Defining emergency procedures for the emergency physician

editorials DEFINING EMERGENCY PROCEDURES FoR THE EMERGENCY PHYSICIAN AMONG THE INTERESTING PAPERS in this issue ofJACEP, is "Complications of Subclavian Sticks," by William F. Mitty, MD, and Thomas F. Nealon, MD. This paper describes, for us, the complications of subclavian sticks, the normal anatomy involved and how to avoid complications. It also reviews the issues relative to these complications. It is with the authors' conclusions that we wish to take issue. It is their conclusion that in order to avoid complications, subclavian sticks need to be done under controlled circumstances in "intensive care units" or :'operating rooms," as opposed to being done under emergency situations in emergency departments. If the point of their article is, as it appears to be, that performance of subclavian sticks by inexperienced personnel leads to many, easily avoided complications, then we can raise no legitimate argument. However, we feel that inexperienced personnel are found in all hospital areas, not only in the emergency department. We agree with the authors that these procedures should be done by closely supervised and/or welltrained personnel. However, it is our contention that there is no reason why closely supervised personnel cannot be developed to maintain the emergency department. The experience of Drs. Mitty and Nealon is not the experience of many other hospitals or many other emergency departments. Conflicts over the tasks to be performed by emergency Physicians continue to be a source of debate. In this issue, [}rs.Mitty and Nealon advocate abolishing the use of subClavian sticks in the emergency department while other ~thors advocate moving new procedures into the emergencydepartment and into the hands of emergency physicians. Richard Caldwell, MD's article on the management QfCpidural hematomas makes the point, although many ofUs might disagree, that trephination might well be a

Jan/Feb 1975

procedure that emergency physicians may be called upon to perform under certain circumstances. Although his experience may be restricted to certain small community hospitals without the easy availability of neurosurgeons, perhaps, with this in mind, training programs should be reoriented. We wonder how many readers would agree with Dr. Caldwell that emergency physicians should be trained and able to perform trephination? In addition, William D. O'Riordan, MD, in his article, "Foreign Bodies Inhaled by Children," advocates training emergency physicians in not only laryngoscopy but bronchoscopy. His case reports make a very nice argument in support of this type of training. It seems that based on the contents of this issue, emergency medicine would lose one procedure, subclavian sticks, and gain two others, bronchoscopy and trephination.

The Editor

MORE ISSUE HIGHLIGHTS WITH P R I D E , J A C E P P U B L I S H E S the recommendations of an international symposium on emergency care delivery systems and mobile intensive care, which Peter Safar, MD, was kind enough to submit in Emergency Forum. The symposium recommendations are published in their entirety without editing. In addition, John Wiegenstein, MD's comments to the first meeting of the provisional section on emergency medicine are also included in Emergency Forum. Dr. Wiegenstein's remarks on emergency medicine education are especially appropriate since our J a n u a r y / F e b r u a r y issue concludes publication of the papers submitted to us from the annual meeting of the University Association for Emergency Medical Service.

Journal of the American College of Emergency Physicians

The Editor

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