care provider is beneficial or cannot safely be delayed until arrival to the hospital." If an i n t e n t of the authors was to evaluate the safety and benefit of prehospital pharmacologic therapy, t h e y should have reviewed studies that compared one drug versus no t r e a t m e n t u n t i l ED arrival. T h i s w o u l d h a v e m o r e precisely answered the question instead of using studies comparing one t h e r a p e u t i c i n t e r v e n t i o n w i t h another. T h e trial of b r e t y l i u m for cardiac arrest ] was n o t a prehospital study, so conclusions about its use in the field m a y not be valid. Studies that are i n t e n d e d to d e t e r m i n e t h e safety and benefit of p r e h o s p i t a l t h e r a p y s h o u l d be l i m i t e d to the prehospital setting, where such factors as the l i m i t a t i o n s in paramedic's knowledge base and scope of practice, the prehospital environment, and earlier adm i n i s t r a t i o n of pharmacologic therapy m a y affect the results. R e m o v i n g the aforementioned studies from the review, five drugs r e m a i n : d e x a m e t h a s o n e for p u l s e l e s s idiov e n t r i c u l a r r h y t h m (PIVR}, c a l c i u m for e l e c t r o m e c h a n i c a l dissociation and asystole, atropine for refractory asystole or PIVR, lidocaine prophylaxis for suspected m y o c a r d i a l infarction, and streptokinase for acute m y o c a r d i a l infarction. The first two drugs were not r e c o m m e n d e d in the prehospital or ED m a n a g e m e n t of v i c t i m s of cardiac arrest at the t i m e the r e v i e w was s u b m i t t e d , z O n l y l i d o c a i n e p r o p h y l a x i s of s u s p e c t e d m y o c a r d i a l i n f a r c t i o n and atropine for refractory asystole or PIVR r e m a i n as standards of care,
If t h e a u t h o r s w i s h e d to r e v i e w c u r r e n t p r e h o s p i t a l p h a r m a c o l o g i c therapy, o n l y the s t u d i e s of a t r o p i n e for a s y s t o l e or PIVR, 3 l i d o c a i n e p r o p h y l a x i s , 4 a n d s t r e p t o k i n a s e for a c u t e m y o c a r d i a l i n f a r c t i o n 5 s h o u l d h a v e been included. As Shuster and Chong correctly p o i n t out, these studies are l i m i t e d by their small s a m p l e sizes. As a result, these studies could not rule out the p o s s i b i l i t y of an i m p r o v e d outcome. W h i l e t h e a u t h o r s ' s u m m a r y s t a t e m e n t regarding the lack of proven efficacy of prehospital pharmacologic therapy is correct, it should be judged by the data that support it - very little in this case. T h e p a u c i t y of prehospital r e s e a r c h on drug effectiveness does n o t p e r m i t m a k i n g any valid conclusions.
Stephen E Jones, MD Director, Prehospital Care Los Angeles County/USC Medical Center
Franklin D Pratt, MD Medical Director, Fire Department County of Los Angeles 1. Nowak RM, Bodnar TJ, Dronen S, et al: Bretylium tosylate as initial treatment for cardiopulmonary arrest: Randomized comparison with placebo. Ann ErnergMed 1981;10:404-407. 2. Standards and guidelines for cardiopuhrronary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986;255:2905-2984. 3. Con GA, Clinton JE, Ruiz E: Use of atropine for bradyasystolic prehospital cardiac arrest. Ann EmergMed 1981;10:462-467. 4. Hargarten KM, Aprahamian C, Stueven HA, et al: Prophylactic lidocaine in the prehospital patient with chest pain of suspected cardiac origin. Arm EmergMed 1986;15:881-885. 5. villemant D, Barriot P, Riou B, et al: Achievement of thrombolysis at home in cases of acute myocardial infarction (letter). Lancet 1987;t: 228-229.
