CORRESPONDENCE
problem. A written record in the ED of individuals who make frequent prescription requests may help to identify potential abusers. We must, of course, avoid unjustly stigmatizing such patients. While it is unfortunate that the ED staff must be involved in policing activities, the prev e n t i o n of prescription fraud will u l t i m a t e l y benefit all l e g i t i m a t e users of the health care system.
Richard M Rosenberg, MD Barton H Lerner, MD Emergency Services Columbia-Presbyterian Medical Center N e w York I. Wilford BB: Abuse of prescription drugs. West J Med 1990;152:609-612. 2. Taibbi M, Phillips AS: Prescription for danger. WCBS-TV News, April 25-26, 1991. 3. Cushman P: Clonidine and alcohol withdrawal. Adv Alcohol Subst Abuse 1987;7:17~28. 4. Caballeria J, Baraona E, Rodamilans M, et ah Effects of cimetidine on gastric alcohol dehydrogenase activity and blood e t h a n o l levels. Gastroenterology 1989; 96:388-392. 5. Somogyi A, Muirhead M: Pharmacokinetic interac tions of cimetidine 1987. CJin Pharmacokinet 1987;12: 321-366. 6. Webster LK, Jones DB, 8mallwood RA: Influence of cimetidine and ranitidine on ethanol pharmacokinetics. Aust N Z J Med 1985j5:359-360.
given flumazenil to reverse the sedative effects of midazolam. Chiolero et al 3 also found significant increases in intracranial pressure following flumazenil administration to patients with severe head injury. Space-occupying lesions are a comm o n c a u s e of c o m a ; before flumazenil can be administered safely to all comatose patients, its effects on intracranial pressure must be clarified.
Francois R LaFleche, MD, FRCPC Department of Emergency Medicine Vancouver General Hospital Vancouver, British Columbia, Canada David P MiJzman, MD Department of Emergency Medicine Georgetown University Hospital Washington, DC 1. Forster A, Juge O, Louis M, et al: Effects of a specific benzodiazepine antagonist (Ro15 1788] on cerebral blood flow. Anaesth Analg 1987;66:309-313. 2. Fleischer IE, Milde [H, Moyer TP, et ah Cerebral effects of high-dose midazolam and subsequent reversal with R o t 5 d 7 8 8 in dogs. Anaesthesiology 1988;68: 234 242. 3. Chiolero RL, Ravussin P, Anderes IP, et a[: Midazolam reversal with Ro15 1788 in patients with severe head injury. AnaesthesioJogy 1986;65:No.3A:A358.
Flumazenil & Coma
The CDC's Role in Emergency Preparedness and Response
To the Editor: We noted with interest the excellent review " F l u m a z e n i h A New Benzodiazepine Antagonist" [February 1991;20:181-188], by Votey et al. Although it appears very promising, flumazenil's potential side effects must be further elucidated before it can be used in coma of unknown etiology. The authors point out the potential for complications in ingestions involving chloral hydrate and possibly even tricyclic antidepressants. However, they did not discuss the effects of flumazenil on cerebral blood flow and intracranial pressure. Alt h o u g h Forster et al ~ found flumazenil to have no effect on these parameters when it was given to seven healthy volunteers, Fleischer et al 2 described a significant increase in intracranial pressure in nine dogs
To the Editor. Dr Mickel is to be commended for addressing an issue of critical importance to the future of emergency medicine in his editorial "Critical Need for a N a t i o n a l I n s t i t u t e of Emergency Medicine" [November 1990;19:1340-1341]. T h e f u r t h e r growth and development of the specialty will depend on high-quality research being conducted in important areas such as resuscitation, toxicology, prehospital emergency medical services, and the public health aspects of emergency medical care. The basic premise of his editorial was that responsibility for research relevant to emergency medicine is f r a g m e n t e d a m o n g m a n y federal agencies, with some important areas not addressed by any agency at all. One research area that Dr Mickel identified as critical concerns medi-
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Annals of Emergency Medicine
cal conditions associated with disasters. Regarding the latter, he states that "... no federal agency is responsible for i n v e s t i g a t i o n s into the causes and t r e a t m e n t of medical problems related to disasters." This is not the case. The Centers for Disease C o n t r o l (CDC), an a g e n c y within the US Public Health Service (PHS), has long been responsible for conducting investigations into the health effects and medical consequences of natural and technological disasters. Another PHS agency, the National Institute on Mental Health, funds research on psychosocial responses to disasters and supports disaster preparedness to cope with the psychological stress associated with e n v i r o n m e n t a l c r i s e s and catastrophic events. Within the PHS, the CDC has been designated as the lead agency for responding to technological hazards and natural disasters. As the primary US government health agency in disaster situations, the CDC is responsible for coordinating and managing the overall PHS response; alerting other appropriate federal agencies; helping to assess the health impact of an event; consulting with state and local health agencies on the medical resources required and helping to locate those needed resources; advising federal, state, and local officials on emergency response and worker protection issues; and establishing public health surveillance systems. For the past 20 years, no other institution in the world has been able to match the CDC's rich and diversified experience in responding to natural and man-made disasters, both domestically and internationally. Through the involvement of CDC medical staff in the massive international relief operation mounted during the civil war in Nigeria in the late 1960s, techniques were developed for rapidly assessing nutritional status and for conducting surveys to identify populations in need. In the 1970s and 1980s, the CDC conducted investigations following earthquakes in Peru, Nicaragua, and Guatemala, 1 a cyclone in the Bay of Bengal, z a chemical release in Bhopal, India, 3 floods in Bangladesh, and the volca20:12 December 1991
problem. A written record in the ED of individuals who make frequent prescription requests may help to identify potential abusers. We must, of course, avoid unjustly stigmatizing such patients. While it is unfortunate that the ED staff must be involved in policing activities, the prev e n t i o n of prescription fraud will u l t i m a t e l y benefit all l e g i t i m a t e users of the health care system.
