EDITORIALS U N E M - - History and Future
e m e r g e n c y medicine b u t r a t h e r with deciding how all s p e c i a l i s t s a n d e m e r g e n c y p h y s i c i a n s can a d v a n c e emergency medicine t h r o u g h academic and research programs. We are no longer h a m p e r e d by the lack of recognition, we are no longer bound to dean's panels, we are no longer limited by small n u m b e r s of scientific p a p e r s c o n c e r n i n g p a r t i a l a r e a s of e m e r g e n c y medicine or l e n g t h y discussions of '~roles" in emergency medicine. Now, UA/EM is able to p r e s e n t a more v a r i e d a n d a d v a n c e d s c i e n t i f i c p r o g r a m . Instead of a dean's panel, UA/EM will present a stateof-the-art discussion of b u r n care with recognized aut h o r i t i e s participating. I n s t e a d of limited discussion of a g r e a t n u m b e r of scientific papers, more time will be s p e n t on scientific p a p e r s or groups of papers t h a t d e m o n s t r a t e our c o m m i t m e n t to q u a l i t y research and academics. In order to continue our support of research and a c a d e m i c a d v a n c e m e n t , t h e U A / E M will p r e s e n t a combined workshop with the Society for Teachers of E m e r g e n c y Medicine. The t h e m e of this workshop is, quite simply and appropriately, the goal of both org a n i z a t i o n s , ie, excellence in e m e r g e n c y m e d i c i n e t h r o u g h q u a l i t y research and academic advancement. The two o r g a n i z a t i o n s will provide an e d u c a t i o n a l forum t h a t will include sessions on research, project design, funding, statistics, e v a l u a t i o n of research, and scientific writing. This combined workshop is a progression from the old format of two days for UA/EM and one d a y for STEM w i t h m i n i m a l crossover. This p r o g r a m will g r e a t l y benefit all residents as well as those of us who have concluded our formal t r a i n i n g but continue to l e a r n and p a r t i c i p a t e in academics a n d research. This is an i n v i t a t i o n from UA/EM and STEM to each of you to come to San Francisco in May. We are offering a b r o a d e r a n d more scientific p r o g r a m designed to accomplish our goal of excellence in emergency medicine t h r o u g h sound academic programs and intelligent, t h o u g h t - p r o v o k i n g research. We are reinforcing the need for i n p u t by t r a d i t i o n a l specialists in the developing specialty of e m e r g e n c y medicine. Finally, we are h a v i n g the m e e t i n g in San Francisco, California, complete with sun, scenery and sea. How can you lose?
n M a r c h 1970, 138 p h y s i c i a n s from 96 m e d i c a l I schools t h r o u g h o u t the U n i t e d States and C a n a d a met to discuss e m e r g e n c y d e p a r t m e n t a d m i n i s t r a t i v e problems, t r a n s p o r t a t i o n a n d communication systems, regional o r g a n i z a t i o n of e m e r g e n c y medical services and problems in the academic area. From this enthusiastic m e e t i n g s p r u n g the U n i v e r s i t y Association for Emergency Medical Services. (In 1977 its name was c h a n g e d to U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine [UA/EM].) This organization was conceived and developed p r i m a r i l y by faculty who directed univ e r s i t y e m e r g e n c y d e p a r t m e n t s . T h e o b j e c t i v e s of UA/EM were clearly e s t a b l i s h e d in i t s constitution, in essence s t a t i n g t h a t i m p r o v e m e n t s in the q u a l i t y and delivery of e m e r g e n c y medical care would be p u r s u e d by collecting, a n a l y z i n g a n d d i s s e m i n a t i n g information r e g a r d i n g e m e r g e n c y medical system problems. A major focus of U A / E M was to provide an a n n u a l scientific forum to discuss problems such as the participation of academic physicians in emergency medical systems, m a n a g e m e n t of e m e r g e n c y d e p a r t m e n t s , imp l e m e n t a t i o n of e m e r g e n c y medical service s y s t e m s legislation, and academic