In Reply: Drs Jones and Pratt are quite correct. Studies to evaluate the safety and benefit of prehospital pharmacologic therapy should compare patients w h o receive prehospital drug therapy w i t h p a t i e n t s who receive no drugs u n t i l they arrive at the e m e r g e n c y department. The fact is that there are so few such studies that directly address the issue t h a t we expanded our analysis in order to assess even indirect evidence of the efficacy of prehospital pharmacologic therapy. We too concluded that there is no published scientific evidence on w h i c h to base an opinion about prehospital pharmacologic intervention. We are c u r r e n t l y u n d e r t a k i n g a three-year prospective trial to c o m p a r e o u t c o m e s in p a t i e n t s w i t h c h e s t p a i n w h o are e i t h e r g i v e n p h a r m a c o l o g i c t h e r a p y by paramedics or transported directly to the ED by BLS crews. We are able to e t h i c a l l y compare these two groups because in H a m i l t o n we have only enough ALS crews to reach 30% of Code 4 emergencies. We e n c o u r a g e o t h e r efforts to o b j e c t i v e l y assess t h e value of prehospital interventions.
Michael Shuster, MD, FRCP(C) Director, Paramedic Program John Chong, MD, FRCP(C) Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, Ontario, Canada
Tympanic Membrane Thermometers To the Editor: I read the a r t i c l e e n t i t l e d " E v a l u a t i o n of a T y m p a n i c M e m b r a n e T h e r m o m e t e r in an O u t p a t i e n t Clinical Sett i n g " [ S e p t e m b e r 1989;18:1004-1006] w i t h c o n s i d e r a b l e interest. However, the conclusions of the study are subject to c r i t i c i s m because of inadequate m e t h o d o l o g i c a l reporting of errors. First, a glass-mercury t h e r m o m e t e r requires more than t h e t h r e e to five m i n u t e s for e q u i l i b r a t i o n t h a t D r Ros 19:3 March 1990
used in his study.l, 2 Various reports of duration of therm o m e t e r p l a c e m e n t u n t i l achieving o p t i m a l t e m p e r a t u r e conclude that eight to ten m i n u t e s is best. 3 Children and afebrile adults require the longest equilibration times.4, 5 Secondly, because the p h y s i c i a n obtaining the t y m p a n i c t e m p e r a t u r e was reportedly n o t blinded to the results of oral or rectal temperature, the possibility of introducing bias in evaluating t e m p e r a t u r e correlation is raised.
Annals of Emergency Medicine
341/185
CORRESPONDENCE
N o m e n t i o n is m a d e of calibration of either t h e r m o m e ter. N o m e n t i o n of the m o d e of the First T e m p ® during t e m p e r a t u r e m e a s u r e m e n t is r e p o r t e d . B e c a u s e F i r s t T e m p ® reports t e m p e r a t u r e values as "core," "rectal," or "oral" equivalents, considerable variation in t e m p e r a t u r e results m a y have resulted in the relatively poor correlation observed. C o m b i n i n g the r e s u l t s of oral and r e c t a l t e m p e r a t u r e to derive a single regression line, w i t h o u t correcting for differences b e t w e e n oral and rectal temperature, is inappropriate. Finally, no m e n t i o n is m a d e of excluding p a t i e n t s w i t h factors k n o w n to spuriously influence oral t e m p e r a t u r e m e a s u r e m e n t , such as t a c h y p n e a or h o t and cold liquid ingestion.6, 7 U n l e s s clarification of these issues is possible, I recomm e n d caution in accepting the conclusions of this study. Thomas E Terndrup, M D Departments of Critical Care & Emergency Medicine and Pediatrics S U N Y Health Science Center Syracuse, N e w York
l, Nichols GA, Fielding JJ, McKevitt RK, et al: Taking oral temperatures of febrile patients. Nurs Res 1969;18:448-450. 2. Nichols GA, Kucha DH: Oral measurements. Am J Nuts 1972;72: 1091-1093. 3. Nichols GA, Kulvi RL, Life HR, et al: Measuring oral and rectal temperatures of febrile children. Nurs Res 1972;21:261-264. 4. Nichols GA, Ruskin MMt Glor BAK, et al: Oral, axillary, and rectal temperature determinations and relationships. Nurs Res 1966~15:307-310. 5. Baker NC, Bidwell-Cerone S, Gaze N, et al: The effect of type of thermometer and length of time inserted on oral temperature measurements of afebrile subjects. Nurs Res 1984;33:109-111.
