EDITORIALS
7. Haft JI, Habbab MA: T r e a t m e n t of atrial ar rhythmias: Effectiveness of verapamil when preceded by c a l c i u m infusion. A r c h Intern Me d 1986;146: 1085-1089. 8. Stringer KA, Hicks P, Royal 8H, et ah Verapamil preceded by calcimn in supraventricular taehycardia. Drug Inte]l Clin PharmacoI 1988;22:575-576. 9. Barnett JC, Touchon RC: Short-term control of supraventricular tachycardia with verapamiI infusion and
calcium pretreatment. Chest 1990;97:1106d109. 10. McEvoy G [ed]: Replacement preparations - Calcium salts, in American HospitaI Formulary Service 90. Bethesda, Maryland: American Society of Hospital Pharmacists; 1990;1414-1417. 11. Guadagnino V, Greengart A, Hollander G, et ah Treatment of severe left ventricular dysfunction with calcium chloride in patients receiving verapamil. J Clin Pharmacol 1987;27:407-409.
12. White RD, G o l d s m i t h RS, Rodriguez R, et al: Plasma ionic calcium levels following injection of chlo ride, glnconate, and gluceptate salts of calcium. J Thorac Cardiovasc Surg 1976;7h609-613. I3. Lipman J, lardine I, Roos C, et ah Intravenous cal cium chloride as an antidote to verapamil-induced hy potension. Intens Care Med 1982;8:55 57. 14. Watanabe Y, Nishimura M: Calcium-verapamii in teraction on the A-V node. Int J Cardiol 1984;6:275 277.
Annals Due for Change? Five r e c e n t e d i t o r i a l s in Annals [ N o v e m b e r 1990;19:1338-1346] comb i n e d to m a k e an i m p r e s s i v e l y disc e r n i n g and p r o v o c a t i v e call for a critical appraisal of the scope, source, support, and d i s s e m i n a t i o n of the research that is essential to advancing the specialty of e m e r g e n c y medicine. A l t h o u g h all of the e d i t o r i a l s were plainly pertinent, and each will elicit articulate responses, I l i m i t m y comm e n t s to the relationship posited bet w e e n Annals and academic respectability. 1 Dr W h i t e invites "fostering debate" as the first step. W i t h this I agree, but a solution to his p r o b l e m does not lie in overhauling a journal. His p r o b l e m is k n o w n to all of us. " C a t c h 22" is e n d e m i c in life. National Institutes of H e a l t h funding is controlled by a group of "old boys." The spoils go to those already rich, as t h e y h a v e b e e n for t w o m i l l e n i a (Matthew 25:29, " T h e m t h a t has, gets"). But e m e r g e n c y m e d i c i n e is not an oligarchy to be d o m i n a t e d by academia, and Annals is n o t in need of invasive surgery. It is an excellent journal. It gets better and better. A n d it serves a very special purpose. It behooves the A m e r i c a n College of Emergency Physicians to support a journal that emergency physicians recognize as our own. All of us have special interests within emergency m e d i c i n e , w h e t h e r it is e m e r g e n c y medical services, management, teaching, research, or c l i n i c a l care. T h e u n i q u e e s s e n c e of e m e r g e n c y m e d i c i n e is n o t free radicals, m e m branes and channels, or cellular physi o l o g y of m u l t i p l e o r g a n f a i l u r e . Rather, it is t h a t w e m u s t t a k e all comers who c l a i m or manifest emergencies of u n l i m i t e d variety, in what170/589
ever number and by whatever m e t h o d t h e y arrive, at any and all t i m e s , and r e g a r d l e s s of a b i l i t y to pay. To do that, we m u s t harvest and put to use the research of m e d i c i n e at large by r e a d i n g w i d e l y and by rep o r t i n g our findings in the j o u r n a l s t h r o u g h w h i c h t h e greatest i m p a c t on progress in e m e r g e n c y m e d i c i n e can be made. Yes, Annals m i g h t c o n s i d e r s o m e change, and it a p p e a r s t h a t it is. I agree w i t h Dr W h i t e that the Annals Editorial Board should look m o r e like a panel of scientific advisors than the b o a r d of d i r e c t o r s of a p u b l i s h i n g house. But I c a n n o t agree w i t h his proposal to e l i m i n a t e individual