recognition. Prior to 1973, papers and topics of discussion at the a n n u a l scientific m e e t i n g were centered a r o u n d the surgeon and surgical problems in the e m e r g e n c y d e p a r t m e n t w i t h little m e n t i o n of the need for developing s p e c i a l t y t r a i n i n g in e m e r g e n c y medicine. However, d u r i n g his p r e s i d e n t i a l a d d r e s s in 1973, Robert Rutherford, MD, a s k e d U A / E M m e m b e r s to consider the question of who should r u n emergency departments. This provoked careful consideration of e m e r g e n c y m e d i c i n e d u r i n g t h e r e m a i n d e r of t h e meeting. At t h e 1974 a n n u a l m e e t i n g in Dallas, t h e UA/EMS Executive Council u n a n i m o u s l y approved a resolution s t a t i n g t h a t e m e r g e n c y medicine should be recognized as a specialty and t h a t residency t r a i n i n g programs were essential. Subsequently, the membership voted in favor of this position. Consequently, the tone of the A n n u a l M e e t i n g changed in the direction of t r e a t i n g e m e r g e n c y medicine as an academic e n t i t y and the e m e r g e n c y physician ,as a reality. Since then, UA/EM h a s continued to n u r t u r e and develop e m e r g e n c y medicine as a specialty while considering the e d u c a t i o n a l needs and research d e m a n d s of o t h e r specialists. Much of t h i s h a s been accomplished by active involvement in the development a n d support of e m e r g e n c y medicine residencies and the Liaison Residency E n d o r s e m e n t Committee, by participation on committees for board e s t a b l i s h m e n t and subsequent r e p r e s e n t a t i o n on the A m e r i c a n Board of Medical Specialties, and by continuing to encourage emergency physicians to become active in the UAJEM programs.
Joseph F. Waeckerle, MD (Dr. Waeckerle, program cochairman for the 1978 UA/EM Annual Meeting, is an assistant professor at the University of Missouri Kansas City School of ~Fledicine and vice chairman, Department of Emergency Health Services.)
Intracardiac Injections of Medication he article ~'Paramedic Use of Medications in PreSudden C a r d i a c Death" by A m e y et al (p 130) is a welcome addition to the d e a r t h of medical l i t e r a t u r e on this subject. The absence of such literature was noted by Skelton (Emergency Product News, 1978, p 64). A MEDLINE search revealed only one arti-
T hospital
UA/EM Annual MeeUng U A / E M c o n t i n u e s to c o n t r i b u t e s i g n i f i c a n t l y through its a n n u a l scientific meeting. This meeting is no longer concerned w i t h d e t e r m i n i n g the need for
7:4 (Apr) 1978
JACEP
170/65
cle on use of i n t r a c a r d i a c injections, based on anecdotal evidence only, w i t h o u t definitive research. Other authors in the same publication, Jeffries (p 65) and Gazz a n i g a (p 50), spoke to the issue b u t also noted lack of research on which to base definitive decisions. At a debate at the N a t i o n a l E M S P a r a m e d i c T r a i n i n g Symposium ( F e b r u a r y 1978) sponsored by H E W and ACEP ( a m o n g o t h e r s ) b e t w e e n R o g e r W h i t e , MD a n d M o h a m m e d Ahkter, MD, both addressed the lack of information. It is a m a z i n g t h a t such procedures can be used and even discussed by the A m e r i c a n H e a r t Association Advanced Cardiac Life Support course without good research h a v i n g been done. It was my clinical impression t h a t the s u r v i v a l rate of cardiac a r r e s t increased when i n t r a c a r d i a c injections, p a r t i c u l a r l y of epinephrine, were added to the a r m a m e n t a r i u m of the E M T - P a r a m e d i c s w o r k i n g in the K a n s a s City, Kansas, fire department. This was not at all well d o c u m e n t e d , a n d therefore, not reported. It is h e a r t e n i n g to see a long-held belief finally documented. It seems logical t h a t a large bolus of m e d i c a t i o n injected d i r e c t l y into the v e n t r i c l e will produce large concentrations in the myocardial musc u l a r t i s s u e . It m a y be a b s o r b e d t h r o u g h t h e endothelium but more r a p i d l y picked up by the coronary a r t e r i e s and carried into the cells themselves. An endotracheal injection m u s t be absorbed t h r o u g h the alv e o l a r m e m b r a n e . An i n t r a v e n o u s injection would c e r t a i n l y be diluted as it passes t h r o u g h the r i g h t heart, lungs, and left h e a r t before being picked up by coronary arteries. The frequently discussed chance of coronary art e r y l a c e r a t i o n t h e o r e t i c a l l y should be s m a l l if the s u b x y p h o i d a p p r o a c h is used and the possibility of p n e u m o t h o r a x a l m o s t n o n e x i s t e n t b e c a u s e the int r a c a r d i a c needle has an a i r t i g h t syringe a t t a c h e d to the end. There is the possibility of laceration of the lungs by the needle, b u t the incidence of this should be small. It would be much more l i k e l y to assume t h a t if a p n e u m o t h o r a x did develop while resuscitation was underway, it would be due to compression of the chest while the lungs were being expanded, thus r u p t u r i n g a p u l m o n a r y bleb. A m e y et al have d e m o n s t r a t e d t h a t i n t r a c a r d i a c injections can be s i m p l y a c c o m p l i s h e d w i t h only a s l i g h t increase in the complication r a t e and only a slightly prolonged hospital and critical care unit stay. A proponent of i n t r a c a r d i a c e p i n e p h r i n e would like to t h i n k t h a t this increased critical care unit and hosp i t a l i z a t i o n period was secondary to the more severe cardiac disease of those p a t i e n t s r e q u i r i n g intracardiac epinephrine. Unfortunately, the authors have not shown this. N e i t h e r have they shown t h a t intracardiac epinephrine was beneficial. They do not indicate, for example, if it was the i n t r a c a r d i a c medication t h a t resuscitated the patients, as opposed to subsequent int r a v e n o u s m e d i c a t i o n s . N o r do t h e y i n d i c a t e t h e n u m b e r of survivors vs nonsurvivors in either the int r a c a r d i a c medication group or the intravenous medication group. The fact t h a t it required, on the average, twice as m a n y defibrillations to produce survivors from the int r a c a r d i a c group vs the i n t r a v e n o u s group could indicare t h a t the i n t r a c a r d i a c group had the most severe cardiac pathology. It could also be construed, however, t h a t the injections of i n t r a c a r d i a c epinephrine made t h e p a t i e n t s m o r e r e f r a c t o r y to r e s u s c i t a t i o n a n d therefore, was d e t r i m e n t a l r a t h e r t h a n beneficial. If
66/171
this k i n d of information is a v a i l a b l e to the authors, it would be very helpful to see it in print. The authors have d e m o n s t r a t e d t h a t intracardiac medications c a n be given in the p r e h o s p i t a l period and t h a t victims survive. They have not d e m o n s t r a t e d that the complication rate was less or t h a t the intracardiac route was more effective t h a n the i n t r a v e n o u s route, or if, in fact, time had been t a k e n to e s t a b l i s h an int r a v e n o u s route, it would have not been as effective or perhaps more effective t h a n i n t r a c a r d i a c injection. The authors are to be c o n g r a t u l a t e d on t a k i n g the first step t o w a r d a n s w e r i n g the question of intracardiac medications. The next step is a prospective study c o m p a r i n g the two methods to identify, if one has any superiority over the other either in prolonged survival or reduced complications. There have been enough articles in the l i t e r a t u r e like t h a t of Schechter 1 w h i c h d a m n b u t g i v e no o b j e c t i v e e v i d e n c e to b a c k up prejudices.
Norman E. McSwain, Jr, MD, FACS (Dr. McSwain is associate professor of surgery at Tulane University School of Medicine, New Orleans, Louisiana.) REFERENCES 1. Schecter DC: Transthoracic epinephrine injection in heart resuscitation is dangerous. JAMA 234:1184, 1975.