6. Tanberg D, Sklar D: Effect of tachypnea on the estimation of body temperature by an oral thermometer. N ErzglJ Med 1983;308-945-946. 7. Temdrup TE, Allegra JR, Kealy JA: A comparison of oral, rectal and tympanic membrane-derivedtemperature changes after ingestion of liquids and smoking. Am ] Emerg Med 1989;7:150-154.
in Reply: I t h a n k Dr Terndrup for his c o m m e n t s and questions. The glass-mercury t h e r m o m e t e r m e a s u r e m e n t s were obtained by holding the t h e r m o m e t e r in the orifice u n t i l stabilization of the reading - a process u s u a l l y t a k i n g app r o x i m a t e l y three to five m i n u t e s (no a t t e m p t s were m a d e to record the exact duration of this procedure). The physician obtaining the t y m p a n i c m e m b r a n e temperature was blinded to the results of oral and rectal meas u r e m e n t s that were obtained b y the nursing personnel. The t y m p a n i c m e m b r a n e t h e r m o m e t e r was always used in the appropriate m o d e - ie, if rectal t e m p e r a t u r e was normal, the device was in the rectal mode, etc. T h e results of oral and rectal t e m p e r a t u r e s were combined because of the relatively s m a l l n u m b e r of s t u d y subjects in each group and the low l i k e l i h o o d of the n e w device r e p l a c i n g the m e a s u r e m e n t of rectal and oral t e m peratures only. Finally, we have a policy of n o t allowing our p a t i e n t s to ingest liquids prior to being evaluated, and tachypneic patients do not have oral t e m p e r a t u r e m e a s u r e m e n t s . Simon P R o s , MD Pediatric Emergency Medicine Loyola University Stritch School of Medicine Maywood, Illinois
Saliva Teststrips for Alcohol Testing To the Editor: We read w i t h i n t e r e s t the a r t i c l e by S c h w a r t z et al, "Evaluation of C o l o r i m e t r i c D i p s t i c k Test to D e t e c t Alcohol in Saliva: A Pilot Study" [September 1989;18: 1001-1003]. U s i n g a n o t h e r c o m m e r c i a l l y available salivary alcohol dipstick that was referred to in their article, the AlcoScan ~ (Lifescan, Inc), we also found c o l o r i m e t r i c s c r e e n i n g a useful test for a l c o h o l i n t o x i c a t i o n in the e m e r g e n c y department. The AlcoScan ~ saliva teststrip for salivary alcohol also uses a color change from no color, to light blue, to dark purple corresponding w i t h semiquantitative i n c r e m e n t s of 0, 0.01 g%, 0.05 g%, and 0.1 g% b l o o d a l c o h o l l e v e l s . We w e r e o r i g i n a l l y i n t e r e s t e d in using the teststrip to screen psychiatric patients requiring medical clearance w i t h a blood alcohol level of less than 0.1 g%, but our s t u d y group also included patients w i t h t r a u m a and m e d i c a l l y related conditions. F r o m January to M a r c h 1988, 38 patients were tested a n d t h e r e s u l t s of t h e t e s t s t r i p c o m p a r e d to a s i m u l taneous blood alcohol run on the hospital T D x REA Eth186/342
anol A s s a y (Abbot Laboratories). O u r results were n o t reported due to the s t a t i s t i c a l l y s m a l l sample size and subsequent lack of supplies by the manufacturer. We found that the teststrip (AS) was very good at separating patients w i t h a blood alcohol of m o r e than 0.1 g% from those w i t h levels less than 0.05 g%. Blood alcohol levels ranged from 0 to 0.43 g%. Seven s p e c i m e n s were 0, all of w h i c h correlated w i t h the teststrip, except one that was read at 0.01 g% by AS. All 11 samples less t h a n 0.05 g% blood alcohol were confirmed by the teststrip to be in the same range; all 26 specimens found to be greater than or equal to 0.1 g% by blood alcohol were confirmed by the teststrip, except for three samples that were lower as a result of saliva sampling error (no saliva or d i l u t i o n from water ingested prior to sampling). One test s a m p l e correlated poorly for an u n k n o w n reason - BA 0.32, AS m o r e t h a n 0.05 g%. Therefore, as a screening m o d a l i t y the teststrip was excellent at separating p a t i e n t s w i t h BA of 0.1 g% or m o r e
