to deviations from the algorithm in real-world clinical practice.