Basic Decisions in Emergency Department Cases r. Wolcott's article, "Basic Decisions in Emergency D e p a r t m e n t Cases" (p 149) points out t h a t t h e e m e r g e n c y p h y s i c i a n s c o n t i n u a l l y face undiffere n t i a t e d problems in need of basic decisions. First, is resuscitation necessary? - - a decision u s u a l l y easily decided by the emergency d e p a r t m e n t staff. Second, is f u r t h e r differentiation of the p r o b l e m necessary prior to definitive e m e r g e n c y d e p a r t m e n t disposition? If so, to w h a t degree must this be carried out? These l a t t e r decisions often pose more difficulty for the emergency p h y s i c i a n . F i n a l l y , w h a t d i s p o s i t i o n is w a r r a n t e d based upon the above decisions? Difficulty w i t h disposition is u s u a l l y inversely proportional to the degree of the problem differentiation. A l g o r i t h m s m a y be useful in c e r t a i n aspects of this d e c i s i o n - m a k i n g process. However, t r u e b i n a r y decisions are not always possible, and, as a m a t t e r of fact, are u s u a l l y not feasible beyond the first or second decision point. For example, p a t i e n t s w i t h undiffere n t i a t e d a b d o m i n a l pain m a y be d i v i d e d by an alg o r i t h m i c a p p r o a c h i n t o t h o s e w i t h or w i t h o u t peritonitis. However, it is u s u a l l y not possible to decide w h e t h e r or not to a d m i t a p a t i e n t when the problem is differentiated only to t h a t point. P e r h a p s the r e a l value of the algorithmic approach is to m a k e the e m e r g e n c y p h y s i c i a n focus on t h e c r i t i c a l decision point from which a yes, no, or m a y b e answer is necessary. Thus, the physician faced w i t h a b d o m i n a l pain focuses on the presence or absence of p e r i t o n e a l irritation and delays acquisition~of porphyrin levels t h r o u g h several decision points. The more difficult aspect of the algorithmic approach, not addressed in the c u r r e n t article, r e l a t e s to
D
JACEP
7:4 (Apr) 1978
e m e r g e n c y medicine b u t r a t h e r with deciding how all s p e c i a l i s t s a n d e m e r g e n c y p h y s i c i a n s can a d v a n c e emergency medicine t h r o u g h academic and research programs. We are no longer h a m p e r e d by the lack of recognition, we are no longer bound to dean's panels, we are no longer limited by small n u m b e r s of scientific p a p e r s c o n c e r n i n g p a r t i a l a r e a s of e m e r g e n c y medicine or l e n g t h y discussions of '~roles" in emergency medicine. Now, UA/EM is able to p r e s e n t a more v a r i e d a n d a d v a n c e d s c i e n t i f i c p r o g r a m . Instead of a dean's panel, UA/EM will present a stateof-the-art discussion of b u r n care with recognized aut h o r i t i e s participating. I n s t e a d of limited discussion of a g r e a t n u m b e r of scientific papers, more time will be s p e n t on scientific p a p e r s or groups of papers t h a t d e m o n s t r a t e our c o m m i t m e n t to q u a l i t y research and academics. In order to continue our support of research and a c a d e m i c a d v a n c e m e n t , t h e U A / E M will p r e s e n t a combined workshop with the Society for Teachers of E m e r g e n c y Medicine. The t h e m e of this workshop is, quite simply and appropriately, the goal of both org a n i z a t i o n s , ie, excellence in e m e r g e n c y m e d i c i n e t h r o u g h q u a l i t y research and academic advancement. The two o r g a n i z a t i o n s will provide an e d u c a t i o n a l forum t h a t will include sessions on research, project design, funding, statistics, e v a l u a t i o n of research, and scientific writing. This combined workshop is a progression from the old format of two days for UA/EM and one d a y for STEM w i t h m i n i m a l crossover. This p r o g r a m will g r e a t l y benefit all residents as well as those of us who have concluded our formal t r a i n i n g but continue to l e a r n and p a r t i c i p a t e in academics a n d research. This is an i n v i t a t i o n from UA/EM and STEM to each of you to come to San Francisco in May. We are offering a b r o a d e r a n d more scientific p r o g r a m designed to accomplish our goal of excellence in emergency medicine t h r o u g h sound academic programs and intelligent, t h o u g h t - p r o v o k i n g research. We are reinforcing the need for i n p u t by t r a d i t i o n a l specialists in the developing specialty of e m e r g e n c y medicine. Finally, we are h a v i n g the m e e t i n g in San Francisco, California, complete with sun, scenery and sea. How can you lose?