Annals of Emergency Medicine
19:3 March 1990
If t h e a u t h o r s w i s h e d to r e v i e w c u r r e n t p r e h o s p i t a l p h a r m a c o l o g i c therapy, o n l y the s t u d i e s of a t r o p i n e for a s y s t o l e or PIVR, 3 l i d o c a i n e p r o p h y l a x i s , 4 a n d s t r e p t o k i n a s e for a c u t e m y o c a r d i a l i n f a r c t i o n 5 s h o u l d h a v e been included. As Shuster and Chong correctly p o i n t out, these studies are l i m i t e d by their small s a m p l e sizes. As a result, these studies could not rule out the p o s s i b i l i t y of an i m p r o v e d outcome. W h i l e t h e a u t h o r s ' s u m m a r y s t a t e m e n t regarding the lack of proven efficacy of prehospital pharmacologic therapy is correct, it should be judged by the data that support it - very little in this case. T h e p a u c i t y of prehospital r e s e a r c h on drug effectiveness does n o t p e r m i t m a k i n g any valid conclusions.
Stephen E Jones, MD Director, Prehospital Care Los Angeles County/USC Medical Center
Franklin D Pratt, MD Medical Director, Fire Department County of Los Angeles 1. Nowak RM, Bodnar TJ, Dronen S, et al: Bretylium tosylate as initial treatment for cardiopulmonary arrest: Randomized comparison with placebo. Ann ErnergMed 1981;10:404-407. 2. Standards and guidelines for cardiopuhrronary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986;255:2905-2984. 3. Con GA, Clinton JE, Ruiz E: Use of atropine for bradyasystolic prehospital cardiac arrest. Ann EmergMed 1981;10:462-467. 4. Hargarten KM, Aprahamian C, Stueven HA, et al: Prophylactic lidocaine in the prehospital patient with chest pain of suspected cardiac origin. Arm EmergMed 1986;15:881-885. 5. villemant D, Barriot P, Riou B, et al: Achievement of thrombolysis at home in cases of acute myocardial infarction (letter). Lancet 1987;t: 228-229.
In Reply: Drs Jones and Pratt are quite correct. Studies to evaluate the safety and benefit of prehospital pharmacologic therapy should compare patients w h o receive prehospital drug therapy w i t h p a t i e n t s who receive no drugs u n t i l they arrive at the e m e r g e n c y department. The fact is that there are so few such studies that directly address the issue t h a t we expanded our analysis in order to assess even indirect evidence of the efficacy of prehospital pharmacologic therapy. We too concluded that there is no published scientific evidence on w h i c h to base an opinion about prehospital pharmacologic intervention. We are c u r r e n t l y u n d e r t a k i n g a three-year prospective trial to c o m p a r e o u t c o m e s in p a t i e n t s w i t h c h e s t p a i n w h o are e i t h e r g i v e n p h a r m a c o l o g i c t h e r a p y by paramedics or transported directly to the ED by BLS crews. We are able to e t h i c a l l y compare these two groups because in H a m i l t o n we have only enough ALS crews to reach 30% of Code 4 emergencies. We e n c o u r a g e o t h e r efforts to o b j e c t i v e l y assess t h e value of prehospital interventions.