case reports. There is m u c h to be learned from an N-of-1 series if the editor has a d e q u a t e m a t e r i a l f r o m w h i c h to choose. N o t e the report on the hazards of defibrillation through the use of nitroglycerin patches, z This report represented n e i t h e r a curiosity, nor a "first case," nor even a "first case in the English language literature," but rather a lesson learned and a lesson passed on. Annals m i g h t even consider encouraging more (although less verbose) case reports by adopting the l e t t e r s to the journal f o r m a t of t h e American Journal of Ophthal-
mology. R e v i e w w r i t i n g is a difficult art, and Annals s h o u l d c o n t i n u e to encourage c o l l e c t i v e r e v i e w s by t h o s e w h o are e x p e r t s in t h e field.3 Reviews by outsiders as an assigned or s e l f - i n i t i a t e d " t h e s i s " topic have no place in the pages of Annals. Technology has not yet replaced clinical j u d g m e n t , and a n a l y s i s (rather t h a n m e r e t a b u l a t i o n ) of c l i n i c a l experience can m a k e m a j o r c o n t r i b u t i o n s Annals of Emergency Medicine
to the evolution of standards of care. T h e f a c t t h a t a s t u d y is w e l l funded, well executed, and well written does n o t ensure that it m a k e s a valuable c o n t r i b u t i o n to progress in e m e r g e n c y m e d i c i n e . 4 , s But s o m e studies t h a t are " . . . large, rigorous, controlled, and have the p o t e n t i a l to actually change the standards of care . . . " can be p e r f o r m e d by an intere s t e d and d e d i c a t e d e m e r g e n c y department without obligate reliance on " . . . t a x - d e r i v e d m e d i c a l s c h o o l funds . . . . -6,7 Other definitive studies (a good e x a m p l e is the use of prop h y l a c t i c a n t i m i c r o b i a l s in the treatm e n t of wounds) d e m a n d the particip a t i o n of m a n y i n s t i t u t i o n s . Here, ACEP and the Society for A c a d e m i c E m e r g e n c y M e d i c i n e c o u l d be t h e key players in a high-stakes game for only a modest investment in the chips r e q u i r e d for o r g a n i z a t i o n and coordination. No, m o n e y is not the d o m i n a n t ele m e n t in p u r s u i t of power and prestige. T h e c o r n e r s t o n e of our edifice m u s t be i n t e l l e c t u a l r i g o r - h i g h standards by Annals for all accepted a r t i c l e s , h i g h s t a n d a r d s for e m e r gency physicians teaching students and residents, and open r e c o g n i t i o n of h o w m u c h is not known. Is there a s c i e n t i f i c basis for w h a t we are doing? Conversely, are we just tracking an e s t a b l i s h e d rut? A f t e r all, o n e t y m p a n i c m e m b r a n e can always be d e t e r m i n e d to be r e d d e r t h a n t h e other, and dispensing an antim i c r o b i a l is t h e k n e e - j e r k respOnse. But w h e t h e r a m i d d l e ear effusion is p e r p e t r a t e d or p e r p e t u a t e d by m i crobes and w h e t h e r the a n t i m i c r o b i a l will do any good still r e m a i n 50-50 propositions. 20:5 May 1991
EDITORIALS
Keep every tenet open to challenge. T h i n k of s o m e way to test it. Do so. T h e n publish the results somewhere. But do not tear up Annals.
Douglas Lindsey, MD, DrPH, FACEP Section of Emergency Medicine University of Arizona Tucson
20:5 May 1991
1. White BC: Annals and academic respectability. Ann Emerg Med 1990;19:1338-1339.
diography. Ann Emerg Med 1990;19:1280-1287.
2. Wrenn K: The hazards of defibrillation through nitroglycerin patches. Ann Emerg Med 1990;19:1327-1328.
5. Cummins RO, Eisenberg MS: From pain to reperfusion: What role for the prehospital 12-lead ECG? Ann Emerg Med 1990;19:1343-1346.
3. Paradis NA, Koscove EM: Epinephrine in cardiac arrest: A critical review. A n n Emerg Med 1990;19: t288-I301.
6. Hargarten K, Chapman PD, Stueven HA, et ah Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain. Ann Emerg Med 1990; 19:1274-1279.
