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Another Viewpoint: Is Emergency Medicine a Specialty?

This letter has been sent to the editor of the Bul le t in of the American College of Physic ians and is published here for the information of our readers.

IN THE NOVEMBER, 1976 issue o f the Bulletin of The American College of Physicians (pp 2 and 28), the presi- dent of the Amer ican College o f Phys ic ians offered an editorial in which he expressed doubts t ha t emergency medicine fulfi l led the five ~Cri ter ia of a P r i m a r y Spe- cialty Board" as p romulga ted by the Liaison Commi t t ee on Specialty Boards of the Amer ican Medical Associa t ion (AMA).

It is my personal bel ief t ha t of a l l the cr i te r ia , the most difficult to demons t ra te is t ha t emergency medic ine ~En- compasses an ident i f iable body of knowledge which has scientific va l id i ty , is genera l ly recognized by the profes- sion, and is not genera l ly possessed by all physic ians ." Indeed, there seems to be g rea t diff iculty among o ther primary specia l is ts (most of whom are involved from t ime to time in the care of emergency problems) in apprec ia t - ing t h a t t h e i r i n v o l v e m e n t is a l m o s t a l w a y s in pre- selected cases invo lv ing d i sease processes IN T H E I R OWN SPECIALTY.

I am a board cert if ied surgeon who has pract iced t h a t specialty since 1962. I have been in te res ted in emergency medicine and have been act ive in t r e a t i n g emergency problems since tha t t ime. Unt i l about Apr i l of 1976, I, too, shared the viewpoint t h a t I was as much an emer- gency phys ic ian as any of the p rac t i t ioners who had cho- sen to l imi t the i r pract ices to emergency medicine. De- spite the prodding and urg ing of my fr iends in emergency medicine, I r ema ined stiff-necked; I m a i n t a i n e d t ha t I could t h ink and function in emergency medic ine as wel l as any of them.

In April , 1976 I was ~reborn" in my medical t h i n k i n g and in my in te l l ec tua l approach: I began to work as a part-t ime emergency physician. Almost a yea r la ter , I find tha t I am not ye t one of ~them." The s t a rk r ea l i t y h i t me that the l as t t ime I persona l ly had faced the onrush- ing mob of undi f fe rent ia ted pa t i en t s was in 1957 - - and then for only e ight weeks. Since t ha t t ime, a l l my emer- gency pa t ien t s have been cul led and selected for me. I have discovered (at considerable damage to my ego) t h a t I nei ther know it all , r e m e m b e r i t al l nor can do i t al l - - especially wi th the Brobd ingnag ian advances in h e a l t h care knowledge, technique , o rgan iza t ion and de l i ve ry that have occurred in the pas t 20 years . ~

On New Year ' s Eve, 1976, I had learned (re learned? recalled?) enough to be able to correct ly diagnose and treat such d i spa ra t e problems as: var ice l la v i r emia in a 5-raonth-old; pneumonia wi th men ing i t i s in a 3-week-old,

Editorials an an te rosep ta l myoca rd ia l infarc t ion with shock and ar- r y t h m i a in a 62-year-old, a t h r e a t e ne d abor t ion in a 15- yea r -o ld p r i m i p a r a , x i p h i s t e r n a l cos tochondr i t i s mas- que rad ing as a r ecu r r en t pu lmona ry embolus in a 67- yea r -o ld p reke to t i c d iabe t i c w o m a n and me themog lo - b inemia in a 58-year-old emphysema tous man. These, of course, were i n t e r s p e r s e d a m o n g the u sua l f r ac tu res , shootings, upper r e sp i r a to ry infections and such t h a t are the ~bread and but te r" of emergency medical pract ice. I chal lenge any of my col leagues in any of the t r ad i t i ona l special i t ies to allow themse lves the exercise in cr i t ica l object ivi ty to con templa te the i r own personal abi l i t ies , today, wi thou t r e t r a in ing , to deal wi th problems as far afield as those above.

I admi t t ha t I do not work unsupervised. I am, ra the r , v i r t ua l ly a preceptee at the elbows of a group of rea l emergency phys ic ians - - a l l younger than I and al l con- s iderab ly be t t e r at th is spec ia l i ty t han I am today.