Michael Shuster, MD, FRCP(C) Director, Paramedic Program John Chong, MD, FRCP(C) Department of Clinical Epidemiology & Biostatistics McMaster University Hamilton, Ontario, Canada
Tympanic Membrane Thermometers To the Editor: I read the a r t i c l e e n t i t l e d " E v a l u a t i o n of a T y m p a n i c M e m b r a n e T h e r m o m e t e r in an O u t p a t i e n t Clinical Sett i n g " [ S e p t e m b e r 1989;18:1004-1006] w i t h c o n s i d e r a b l e interest. However, the conclusions of the study are subject to c r i t i c i s m because of inadequate m e t h o d o l o g i c a l reporting of errors. First, a glass-mercury t h e r m o m e t e r requires more than t h e t h r e e to five m i n u t e s for e q u i l i b r a t i o n t h a t D r Ros 19:3 March 1990
used in his study.l, 2 Various reports of duration of therm o m e t e r p l a c e m e n t u n t i l achieving o p t i m a l t e m p e r a t u r e conclude that eight to ten m i n u t e s is best. 3 Children and afebrile adults require the longest equilibration times.4, 5 Secondly, because the p h y s i c i a n obtaining the t y m p a n i c t e m p e r a t u r e was reportedly n o t blinded to the results of oral or rectal temperature, the possibility of introducing bias in evaluating t e m p e r a t u r e correlation is raised.
Annals of Emergency Medicine
341/185
CORRESPONDENCE
N o m e n t i o n is m a d e of calibration of either t h e r m o m e ter. N o m e n t i o n of the m o d e of the First T e m p ® during t e m p e r a t u r e m e a s u r e m e n t is r e p o r t e d . B e c a u s e F i r s t T e m p ® reports t e m p e r a t u r e values as "core," "rectal," or "oral" equivalents, considerable variation in t e m p e r a t u r e results m a y have resulted in the relatively poor correlation observed. C o m b i n i n g the r e s u l t s of oral and r e c t a l t e m p e r a t u r e to derive a single regression line, w i t h o u t correcting for differences b e t w e e n oral and rectal temperature, is inappropriate. Finally, no m e n t i o n is m a d e of excluding p a t i e n t s w i t h factors k n o w n to spuriously influence oral t e m p e r a t u r e m e a s u r e m e n t , such as t a c h y p n e a or h o t and cold liquid ingestion.6, 7 U n l e s s clarification of these issues is possible, I recomm e n d caution in accepting the conclusions of this study. Thomas E Terndrup, M D Departments of Critical Care & Emergency Medicine and Pediatrics S U N Y Health Science Center Syracuse, N e w York
l, Nichols GA, Fielding JJ, McKevitt RK, et al: Taking oral temperatures of febrile patients. Nurs Res 1969;18:448-450. 2. Nichols GA, Kucha DH: Oral measurements. Am J Nuts 1972;72: 1091-1093. 3. Nichols GA, Kulvi RL, Life HR, et al: Measuring oral and rectal temperatures of febrile children. Nurs Res 1972;21:261-264. 4. Nichols GA, Ruskin MMt Glor BAK, et al: Oral, axillary, and rectal temperature determinations and relationships. Nurs Res 1966~15:307-310. 5. Baker NC, Bidwell-Cerone S, Gaze N, et al: The effect of type of thermometer and length of time inserted on oral temperature measurements of afebrile subjects. Nurs Res 1984;33:109-111.