4. Aufderheide TP, Hendley GE, Thakur RK, et al: The diagnostic impact of prehospital 12-iead electrocar~
7. Baxt WG: Prophylactic lidocaine. Ann Emerg Med 1990;19:1342-1346.
Annals of Emergency Medicine
590/171
7. Haft JI, Habbab MA: T r e a t m e n t of atrial ar rhythmias: Effectiveness of verapamil when preceded by c a l c i u m infusion. A r c h Intern Me d 1986;146: 1085-1089. 8. Stringer KA, Hicks P, Royal 8H, et ah Verapamil preceded by calcimn in supraventricular taehycardia. Drug Inte]l Clin PharmacoI 1988;22:575-576. 9. Barnett JC, Touchon RC: Short-term control of supraventricular tachycardia with verapamiI infusion and
calcium pretreatment. Chest 1990;97:1106d109. 10. McEvoy G [ed]: Replacement preparations - Calcium salts, in American HospitaI Formulary Service 90. Bethesda, Maryland: American Society of Hospital Pharmacists; 1990;1414-1417. 11. Guadagnino V, Greengart A, Hollander G, et ah Treatment of severe left ventricular dysfunction with calcium chloride in patients receiving verapamil. J Clin Pharmacol 1987;27:407-409.
12. White RD, G o l d s m i t h RS, Rodriguez R, et al: Plasma ionic calcium levels following injection of chlo ride, glnconate, and gluceptate salts of calcium. J Thorac Cardiovasc Surg 1976;7h609-613. I3. Lipman J, lardine I, Roos C, et ah Intravenous cal cium chloride as an antidote to verapamil-induced hy potension. Intens Care Med 1982;8:55 57. 14. Watanabe Y, Nishimura M: Calcium-verapamii in teraction on the A-V node. Int J Cardiol 1984;6:275 277.
Annals Due for Change? Five r e c e n t e d i t o r i a l s in Annals [ N o v e m b e r 1990;19:1338-1346] comb i n e d to m a k e an i m p r e s s i v e l y disc e r n i n g and p r o v o c a t i v e call for a critical appraisal of the scope, source, support, and d i s s e m i n a t i o n of the research that is essential to advancing the specialty of e m e r g e n c y medicine. A l t h o u g h all of the e d i t o r i a l s were plainly pertinent, and each will elicit articulate responses, I l i m i t m y comm e n t s to the relationship posited bet w e e n Annals and academic respectability. 1 Dr W h i t e invites "fostering debate" as the first step. W i t h this I agree, but a solution to his p r o b l e m does not lie in overhauling a journal. His p r o b l e m is k n o w n to all of us. " C a t c h 22" is e n d e m i c in life. National Institutes of H e a l t h funding is controlled by a group of "old boys." The spoils go to those already rich, as t h e y h a v e b e e n for t w o m i l l e n i a (Matthew 25:29, " T h e m t h a t has, gets"). But e m e r g e n c y m e d i c i n e is not an oligarchy to be d o m i n a t e d by academia, and Annals is n o t in need of invasive surgery. It is an excellent journal. It gets better and better. A n d it serves a very special purpose. It behooves the A m e r i c a n College of Emergency Physicians to support a journal that emergency physicians recognize as our own. All of us have special interests within emergency m e d i c i n e , w h e t h e r it is e m e r g e n c y medical services, management, teaching, research, or c l i n i c a l care. T h e u n i q u e e s s e n c e of e m e r g e n c y m e d i c i n e is n o t free radicals, m e m branes and channels, or cellular physi o l o g y of m u l t i p l e o r g a n f a i l u r e . Rather, it is t h a t w e m u s t t a k e all comers who c l a i m or manifest emergencies of u n l i m i t e d variety, in what170/589
ever number and by whatever m e t h o d t h e y arrive, at any and all t i m e s , and r e g a r d l e s s of a b i l i t y to pay. To do that, we m u s t harvest and put to use the research of m e d i c i n e at large by r e a d i n g w i d e l y and by rep o r t i n g our findings in the j o u r n a l s t h r o u g h w h i c h t h e greatest i m p a c t on progress in e m e r g e n c y m e d i c i n e can be made. Yes, Annals m i g h t c o n s i d e r s o m e change, and it a p p e a r s t h a t it is. I agree w i t h Dr W h i t e that the Annals Editorial Board should look m o r e like a panel of scientific advisors than the b o a r d of d i r e c t o r s of a p u b l i s h i n g house. But I c a n n o t agree w i t h his proposal to e l i m i n a t e individual case reports. There is m u c h to be learned from an N-of-1 series if the editor has a d e q u a t e m a t e r i a l f r o m w h i c h to choose. N o t e the report on the hazards of defibrillation through the use of nitroglycerin patches, z This report represented n e i t h e r a curiosity, nor a "first case," nor even a "first case in the English language literature," but rather a lesson learned and a lesson passed on. Annals m i g h t even consider encouraging more (although less verbose) case reports by adopting the l e t t e r s to the journal f o r m a t of t h e American Journal of Ophthal-