This persona l v igne t t e is an h u m b l i n g sel f - reassess- ment and reeva lua t ion . I now know tha t a surgeon (or, a t leas t th is surgeon) t h inks in a different way and in a different context t h a n does an emergency physician. I am also now convinced t ha t each of us special is ts views the world of i l lness and pa t i en t s wi th the biases of our own pe r sona l i t i e s , t r a i n i n g , exper iences , co l l eg ia l i t i e s and turf. More especial ly , I am convinced tha t the ab i l i ty and ski l ls necessary to u n d e r t a k e the care of a large body of undi f fe ren t ia ted pa t i en t s (whose i l lnesses m a y well in- volve t h r e a t to life and l imb in any special ty area), to be able to appropr i a t e ly t r i age and pr ior i t ize care; to safely and appropr i a t e ly d iagnose and manage the first cr i t ica l port ion of care; and to de l iver the pa t i en t al ive and im- proving to the appropr ia t e specia l i s t in another a r ena comprises both an ident i f iab le body of knowledge and is no__t genera l ly possessed by o ther physicians.

I hope t ha t the r eade r wil l search h imse l f in t e rms of my experience and conclude wi th me tha t there is indeed a special i ty cal led emergency medicine tha t c o m p l e m e n t s r a t h e r t h a n t h r e a t e n s t h e house of medic ine . I f one agrees wi th th is premise and recognizes the complexi ty of the new special ty, it follows t ha t a board in emergency medicine is an impor t an t qua l i ty control - - j u s t as it is in o ther special i t ies .

Carl Jelenko, III, MD, FACS Professor of Surgery

Medical College of Georgia, Augusta

Sodium Bicarbonate Administration During Cardiopulmonary Resuscitation

~ ¢ E F F E C T S OF SODIUM BICARBONATE A d m i n i s t r a t i o n dur ing Ca rd iopu lmona ry Resusci ta t ion," by Whi te , e t al (p 187) br ings up a n u m b e r of subjects for discussion.

J ~ P 6:5 (May) 1977 221/65

Above all, i t points out the impor tance of ind iv idua l iz ing sodium b icarbona te the rapy and d rawing a r t e r i a l blood for gas a n a l y s e s du r ing any r e susc i t a t ion t ha t is not r ap id ly successful.

Our own expe r i ence has shown t h a t the ac id -base changes d u r i n g ca rd iopu lmona ry resusc i t a t ion are ex- t r eme ly varied. Minute vent i la t ion dur ing resusc i ta t ion is gene ra l ly at leas t 11/2 to 2 t imes normal values and produces a PCO2 of 25 to 35 mm Hg in most pa t ients . H o w e v e r , i f t h e p a t i e n t has s e v e r e ch ron i c a i r w a y obst ruct ion or very advanced shock, the PCO2 may be g rea te r t h a n 45 mm Hg. It is also not inf requent under these c i r c u m s t a n c e s t h a t the e n d o t r a c h e a l t ube pro- gresses into the r igh t ma in stem bronchus, reducing ven- t i l a t ion in the left lung. This is not a lways c l in ical ly ap- pa r en t and is 'of ten noted only o n c h e s t x-ray films.

In the Whi te ar t icle , i t is not su rp r i s ing t ha t the PCO2 in al l the pa t i en t s who recovered was less t han 50 mm Hg. In contrast , two of the pa t ien ts who were not successfully re- susc i ta ted had a r t e r i a l PCO2 of 90 and 106 mm Hg. Ideal ly, the a r t e r i a l PCO2 should be in the range of 30 to 40 mm Hg, and i f i t is not, the s ta tus of the pa t i en t ' s ven t i l a t ion should be r e -eva lua ted and corrected accordingly.

The a r t e r i a l PO2 levels in six ins tances were r a t h e r low (less t h a n 60 mm Hg). Dur ing ex t e rna l cardiac mas- sage, when the cardiac output is often 1.0 l i t e r /min or less, the PO2 should be at leas t 100 mm Hg; and much h igher PO2s t ha t require 100% oxygen are probably pref- e r ab l e . H o w e v e r , i f t he m i n u t e v e n t i l a t i o n is much g rea te r t h a n the ra te of oxygen del ivery, the FiO2 will be s igni f icant ly reduced, and if pu lmonary function is se- vere ly impai red , the a r t e r i a l PO2 m a y be very low in spite of al l the physic ian ' s efforts.

The b icarbona te level appears to be la rge ly de te rmined by the pa t i en t s ' p r ior acid-base s ta tus , t h e r ap id i ty wi th which resusc i ta t ion is begun, and the effect iveness of the cardiac massage . Pa t i en t s who are doing re l a t ive ly well and then have a cardiac a r res t in the opera t ing room or in tens ive care uni t (where the d iagnosis is r ap id ly made and effective massage begun a lmost immedia te ly ) tend to have r e l a t ive ly normal b icarbonate levels. On severa l oc- casions we have noted such ind iv idua ls wi th a pH exceed- ing 7.70 up to ten minu tes af ter the f irst two ampules of b icarbonate were given.