n M a r c h 1970, 138 p h y s i c i a n s from 96 m e d i c a l I schools t h r o u g h o u t the U n i t e d States and C a n a d a met to discuss e m e r g e n c y d e p a r t m e n t a d m i n i s t r a t i v e problems, t r a n s p o r t a t i o n a n d communication systems, regional o r g a n i z a t i o n of e m e r g e n c y medical services and problems in the academic area. From this enthusiastic m e e t i n g s p r u n g the U n i v e r s i t y Association for Emergency Medical Services. (In 1977 its name was c h a n g e d to U n i v e r s i t y A s s o c i a t i o n for E m e r g e n c y Medicine [UA/EM].) This organization was conceived and developed p r i m a r i l y by faculty who directed univ e r s i t y e m e r g e n c y d e p a r t m e n t s . T h e o b j e c t i v e s of UA/EM were clearly e s t a b l i s h e d in i t s constitution, in essence s t a t i n g t h a t i m p r o v e m e n t s in the q u a l i t y and delivery of e m e r g e n c y medical care would be p u r s u e d by collecting, a n a l y z i n g a n d d i s s e m i n a t i n g information r e g a r d i n g e m e r g e n c y medical system problems. A major focus of U A / E M was to provide an a n n u a l scientific forum to discuss problems such as the participation of academic physicians in emergency medical systems, m a n a g e m e n t of e m e r g e n c y d e p a r t m e n t s , imp l e m e n t a t i o n of e m e r g e n c y medical service s y s t e m s legislation, and academic recognition. Prior to 1973, papers and topics of discussion at the a n n u a l scientific m e e t i n g were centered a r o u n d the surgeon and surgical problems in the e m e r g e n c y d e p a r t m e n t w i t h little m e n t i o n of the need for developing s p e c i a l t y t r a i n i n g in e m e r g e n c y medicine. However, d u r i n g his p r e s i d e n t i a l a d d r e s s in 1973, Robert Rutherford, MD, a s k e d U A / E M m e m b e r s to consider the question of who should r u n emergency departments. This provoked careful consideration of e m e r g e n c y m e d i c i n e d u r i n g t h e r e m a i n d e r of t h e meeting. At t h e 1974 a n n u a l m e e t i n g in Dallas, t h e UA/EMS Executive Council u n a n i m o u s l y approved a resolution s t a t i n g t h a t e m e r g e n c y medicine should be recognized as a specialty and t h a t residency t r a i n i n g programs were essential. Subsequently, the membership voted in favor of this position. Consequently, the tone of the A n n u a l M e e t i n g changed in the direction of t r e a t i n g e m e r g e n c y medicine as an academic e n t i t y and the e m e r g e n c y physician ,as a reality. Since then, UA/EM h a s continued to n u r t u r e and develop e m e r g e n c y medicine as a specialty while considering the e d u c a t i o n a l needs and research d e m a n d s of o t h e r specialists. Much of t h i s h a s been accomplished by active involvement in the development a n d support of e m e r g e n c y medicine residencies and the Liaison Residency E n d o r s e m e n t Committee, by participation on committees for board e s t a b l i s h m e n t and subsequent r e p r e s e n t a t i o n on the A m e r i c a n Board of Medical Specialties, and by continuing to encourage emergency physicians to become active in the UAJEM programs.
Joseph F. Waeckerle, MD (Dr. Waeckerle, program cochairman for the 1978 UA/EM Annual Meeting, is an assistant professor at the University of Missouri Kansas City School of ~Fledicine and vice chairman, Department of Emergency Health Services.)
