LETTERS TO THE EDITOR ing. The material can be modified depending on instrument and medication preference and availability. The intubation and umbilical catheterization materials may be individually wrapped in plastic and gas-sterilized with ethylene oxide. Sterile gloves and 5 and 3.5 French radiopaque catheters are enclosed in the umbilical catheterization unit. An inventory of the materials comprising each tray is available upon request. Whereas this tray has been used primarily in the delivery room, it is also adaptable for use in the nursery and neonatal intensive care unit. AIthough in our unit the three sections of the tray (intubation, catheterization, and medication)are utilized separately, others might find it more convenient to package the three sections as a single tray. We wrap the trays in clear plastic prior to gas sterilization. With transparent wrapping, it is possible to locate each component of the tray, even before the seal is broken. We believe that the development of this tray has shortened the time necessary to set up resuscitative equipment, has improved personnel organization, and has heightened efficiency of resuscitation. We also use this tray as a teaching tool in the orientation of physicians, nurses, and paraprofessionals to neonatal resuscitation. Finally, the tray has reduced the problem of missing equipment and inadequate restocking of supplies for neonatal resuscitation. At the completion of each resuscitation, the respiratory therapist cleans each piece of nondisposable equipment, restocks all disposable items, and places them in their respective cut-outs according to a diagram before the tray is wrapped for gas sterilization. Ronald N. Goldberg, MD Assistant Prokssor of Pediatrics
Arnold C. C. Platzker, MD Associate Professor of Clinical Pediatrics Department of Pediatrirs University of Southern Glifornia School of Medicine Children's Hospital of Los Angeles Los Angeles, California W33 Reprint requeststo Dr.cOldber& Department of Pediatrics (R-131), University of Miami
School of Medicine, Po Box 016960, Miami, FL 33101.
Medical Student views of Anesthesiology To the Editor: The article by Levin, Friedman, and Scott, "Anesthesiology and the Graduating Medical Student A National Survey," (Anesth Analg 58:201-207, 1979) is challenging and impartial. The authors are to be congratulated. It makes the point that "graduating medical students see anesthesiology's lack of relevance to primary care as a major reason for not exploring a career in anesthesiology." The authors contend that this opinion cannot be changed. I suggest that "lack of relevance to primary care" can and should be manipulated in the following manner whenever teaching students: (A) Admit that anesthesiology does indeed lack relevance to primary care. (B) Explain why in the following way: 1. Much of medicine is not primary care. And it may be said, perhaps flippantly, that much of primary care is irrelevant to the individual's needs or complaints. 2. Anesthesiology provides an array of pharmacologic techniques which though not often used in primary care situations are of major value both to patients during surgery and to patients who are critically ill. 3. Anesthesiology has become mechanized to a high degree. Anesthesiologists should be happy that their work is done by machines in accordance with the ideal of supervisory automation. Boredom may ensue, but automation is a fact of life. One should be grateful that chemistry, engineering, and research have helped patients and physicians as much as they have. Besides, there are still many opportunities in clinical anesthesia for handing out equally valuable smiles and kind words. 4. Primary care situations often result in a team effort to resolve serious problems. 5. Medical school graduates who are psychologically equipped for the type of work represented by anesthesiology should not feel inferior, bored or degraded. As the French say: "I1 n'y a pas de sot mitier, il n'y a que de
sottes gens." (There are no silly occupations, only silly people.) John Caron, MD Meridian Regional Hospital Highway 39 North Meridian, Mississippi 39301
lntravascular Migration of Epidural Catheters To the Editor: We do not feel that the recommendation of Ravindran, Albrecht, and McKay (Anesth Analg 58:252-253, 1w9) that the injection of a small volume test dose of local anesthetic through an epidural catheter is sufficient to detect intravenous cannulation and to prevent the resulting and dangerous central nervous system and cardiovascular toxicity. Two years ago on this obstetrical unit a 17year-old healthy parturient experienced a severe convulsion under circumstances almost identical to those reported by Ravindran et al. The main difference was that the convulsions were followed immediately by ventricular tachycardia and then fibrillation. Defibrillation was necessary to restore normal rhythm. The following precautions to avoid future recurrences were initiated. First, we inject the amount of bupivacaine for cesarean section or tubal ligation only through the epidural needle. If an epidural catheter has been previously placed for control of pain during labor it is removed and replaced with an epidural needle. Second, we inject 2 ml of local anesthetic through the epidural needle, wait two circulation times, inject a further 5 ml slowly, wait two circulation times, and repeat until the total volume is administered. Third, we maintain conversation with the patient by a series of questions. Change in the patient's sensorium is a valuable indication of inadvertent intravenous administration of local anesthetic. Fourth, we never perform epidural anesthesia for cesarean section or tubal ligation without attaching an EKG before the injection of the local anesthetic. Fifth, we replaced all 20-gauge epidural catheters with 19gauge. To obtain perineal anesthesia ANESTHESIA AND ANALGESIA V d 58, NO 5, Sept-Oct 1979
443
Arnold C. C. Platzker, MD Associate Professor of Clinical Pediatrics Department of Pediatrirs University of Southern Glifornia School of Medicine Children's Hospital of Los Angeles Los Angeles, California W33 Reprint requeststo Dr.cOldber& Department of Pediatrics (R-131), University of Miami
School of Medicine, Po Box 016960, Miami, FL 33101.
