7-mm plastic endotracheal tube adapter; and a 3-mm plastic (pediatric) endotracheal tube adapter. In the Honolulu ATLS labs I provided instruction only with the latter; the former is also acceptable. I have not made a n y m e a s u r e m e n t s , however, to determ i n e which provides the better oxygen flow rates. The per person costs of Lindsey et al for the dog labs are not comparable to the baboon a n d rhesus m o n k e y labs. I anticipate p r e l i m i n a r i l y t h a t the differences should become properly e v i d e n t upon a detailed, category by category comparison of the respective budgets.
Our average s t u d e n t learns to p u t a n adult-sized catheter into a pediatric-sized vein in u n d e r 60 seconds. We now have a series of over 300 consecutive successful caval c a n n u l a t i o n s u s i n g a Blitt 1 external j u g u l a r technique. We demonstrate, b u t the students do n o t p e r f o r m , t h e D a i l y 2 d i r e c t access to t h e i n n o m i n a t e - i n t e r n a l j u g u l a r route to the cava, a n d large-bore c a n n u l a t i o n of the inferior cava (inserting the IV tube itself through the saphenous i n the groin). Our solution to a d a p t i n g the bag to the cricothyrostomy needle is to attach a 3-ml syringe barrel to the needle hub (courtesy of J e r r y Calkins, MD, resident in anesthesiology). The barrel accommodates the adapter off a 7-mm e n d o t r a c h e a l tube. We feel t h a t e v e r y physician who m a y work in a n emergency d e p a r t m e n t should be able to open a chest with efficiency and dispatch. Several of our s t u d e n t s have done so in 5 seconds or less; the pressure tracing directly visible on the oscilloscope is a r e m a r k a b l e teacher of productive technique in massage. At the F i r s t I n t e r n a t i o n a l Conference on Mass C a s u a l t y M a n a g e m e n t in Safad, Israel in 1978 Professor Ron Rozin, Medical Director, Magen David Adorn (the Israeli e q u i v a l e n t of the Red Cross, the medical a r m of civil defense in Israel) indicated t h a t he is utilizing dogs successfully in similar laboratory exercises to t r a i n nonhospital physicians for a more active role in the emergency care of t r a u m a . We firmly believe t h a t "See one, do one, teach one" is not the route to go if you can do it first i n the laboratory. We see the results every day in the performance of our students and residents on the wards and i n the emergency department.
J. K. Sims, MD Hawaii Emergency Medical Services Program Honolulu, Hawaii 1. Sims JK: Advanced trauma life support laboratory: pilot implementation and evaluation. JACEP 8:150-153, 1979. 2. Sims JK: Advanced Trauma Life Support: A Laboratory Syllabus for Emergency Physicians. Honolulu, Hawaii, HMA-EMS Program, 1977, pp 27, 30.
Animal Bites To the Editor: I would like to commend K e n n e t h Kizer, MD, for his excellent review of the epidemiology of a n i m a l bites (8:134-141, 1979), which is thorough to a degree seldom seen in this area of emergency medicine. However, with profound (but insincere) apologies for my choice of words, I have a bone to pick with his comm e n t s on infecting organisms. He conveys the impression, particularly in the abstract, thatpasteurella multocida is a very common agent, which I believe is a m i s l e a d i n g conclusion. He fails to emphasize t h a t the total n u m b e r of cultures t a k e n in his study was so small (a total of n i n e for dog and cat bites combined) t h a t no statistically valid conclusions can be drawn from them. The purpose of d i s s e m i n a t i n g accurate information would better have been served by omitting these figures from the abstract. Larger studies contradict his findings regarding pasteurella. Goldstein et al 1 found in a series of 24 aerobically and anerobically cultured dog bites that only 21% grew out pasteurella. I n a two-year prospective double-blind study of 85 fresh dog bite wounds (to be published), I found only 1% of wounds grew out pasturella from cultures t a k e n on the first visit, and none became infected. Among wounds t h a t actually became infected, no organisms accounted for more t h a n 15% of infections. Streptococcus, g r a m n e g a t i v e rods, pseudomonas, a n d staph aureus each accounted for a b o u t 10% of infections, vastly overshadowing fiasteurella in importance. Thus the only large a n d systematic studies of dog bite wound infection tend to contradict the impression given in the early anecdotal l i t e r a t u r e tha~tpasteurella is a common offender. Since pasteurella is uniformly sensitive to penicillin, and several of these other org a n i s m s m a y not be, this information m a y lead the t r e a t i n g physician to a choice of different antibiotics, w h e n they are needed.
