The main conclusions of out series of investigations are that the rate of death due to salicylate poisoning alone in Ontario has sharply declined and that the quality of treatment for salicylate poisoning in Ontario hospitals has substantially improved.

ander Milton Ross, who claimed in his biography, Memories of a Reformer,' that he had been a spy for the North. Dr. William Canniff saw service with the Army of the Potomac, and Dr. Alfred S. Oliver was at Fredericksburg. Although most of the sympathy of Canadians was with the We thank June Frank, manager of the North, Wafer was a target of an Coroners Information System, Ontar- anti-North editorial in The British io Ministry of the Solicitor General, Whig (Kingston, Ont., date unfor her assistance with data retrieval. known), which referred to "the on the part of the barbarities Garth Dickinson, MD, FRCPC North which have characterized Cairo, Egypt the present war.... No Canadian Ashley Yeats, MD, CCFP (EM) Department of Emergency Medicine can support the cause of the Ottawa Civic Hospital North consistently with his duties Ottawa, Ont. as a British subject." However, lain MacPhail, MD, CCFP (EM) Wafer returned to the fighting and Emergency physician Maple Ridge Hospital established a long-held tradition Maple Ridge, BC of voluntary service in foreign Michael Tierney, MSc armies by Canadian doctors. Assistant director of pharmacy Ottawa General Hospital Ottawa, Ont.

References 1. McGuigan MA: Death due to salicylate poisoning in Ontario. Can Med Assoc J 1986; 135: 891-894 2. Done AK: Salicylate intoxication significance of measurements of salicylate in blood in cases of acute ingestion. Pediatrics 1960; 26: 800-807 3. McGuigan MA: A two-year review of salicylate deaths in Ontario. Arch Intern Med 1987; 147: 510-512 4. Chow P, Tierney MG, Dickinson GE: Acute intoxications: cases presenting to an adult emergency department. Can Fam Physician 1992; 38: 1379-1382

The Civil War comes to Queen's F a rederick J. McEvoy's article (Can Med Assoc J 1991; 145: 1157, 1158, 1160) is an interesting anecdote of the contributions made by Canadian doctors in the American Civil War. Francis Wafer, a medical student, was one of the estimated 53 532 Canadians who fought in various units. Among these was Dr. AlexNOVEMBER 15, 1992

Charles M. Godfrey, MA, MD 107-484 Church St. Toronto, Ont.

Reference 1. Ross AM: Memories of a Hunter, Rose, Toronto, 1893

vival rates after cardiac arrest ambulance response times must be reduced." In the study ambulance personnel provided two interventions: cardiopulmonary resuscitation (CPR) and electrical defibrillation. Both can be provided by nonambulance allied health personnel.' I am surprised that the authors did not consider firstresponder provision of CPR and defibrillation as a way to reduce response time. In Oakville, Ont., we have introduced a program in which fire fighters, when responding to a cardiac arrest emergency, provide defibrillation. Factors favouring such a program include the response times of fire fighters, the availability of semiautomatic and automatic defibrillators and the relative economy of using personnel who are already dispatched, through tiered response, to the scene. Communities interested in reducing the time to defibrillation for victims of out-of-hospital carReformer, diac arrest could consider a similar program.

Improving the treatment of out-of-hospital cardiac arrest TNhe article "Cardiac arrest in Ontario: circumstances, community response, role of prehospital defibrillation and predictors of survival" (Can Med Assoc J 1992; 147: 191-199), by Dr. Robert J. Brison and associates, discusses the failure of ambulance-based defibrillation programs to influence survival rates for victims of out-of-hospital cardiac arrest. An average ambulance response time of 7.8 minutes and an average time to defibrillation analysis of 13.1 minutes likely contribute to the poor outcome. I take issue with the authors' conclusion that "to improve sur-

Lorne Martin, MD, CCFP (EM) Chief of family medicine Oakville-Trafalgar Memorial Hospital Oakville, Ont.

Reference 1. Cummins RO, Thies WH: Improving survival from sudden cardiac arrest: the "chain of survival" concept. Circulation 1991; 83: 1821-1847

Dr. Martin correctly points out that first responders such as fire fighters can contribute to survival from out-of-hospital cardiac arrest. At the inception of our study there were high expectations for prehospital defibrillation. What has since become apparent is that ambulance services in Ontario alone are unable to respond to most cardiac arrests and to apply defibrillation quickly enough. Reduced time to defibrillation is one of the keys to the successful management of out-ofCAN MED ASSOC J 1992; 147 (10)


Improving the treatment of out-of-hospital cardiac arrest.

The main conclusions of out series of investigations are that the rate of death due to salicylate poisoning alone in Ontario has sharply declined and...
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