Medical Student views of Anesthesiology To the Editor: The article by Levin, Friedman, and Scott, "Anesthesiology and the Graduating Medical Student A National Survey," (Anesth Analg 58:201-207, 1979) is challenging and impartial. The authors are to be congratulated. It makes the point that "graduating medical students see anesthesiology's lack of relevance to primary care as a major reason for not exploring a career in anesthesiology." The authors contend that this opinion cannot be changed. I suggest that "lack of relevance to primary care" can and should be manipulated in the following manner whenever teaching students: (A) Admit that anesthesiology does indeed lack relevance to primary care. (B) Explain why in the following way: 1. Much of medicine is not primary care. And it may be said, perhaps flippantly, that much of primary care is irrelevant to the individual's needs or complaints. 2. Anesthesiology provides an array of pharmacologic techniques which though not often used in primary care situations are of major value both to patients during surgery and to patients who are critically ill. 3. Anesthesiology has become mechanized to a high degree. Anesthesiologists should be happy that their work is done by machines in accordance with the ideal of supervisory automation. Boredom may ensue, but automation is a fact of life. One should be grateful that chemistry, engineering, and research have helped patients and physicians as much as they have. Besides, there are still many opportunities in clinical anesthesia for handing out equally valuable smiles and kind words. 4. Primary care situations often result in a team effort to resolve serious problems. 5. Medical school graduates who are psychologically equipped for the type of work represented by anesthesiology should not feel inferior, bored or degraded. As the French say: "I1 n'y a pas de sot mitier, il n'y a que de
sottes gens." (There are no silly occupations, only silly people.) John Caron, MD Meridian Regional Hospital Highway 39 North Meridian, Mississippi 39301
lntravascular Migration of Epidural Catheters To the Editor: We do not feel that the recommendation of Ravindran, Albrecht, and McKay (Anesth Analg 58:252-253, 1w9) that the injection of a small volume test dose of local anesthetic through an epidural catheter is sufficient to detect intravenous cannulation and to prevent the resulting and dangerous central nervous system and cardiovascular toxicity. Two years ago on this obstetrical unit a 17year-old healthy parturient experienced a severe convulsion under circumstances almost identical to those reported by Ravindran et al. The main difference was that the convulsions were followed immediately by ventricular tachycardia and then fibrillation. Defibrillation was necessary to restore normal rhythm. The following precautions to avoid future recurrences were initiated. First, we inject the amount of bupivacaine for cesarean section or tubal ligation only through the epidural needle. If an epidural catheter has been previously placed for control of pain during labor it is removed and replaced with an epidural needle. Second, we inject 2 ml of local anesthetic through the epidural needle, wait two circulation times, inject a further 5 ml slowly, wait two circulation times, and repeat until the total volume is administered. Third, we maintain conversation with the patient by a series of questions. Change in the patient's sensorium is a valuable indication of inadvertent intravenous administration of local anesthetic. Fourth, we never perform epidural anesthesia for cesarean section or tubal ligation without attaching an EKG before the injection of the local anesthetic. Fifth, we replaced all 20-gauge epidural catheters with 19gauge. To obtain perineal anesthesia ANESTHESIA AND ANALGESIA V d 58, NO 5, Sept-Oct 1979
443