Douglas Lindsey, MD Jane Orient, MD University of Arizona Peter J. Whitney, MD Tucson Hospitals Medical Education Program Tucson, Arizona 1. Blitt CD, Wright WA, Petty WC, et al: Central venous catheterization via the external jugular vein; a technique employing the J-wire. JAMA 229:817-818, 1974. 2. Daily PO, Greipp RB, Shumway NE: Percutaneous internal jugular vein cannulation. Arch Surg 101:534-536, 1970.
Author's Reply The t r a u m a lab skills t a u g h t in the dog labs of Lindsey et al are s i m i l a r to the m a n d a t o r y and optional Advanced T r a u m a Life Support (ATLS) baboon lab skills t a u g h t . 1 For both types of labs, the average t r a i n e e : a n i m a l : i n s t r u c t o r ratio arrived at independe n t l y approximated 2:1:1. There are several differences in the labs. Lindsey et al appear to prefer to c a n n u l a t e the superior v e n a cava by J - w i r i n g the external j u g u l a r vein, 2 whereas Blitt's technique was used as an a l t e r n a t i v e approach i n the ATLS baboon lab. The baboon a n a t o m y precluded utilization of any percutaneous i n t e r n a l jugular v e n i - p u n c t u r e access to the superior v e n a cava, i n actuality. As to the cricothyrostomy adapter (ie, the adapter b e t w e e n the cricothyrostomy tube and the oxygen delivery source), Honolulu's paramedic a m b u l a n c e services have been u s i n g two types of cricothyrostomy adapters: a 3-cc plastic syringe barrel attached to a
68/545
Michael Callaham, MD Assistant Chief Emergency Medicine, Valley Medical Center Fresno, California 1. Goldstein EJC, Baraff LJ, Meislin H, et al: Animal bites.
JACEP 7:417, 1978.
JACEP
8:12 (December) 1979
Our average s t u d e n t learns to p u t a n adult-sized catheter into a pediatric-sized vein in u n d e r 60 seconds. We now have a series of over 300 consecutive successful caval c a n n u l a t i o n s u s i n g a Blitt 1 external j u g u l a r technique. We demonstrate, b u t the students do n o t p e r f o r m , t h e D a i l y 2 d i r e c t access to t h e i n n o m i n a t e - i n t e r n a l j u g u l a r route to the cava, a n d large-bore c a n n u l a t i o n of the inferior cava (inserting the IV tube itself through the saphenous i n the groin). Our solution to a d a p t i n g the bag to the cricothyrostomy needle is to attach a 3-ml syringe barrel to the needle hub (courtesy of J e r r y Calkins, MD, resident in anesthesiology). The barrel accommodates the adapter off a 7-mm e n d o t r a c h e a l tube. We feel t h a t e v e r y physician who m a y work in a n emergency d e p a r t m e n t should be able to open a chest with efficiency and dispatch. Several of our s t u d e n t s have done so in 5 seconds or less; the pressure tracing directly visible on the oscilloscope is a r e m a r k a b l e teacher of productive technique in massage. At the F i r s t I n t e r n a t i o n a l Conference on Mass C a s u a l t y M a n a g e m e n t in Safad, Israel in 1978 Professor Ron Rozin, Medical Director, Magen David Adorn (the Israeli e q u i v a l e n t of the Red Cross, the medical a r m of civil defense in Israel) indicated t h a t he is utilizing dogs successfully in similar laboratory exercises to t r a i n nonhospital physicians for a more active role in the emergency care of t r a u m a . We firmly believe t h a t "See one, do one, teach one" is not the route to go if you can do it first i n the laboratory. We see the results every day in the performance of our students and residents on the wards and i n the emergency department.