Intracardiac Injections of Medication he article ~'Paramedic Use of Medications in PreSudden C a r d i a c Death" by A m e y et al (p 130) is a welcome addition to the d e a r t h of medical l i t e r a t u r e on this subject. The absence of such literature was noted by Skelton (Emergency Product News, 1978, p 64). A MEDLINE search revealed only one arti-
T hospital
UA/EM Annual MeeUng U A / E M c o n t i n u e s to c o n t r i b u t e s i g n i f i c a n t l y through its a n n u a l scientific meeting. This meeting is no longer concerned w i t h d e t e r m i n i n g the need for
7:4 (Apr) 1978
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cle on use of i n t r a c a r d i a c injections, based on anecdotal evidence only, w i t h o u t definitive research. Other authors in the same publication, Jeffries (p 65) and Gazz a n i g a (p 50), spoke to the issue b u t also noted lack of research on which to base definitive decisions. At a debate at the N a t i o n a l E M S P a r a m e d i c T r a i n i n g Symposium ( F e b r u a r y 1978) sponsored by H E W and ACEP ( a m o n g o t h e r s ) b e t w e e n R o g e r W h i t e , MD a n d M o h a m m e d Ahkter, MD, both addressed the lack of information. It is a m a z i n g t h a t such procedures can be used and even discussed by the A m e r i c a n H e a r t Association Advanced Cardiac Life Support course without good research h a v i n g been done. It was my clinical impression t h a t the s u r v i v a l rate of cardiac a r r e s t increased when i n t r a c a r d i a c injections, p a r t i c u l a r l y of epinephrine, were added to the a r m a m e n t a r i u m of the E M T - P a r a m e d i c s w o r k i n g in the K a n s a s City, Kansas, fire department. This was not at all well d o c u m e n t e d , a n d therefore, not reported. It is h e a r t e n i n g to see a long-held belief finally documented. It seems logical t h a t a large bolus of m e d i c a t i o n injected d i r e c t l y into the v e n t r i c l e will produce large concentrations in the myocardial musc u l a r t i s s u e . It m a y be a b s o r b e d t h r o u g h t h e endothelium but more r a p i d l y picked up by the coronary a r t e r i e s and carried into the cells themselves. An endotracheal injection m u s t be absorbed t h r o u g h the alv e o l a r m e m b r a n e . An i n t r a v e n o u s injection would c e r t a i n l y be diluted as it passes t h r o u g h the r i g h t heart, lungs, and left h e a r t before being picked up by coronary arteries. The frequently discussed chance of coronary art e r y l a c e r a t i o n t h e o r e t i c a l l y should be s m a l l if the s u b x y p h o i d a p p r o a c h is used and the possibility of p n e u m o t h o r a x a l m o s t n o n e x i s t e n t b e c a u s e the int r a c a r d i a c needle has an a i r t i g h t syringe a t t a c h e d to the end. There is the possibility of laceration of the lungs by the needle, b u t the incidence of this should be small. It would be much more l i k e l y to assume t h a t if a p n e u m o t h o r a x did develop while resuscitation was underway, it would be due to compression of the chest while the lungs were being expanded, thus r u p t u r i n g a p u l m o n a r y bleb. A m e y et al have d e m o n s t r a t e d t h a t i n t r a c a r d i a c injections can be s i m p l y a c c o m p l i s h e d w i t h only a s l i g h t increase in the complication r a t e and only a slightly prolonged hospital and critical care unit stay. A proponent of i n t r a c a r d i a c e p i n e p h r i n e would like to t h i n k t h a t this increased critical care unit and hosp i t a l i z a t i o n period was secondary to the more severe cardiac disease of those p a t i e n t s r e q u i r i n g intracardiac epinephrine. Unfortunately, the authors have not shown this. N e i t h e r have they shown t h a t intracardiac epinephrine was beneficial. They do not indicate, for example, if it was the i n t r a c a r d i a c medication t h a t resuscitated the patients, as opposed to subsequent int r a v e n o u s m e d i c a t i o n s . N o r do t h e y i n d i c a t e t h e n u m b e r of survivors vs nonsurvivors in either the int r a c a r d i a c medication group or the intravenous medication group. The fact t h a t it required, on the average, twice as m a n y defibrillations to produce survivors from the int r a c a r d i a c group vs the i n t r a v e n o u s group could indicare t h a t the i n t r a c a r d i a c group had the most severe cardiac pathology. It could also be construed, however, t h a t the injections of i n t r a c a r d i a c epinephrine made t h e p a t i e n t s m o r e r e f r a c t o r y to r e s u s c i t a t i o n a n d therefore, was d e t r i m e n t a l r a t h e r t h a n beneficial. If