In contras t , pa t i en t s who were c r i t i ca l ly ill wi th shock or hepat ic or r ena l fai lure will often develop a pH less than 7.0 and b ica rbona te levels less t h a n 5 mEq/ l i t e r wi th in 2 to 3 minu tes of the cardiac ar res t . The under ly- ing condit ion of the pa t ien t s in the repor t by White , et al is not s ta ted, but since t r a u m a vict ims were excluded, it is l ike ly t h a t they were an older age group wi th signifi- cant under ly ing disease. Fur the rmore , the de lay before resusc i ta t ion was begun and the dura t ion and effective- ness of the resusc i ta t ive maneuvers pr ior to a r r iva l a t the hospi ta l a re also not apparent . In al l l ikelihood, there were at leas t 15 minu tes of resusc i ta t ion pr ior to a r r iva l in the emergency depar tment .

Ano the r factor which must be considered is the type and volume of o ther fluids adminis te red . If large volumes of 0.3 normal sa l ine were given, they could pa r t i a l l y di-

lute out the sodium ions, b ica rbona te ions, and osmolar. i ty changes t h a t might occur wi th sodium bicarbonat~ a d m i n i s t r a t i o n . I f the u n d e r l y i n g p r o b l e m was a~t t r a u m a or h e m o r r h a g e , i t is u n l i k e l y t h a t excessivs quant i t i es of fluid were given. In some pa t ien ts with rel. a t ive ly good rena l function, some (but probably not a large amount ) of the sodium and osmola r load might have been excreted.

I found the high glucose levels (which were greater t han 300 rag/100 ml in 12 of the 17 pat ients) somewhat dis turbing. The r e su l t ing hyperosmola l i ty , par t icular ly if g rea te r t han 350 mOsm/kg, may have a signif icant del. e ter ious effect. Fu r the rmore , if the sodium concentra. t ions were corrected upward by 1.6 mEq/ l i te r for each 100 mg/100 ml t ha t the glucose levels were above normal, the sodium levels would be 150 mEq/ l i t e r or h igher in 8 of the 17 pa t ien ts . The exact causes of the high glucose levels are not clear. However, as the authors mention, mul t ip le endocrine factors tend to cause hyperglycemia and added glucose may severe ly aggrava te the situation.

Ser ia l a r t e r i a l blood gases should probably be drawn, preferably th rough an a r t e r i a l ca the ter , every ten rain. utes dur ing a resusci ta t ion t ha t is not rap id ly successful. An a r t e r i a l ca the t e r is very helpful ~n obta in ing serial samples and prevents the i nadve r t en t d rawing of venous s a m p l e s t h a t o c c a s i o n a l l y occurs w i th percutaneous needle aspi ra t ions . Al though it may t ake 10 to 15 rain, utes or longer to obta in a full blood gas report, it usually only t akes a minu te or two to get a pH, which in itself can be ex t r eme ly helpful. A high pH (par t icular ly above 7.55) i n d i c a t e s t h a t b i c a r b o n a t e is not immedia te ly needed and t ha t the minu te ven t i l a t ion should be re. duced somewhat . A low pH (par t i cu la r ly below 7.20) is probably due to a low bicarbonate , due to poor t issue per- fusion. Under such c i rcumstances , b icarbonate can be giv- en. Efforts to ra ise the pH by inc reas ing vent i la t ion may occasional ly be war ran ted . However , if the a r te r ia l PC02= is pushed below 25 mm Hg, th is may interfere with cere- bral c irculat ion.

Another advan tage of an i n t r a - a r t e r i a l ca the te r is that it can be then hooked up to a blood pressure recorder, The effectiveness of cardiac massage can be evaluated much more accura te ly than by pa lpa t ion of pulses. We have f requent ly found tha t the systolic pressure produced by ex te rna l cardiac massage was less than 60 mm I-Ig. When the phys ic ians were informed of the fact, they al- most inva r i ab ly were able to rap id ly adjust the i r efforts to produce a systolic blood pressure of 80 to 100 mm Hg or higher.

In summary , I bel ieve t ha t the use of sodium bicarbo- na te dur ing ca rd iopu lmonary resusc i ta t ion must be indi- vidualized. The cur ren t fo rmula should serve only as a rough guide. Ar t e r i a l blood gases should probably be ob- ta ined at leas t every ten minu tes dur ing any resuscita" t ive effort not rap id ly successful.

Robert F. Wilson, MD

(Dr. Wilson is Professor of Surgery and Director of Tho" racic and Cardiovascular Surgery at Wayne State U hi° versity School of Medicine, Detroit, Michigan.)

661222 B:5 (May) 1977 , ,~P