J. K. Sims, MD Hawaii Emergency Medical Services Program Honolulu, Hawaii 1. Sims JK: Advanced trauma life support laboratory: pilot implementation and evaluation. JACEP 8:150-153, 1979. 2. Sims JK: Advanced Trauma Life Support: A Laboratory Syllabus for Emergency Physicians. Honolulu, Hawaii, HMA-EMS Program, 1977, pp 27, 30.
Animal Bites To the Editor: I would like to commend K e n n e t h Kizer, MD, for his excellent review of the epidemiology of a n i m a l bites (8:134-141, 1979), which is thorough to a degree seldom seen in this area of emergency medicine. However, with profound (but insincere) apologies for my choice of words, I have a bone to pick with his comm e n t s on infecting organisms. He conveys the impression, particularly in the abstract, thatpasteurella multocida is a very common agent, which I believe is a m i s l e a d i n g conclusion. He fails to emphasize t h a t the total n u m b e r of cultures t a k e n in his study was so small (a total of n i n e for dog and cat bites combined) t h a t no statistically valid conclusions can be drawn from them. The purpose of d i s s e m i n a t i n g accurate information would better have been served by omitting these figures from the abstract. Larger studies contradict his findings regarding pasteurella. Goldstein et al 1 found in a series of 24 aerobically and anerobically cultured dog bites that only 21% grew out pasteurella. I n a two-year prospective double-blind study of 85 fresh dog bite wounds (to be published), I found only 1% of wounds grew out pasturella from cultures t a k e n on the first visit, and none became infected. Among wounds t h a t actually became infected, no organisms accounted for more t h a n 15% of infections. Streptococcus, g r a m n e g a t i v e rods, pseudomonas, a n d staph aureus each accounted for a b o u t 10% of infections, vastly overshadowing fiasteurella in importance. Thus the only large a n d systematic studies of dog bite wound infection tend to contradict the impression given in the early anecdotal l i t e r a t u r e tha~tpasteurella is a common offender. Since pasteurella is uniformly sensitive to penicillin, and several of these other org a n i s m s m a y not be, this information m a y lead the t r e a t i n g physician to a choice of different antibiotics, w h e n they are needed.
Douglas Lindsey, MD Jane Orient, MD University of Arizona Peter J. Whitney, MD Tucson Hospitals Medical Education Program Tucson, Arizona 1. Blitt CD, Wright WA, Petty WC, et al: Central venous catheterization via the external jugular vein; a technique employing the J-wire. JAMA 229:817-818, 1974. 2. Daily PO, Greipp RB, Shumway NE: Percutaneous internal jugular vein cannulation. Arch Surg 101:534-536, 1970.
Author's Reply The t r a u m a lab skills t a u g h t in the dog labs of Lindsey et al are s i m i l a r to the m a n d a t o r y and optional Advanced T r a u m a Life Support (ATLS) baboon lab skills t a u g h t . 1 For both types of labs, the average t r a i n e e : a n i m a l : i n s t r u c t o r ratio arrived at independe n t l y approximated 2:1:1. There are several differences in the labs. Lindsey et al appear to prefer to c a n n u l a t e the superior v e n a cava by J - w i r i n g the external j u g u l a r vein, 2 whereas Blitt's technique was used as an a l t e r n a t i v e approach i n the ATLS baboon lab. The baboon a n a t o m y precluded utilization of any percutaneous i n t e r n a l jugular v e n i - p u n c t u r e access to the superior v e n a cava, i n actuality. As to the cricothyrostomy adapter (ie, the adapter b e t w e e n the cricothyrostomy tube and the oxygen delivery source), Honolulu's paramedic a m b u l a n c e services have been u s i n g two types of cricothyrostomy adapters: a 3-cc plastic syringe barrel attached to a
68/545
Michael Callaham, MD Assistant Chief Emergency Medicine, Valley Medical Center Fresno, California 1. Goldstein EJC, Baraff LJ, Meislin H, et al: Animal bites.
JACEP 7:417, 1978.
JACEP
8:12 (December) 1979