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this k i n d of information is a v a i l a b l e to the authors, it would be very helpful to see it in print. The authors have d e m o n s t r a t e d t h a t intracardiac medications c a n be given in the p r e h o s p i t a l period and t h a t victims survive. They have not d e m o n s t r a t e d that the complication rate was less or t h a t the intracardiac route was more effective t h a n the i n t r a v e n o u s route, or if, in fact, time had been t a k e n to e s t a b l i s h an int r a v e n o u s route, it would have not been as effective or perhaps more effective t h a n i n t r a c a r d i a c injection. The authors are to be c o n g r a t u l a t e d on t a k i n g the first step t o w a r d a n s w e r i n g the question of intracardiac medications. The next step is a prospective study c o m p a r i n g the two methods to identify, if one has any superiority over the other either in prolonged survival or reduced complications. There have been enough articles in the l i t e r a t u r e like t h a t of Schechter 1 w h i c h d a m n b u t g i v e no o b j e c t i v e e v i d e n c e to b a c k up prejudices.
Norman E. McSwain, Jr, MD, FACS (Dr. McSwain is associate professor of surgery at Tulane University School of Medicine, New Orleans, Louisiana.) REFERENCES 1. Schecter DC: Transthoracic epinephrine injection in heart resuscitation is dangerous. JAMA 234:1184, 1975.
Basic Decisions in Emergency Department Cases r. Wolcott's article, "Basic Decisions in Emergency D e p a r t m e n t Cases" (p 149) points out t h a t t h e e m e r g e n c y p h y s i c i a n s c o n t i n u a l l y face undiffere n t i a t e d problems in need of basic decisions. First, is resuscitation necessary? - - a decision u s u a l l y easily decided by the emergency d e p a r t m e n t staff. Second, is f u r t h e r differentiation of the p r o b l e m necessary prior to definitive e m e r g e n c y d e p a r t m e n t disposition? If so, to w h a t degree must this be carried out? These l a t t e r decisions often pose more difficulty for the emergency p h y s i c i a n . F i n a l l y , w h a t d i s p o s i t i o n is w a r r a n t e d based upon the above decisions? Difficulty w i t h disposition is u s u a l l y inversely proportional to the degree of the problem differentiation. A l g o r i t h m s m a y be useful in c e r t a i n aspects of this d e c i s i o n - m a k i n g process. However, t r u e b i n a r y decisions are not always possible, and, as a m a t t e r of fact, are u s u a l l y not feasible beyond the first or second decision point. For example, p a t i e n t s w i t h undiffere n t i a t e d a b d o m i n a l pain m a y be d i v i d e d by an alg o r i t h m i c a p p r o a c h i n t o t h o s e w i t h or w i t h o u t peritonitis. However, it is u s u a l l y not possible to decide w h e t h e r or not to a d m i t a p a t i e n t when the problem is differentiated only to t h a t point. P e r h a p s the r e a l value of the algorithmic approach is to m a k e the e m e r g e n c y p h y s i c i a n focus on t h e c r i t i c a l decision point from which a yes, no, or m a y b e answer is necessary. Thus, the physician faced w i t h a b d o m i n a l pain focuses on the presence or absence of p e r i t o n e a l irritation and delays acquisition~of porphyrin levels t h r o u g h several decision points. The more difficult aspect of the algorithmic approach, not addressed in the c u r r e n t article, r e l a t e s to
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JACEP
7:4 (Apr) 1978