mology. R e v i e w w r i t i n g is a difficult art, and Annals s h o u l d c o n t i n u e to encourage c o l l e c t i v e r e v i e w s by t h o s e w h o are e x p e r t s in t h e field.3 Reviews by outsiders as an assigned or s e l f - i n i t i a t e d " t h e s i s " topic have no place in the pages of Annals. Technology has not yet replaced clinical j u d g m e n t , and a n a l y s i s (rather t h a n m e r e t a b u l a t i o n ) of c l i n i c a l experience can m a k e m a j o r c o n t r i b u t i o n s Annals of Emergency Medicine
to the evolution of standards of care. T h e f a c t t h a t a s t u d y is w e l l funded, well executed, and well written does n o t ensure that it m a k e s a valuable c o n t r i b u t i o n to progress in e m e r g e n c y m e d i c i n e . 4 , s But s o m e studies t h a t are " . . . large, rigorous, controlled, and have the p o t e n t i a l to actually change the standards of care . . . " can be p e r f o r m e d by an intere s t e d and d e d i c a t e d e m e r g e n c y department without obligate reliance on " . . . t a x - d e r i v e d m e d i c a l s c h o o l funds . . . . -6,7 Other definitive studies (a good e x a m p l e is the use of prop h y l a c t i c a n t i m i c r o b i a l s in the treatm e n t of wounds) d e m a n d the particip a t i o n of m a n y i n s t i t u t i o n s . Here, ACEP and the Society for A c a d e m i c E m e r g e n c y M e d i c i n e c o u l d be t h e key players in a high-stakes game for only a modest investment in the chips r e q u i r e d for o r g a n i z a t i o n and coordination. No, m o n e y is not the d o m i n a n t ele m e n t in p u r s u i t of power and prestige. T h e c o r n e r s t o n e of our edifice m u s t be i n t e l l e c t u a l r i g o r - h i g h standards by Annals for all accepted a r t i c l e s , h i g h s t a n d a r d s for e m e r gency physicians teaching students and residents, and open r e c o g n i t i o n of h o w m u c h is not known. Is there a s c i e n t i f i c basis for w h a t we are doing? Conversely, are we just tracking an e s t a b l i s h e d rut? A f t e r all, o n e t y m p a n i c m e m b r a n e can always be d e t e r m i n e d to be r e d d e r t h a n t h e other, and dispensing an antim i c r o b i a l is t h e k n e e - j e r k respOnse. But w h e t h e r a m i d d l e ear effusion is p e r p e t r a t e d or p e r p e t u a t e d by m i crobes and w h e t h e r the a n t i m i c r o b i a l will do any good still r e m a i n 50-50 propositions. 20:5 May 1991
EDITORIALS
Keep every tenet open to challenge. T h i n k of s o m e way to test it. Do so. T h e n publish the results somewhere. But do not tear up Annals.
Douglas Lindsey, MD, DrPH, FACEP Section of Emergency Medicine University of Arizona Tucson
20:5 May 1991
1. White BC: Annals and academic respectability. Ann Emerg Med 1990;19:1338-1339.
diography. Ann Emerg Med 1990;19:1280-1287.
2. Wrenn K: The hazards of defibrillation through nitroglycerin patches. Ann Emerg Med 1990;19:1327-1328.
5. Cummins RO, Eisenberg MS: From pain to reperfusion: What role for the prehospital 12-lead ECG? Ann Emerg Med 1990;19:1343-1346.
3. Paradis NA, Koscove EM: Epinephrine in cardiac arrest: A critical review. A n n Emerg Med 1990;19: t288-I301.
6. Hargarten K, Chapman PD, Stueven HA, et ah Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain. Ann Emerg Med 1990; 19:1274-1279.
4. Aufderheide TP, Hendley GE, Thakur RK, et al: The diagnostic impact of prehospital 12-iead electrocar~
7. Baxt WG: Prophylactic lidocaine. Ann Emerg Med 1990;19:1342-1346.
Annals of Emergency Medicine
590/171