6. Tanberg D, Sklar D: Effect of tachypnea on the estimation of body temperature by an oral thermometer. N ErzglJ Med 1983;308-945-946. 7. Temdrup TE, Allegra JR, Kealy JA: A comparison of oral, rectal and tympanic membrane-derivedtemperature changes after ingestion of liquids and smoking. Am ] Emerg Med 1989;7:150-154.
in Reply: I t h a n k Dr Terndrup for his c o m m e n t s and questions. The glass-mercury t h e r m o m e t e r m e a s u r e m e n t s were obtained by holding the t h e r m o m e t e r in the orifice u n t i l stabilization of the reading - a process u s u a l l y t a k i n g app r o x i m a t e l y three to five m i n u t e s (no a t t e m p t s were m a d e to record the exact duration of this procedure). The physician obtaining the t y m p a n i c m e m b r a n e temperature was blinded to the results of oral and rectal meas u r e m e n t s that were obtained b y the nursing personnel. The t y m p a n i c m e m b r a n e t h e r m o m e t e r was always used in the appropriate m o d e - ie, if rectal t e m p e r a t u r e was normal, the device was in the rectal mode, etc. T h e results of oral and rectal t e m p e r a t u r e s were combined because of the relatively s m a l l n u m b e r of s t u d y subjects in each group and the low l i k e l i h o o d of the n e w device r e p l a c i n g the m e a s u r e m e n t of rectal and oral t e m peratures only. Finally, we have a policy of n o t allowing our p a t i e n t s to ingest liquids prior to being evaluated, and tachypneic patients do not have oral t e m p e r a t u r e m e a s u r e m e n t s . Simon P R o s , MD Pediatric Emergency Medicine Loyola University Stritch School of Medicine Maywood, Illinois
Saliva Teststrips for Alcohol Testing To the Editor: We read w i t h i n t e r e s t the a r t i c l e by S c h w a r t z et al, "Evaluation of C o l o r i m e t r i c D i p s t i c k Test to D e t e c t Alcohol in Saliva: A Pilot Study" [September 1989;18: 1001-1003]. U s i n g a n o t h e r c o m m e r c i a l l y available salivary alcohol dipstick that was referred to in their article, the AlcoScan ~ (Lifescan, Inc), we also found c o l o r i m e t r i c s c r e e n i n g a useful test for a l c o h o l i n t o x i c a t i o n in the e m e r g e n c y department. The AlcoScan ~ saliva teststrip for salivary alcohol also uses a color change from no color, to light blue, to dark purple corresponding w i t h semiquantitative i n c r e m e n t s of 0, 0.01 g%, 0.05 g%, and 0.1 g% b l o o d a l c o h o l l e v e l s . We w e r e o r i g i n a l l y i n t e r e s t e d in using the teststrip to screen psychiatric patients requiring medical clearance w i t h a blood alcohol level of less than 0.1 g%, but our s t u d y group also included patients w i t h t r a u m a and m e d i c a l l y related conditions. F r o m January to M a r c h 1988, 38 patients were tested a n d t h e r e s u l t s of t h e t e s t s t r i p c o m p a r e d to a s i m u l taneous blood alcohol run on the hospital T D x REA Eth186/342
anol A s s a y (Abbot Laboratories). O u r results were n o t reported due to the s t a t i s t i c a l l y s m a l l sample size and subsequent lack of supplies by the manufacturer. We found that the teststrip (AS) was very good at separating patients w i t h a blood alcohol of m o r e than 0.1 g% from those w i t h levels less than 0.05 g%. Blood alcohol levels ranged from 0 to 0.43 g%. Seven s p e c i m e n s were 0, all of w h i c h correlated w i t h the teststrip, except one that was read at 0.01 g% by AS. All 11 samples less t h a n 0.05 g% blood alcohol were confirmed by the teststrip to be in the same range; all 26 specimens found to be greater than or equal to 0.1 g% by blood alcohol were confirmed by the teststrip, except for three samples that were lower as a result of saliva sampling error (no saliva or d i l u t i o n from water ingested prior to sampling). One test s a m p l e correlated poorly for an u n k n o w n reason - BA 0.32, AS m o r e t h a n 0.05 g%. Therefore, as a screening m o d a l i t y the teststrip was excellent at separating p a t i e n t s w i t h BA of 0.1 g% or m o r e
Annals of Emergency Medicine
19:3 March 1990