Richard M Rosenberg, MD Barton H Lerner, MD Emergency Services Columbia-Presbyterian Medical Center N e w York I. Wilford BB: Abuse of prescription drugs. West J Med 1990;152:609-612. 2. Taibbi M, Phillips AS: Prescription for danger. WCBS-TV News, April 25-26, 1991. 3. Cushman P: Clonidine and alcohol withdrawal. Adv Alcohol Subst Abuse 1987;7:17~28. 4. Caballeria J, Baraona E, Rodamilans M, et ah Effects of cimetidine on gastric alcohol dehydrogenase activity and blood e t h a n o l levels. Gastroenterology 1989; 96:388-392. 5. Somogyi A, Muirhead M: Pharmacokinetic interac tions of cimetidine 1987. CJin Pharmacokinet 1987;12: 321-366. 6. Webster LK, Jones DB, 8mallwood RA: Influence of cimetidine and ranitidine on ethanol pharmacokinetics. Aust N Z J Med 1985j5:359-360.
given flumazenil to reverse the sedative effects of midazolam. Chiolero et al 3 also found significant increases in intracranial pressure following flumazenil administration to patients with severe head injury. Space-occupying lesions are a comm o n c a u s e of c o m a ; before flumazenil can be administered safely to all comatose patients, its effects on intracranial pressure must be clarified.
Francois R LaFleche, MD, FRCPC Department of Emergency Medicine Vancouver General Hospital Vancouver, British Columbia, Canada David P MiJzman, MD Department of Emergency Medicine Georgetown University Hospital Washington, DC 1. Forster A, Juge O, Louis M, et al: Effects of a specific benzodiazepine antagonist (Ro15 1788] on cerebral blood flow. Anaesth Analg 1987;66:309-313. 2. Fleischer IE, Milde [H, Moyer TP, et ah Cerebral effects of high-dose midazolam and subsequent reversal with R o t 5 d 7 8 8 in dogs. Anaesthesiology 1988;68: 234 242. 3. Chiolero RL, Ravussin P, Anderes IP, et a[: Midazolam reversal with Ro15 1788 in patients with severe head injury. AnaesthesioJogy 1986;65:No.3A:A358.
Flumazenil & Coma
The CDC's Role in Emergency Preparedness and Response
To the Editor: We noted with interest the excellent review " F l u m a z e n i h A New Benzodiazepine Antagonist" [February 1991;20:181-188], by Votey et al. Although it appears very promising, flumazenil's potential side effects must be further elucidated before it can be used in coma of unknown etiology. The authors point out the potential for complications in ingestions involving chloral hydrate and possibly even tricyclic antidepressants. However, they did not discuss the effects of flumazenil on cerebral blood flow and intracranial pressure. Alt h o u g h Forster et al ~ found flumazenil to have no effect on these parameters when it was given to seven healthy volunteers, Fleischer et al 2 described a significant increase in intracranial pressure in nine dogs
To the Editor. Dr Mickel is to be commended for addressing an issue of critical importance to the future of emergency medicine in his editorial "Critical Need for a N a t i o n a l I n s t i t u t e of Emergency Medicine" [November 1990;19:1340-1341]. T h e f u r t h e r growth and development of the specialty will depend on high-quality research being conducted in important areas such as resuscitation, toxicology, prehospital emergency medical services, and the public health aspects of emergency medical care. The basic premise of his editorial was that responsibility for research relevant to emergency medicine is f r a g m e n t e d a m o n g m a n y federal agencies, with some important areas not addressed by any agency at all. One research area that Dr Mickel identified as critical concerns medi-
160/1397
Annals of Emergency Medicine
cal conditions associated with disasters. Regarding the latter, he states that "... no federal agency is responsible for i n v e s t i g a t i o n s into the causes and t r e a t m e n t of medical problems related to disasters." This is not the case. The Centers for Disease C o n t r o l (CDC), an a g e n c y within the US Public Health Service (PHS), has long been responsible for conducting investigations into the health effects and medical consequences of natural and technological disasters. Another PHS agency, the National Institute on Mental Health, funds research on psychosocial responses to disasters and supports disaster preparedness to cope with the psychological stress associated with e n v i r o n m e n t a l c r i s e s and catastrophic events. Within the PHS, the CDC has been designated as the lead agency for responding to technological hazards and natural disasters. As the primary US government health agency in disaster situations, the CDC is responsible for coordinating and managing the overall PHS response; alerting other appropriate federal agencies; helping to assess the health impact of an event; consulting with state and local health agencies on the medical resources required and helping to locate those needed resources; advising federal, state, and local officials on emergency response and worker protection issues; and establishing public health surveillance systems. For the past 20 years, no other institution in the world has been able to match the CDC's rich and diversified experience in responding to natural and man-made disasters, both domestically and internationally. Through the involvement of CDC medical staff in the massive international relief operation mounted during the civil war in Nigeria in the late 1960s, techniques were developed for rapidly assessing nutritional status and for conducting surveys to identify populations in need. In the 1970s and 1980s, the CDC conducted investigations following earthquakes in Peru, Nicaragua, and Guatemala, 1 a cyclone in the Bay of Bengal, z a chemical release in Bhopal, India, 3 floods in Bangladesh, and the volca20:12 December 1991
