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Disaster drills
CORRESPONDENCE Emergency Transtracheal Ventilation
acidosis i m p r o v e s , ie, lessens, as well. At the end of a period of total apnea, the pH will not be h i g h e r t h a n a pH d u r i n g ventilation. I'm sure the A H A c r i t e r i a were not intended to Substitute for common sense. A l t h o u g h t h e r e are a g r e a t m a n y problems w i t h my paper, D r . J o h n s o n h a s n ' t r e a l l y addressed a n y of them. Instead, he h a s used an A H A calculation t h a t r e a l l y isn't a p p r o p r i a t e to dog e x p e r i m e n t a t i o n to justify e x p e r i m e n t a l values t h a t do not m a k e a n y logical sense. At the s a m e time, I a m gratified by his close r e a d i n g of the paper.
To the Editor: R e g a r d i n g Dr. Dunlap's article, ~'A Modified, Simple Device for the E m e r g e n c y A d m i n i s t r a t i o n of Percutaneous T r a n s t r a c h e a l Ventilation" (7:42-46, 1978), in Tables 1 and 2 a footnote reads ~'tUnderlined results a r e p r o b a b l e l a b o r a t o r y e r r o r s . " I n c l u d e d in these t a b l e s are five u n d e r l i n e d values, t h r e e pertaining to pH. U s i n g A m e r i c a n H e a r t Association (AHA) criteria 1 in its advanced cardiac life support course, two of these three a p p a r e n t pH errors can be found to be correct a n d the t h i r d can be approximated.
Larry Dunlap, MD Sacred Heart General Hospital Eugene, Oregon
Table 1. Dog 3
pH 7.69 pO2 24 pCO2 53 HCO3 ?
Disaster Drills
Based on the subsequently reported values for dog 3, the u n m e a s u r e d HCO~ would probably be 18 to 20. A pCO2 of 53 will yield a p H of 7.30. The p H of 7.69 (if it were true) would require a HCO3 of 46 which seems unlikely. Therefore, l a b o r a t o r y error is likely. The pH by calculation was probably 7.30.
To the Editor: I m u s t disagree with Dr. Holloway's position in "The EMS S y s t e m a n d D i s a s t e r Planning: Some Observations," (7:60-61, 1978) t h a t d i s a s t e r "drills" function p r i m a r i l y to appease officialdom, promote good public relations, a n d test the s t r u c t u r e of a multiple c a s u a l t y incident response. C e r t a i n l y our older concepts of simple drills are of limited use. In t h e i r stead, I propose t h a t we consider four levels of "drill." 1) Conventional drills involving the entire hospital staff, w i t h r e p e a t e d notification of the date and t i m e of drill. 2) U n a n n o u n c e d telephone surveys in which key respondents of the d i s a s t e r p l a n are called a t a given time and asked t h r e e questions: a) W h a t is your disast e r a s s i g n m e n t ? b) In addition to yourself, how m a n y skilled personnel would you be able to b r i n g to a disaster? c) W h a t would y o u r response t i m e be if this were an a c t u a l disaster? 3) Announced mock d i s a s t e r s e n l i s t i n g community resources to produce a s i m u l a t e d p a t i e n t load sufficient to t e s t t h e c a p a b i l i t i e s of the hospital. 4) U n a n n o u n c e d mock d i s a s t e r s c o n d u c t e d in such a fashion t h a t t h e r e s p o n d i n g staff is u n a w a r e of the fact t h a t it is a mock d i s a s t e r u n t i l t h e i r actual a r r i v a l at the hospital. Such a d i s a s t e r r e h e a r s a l m u s t be conducted with the i n v o l v e m e n t of t h e entire hospital staff, and cert a i n l y with t h e i r approval. Once such cooperation and support is secured, the above drills can be carried out in such a fashion as. to both orchestrate the r e h e a r s a l of i n d i v i d ~ M ~ o l e s in the d i s a s t e r plan, and to test the d i s a s t e r p r e p a r e d n e s s of the hospital. D i s a s t e l~ P l a n n e r s f r e q u e n t l y f i n d t h e m s e l v e s o p e r a t i n g in a ~ c U u m , w i t h only episodic i n t e r e s t on the p a r t of t h e i r Colleagues. A p p r o p r i a t e d i s a s t e r drills are an excellent d e v i c e for:reminding the hospital staff t h a t a m u l t i p l e c a s u a l t y incident m a y overwhelm the existing facilities at a n y time.
Table 2. Dog 1
pH 7.48 pO2 20 pCO2 29 HCO3 22 A n isolated pCO2 of 29 would yield a pH of 7.488. An isolated HCO3 of 22 would decrease the p H by 0.03 yielding a n e t pH of 7.486. There was no l a b o r a t o r y error involved.
Table 2. Dog 2
pH 7.46 p02 24 pCO2 31
HCO322
An isolated pCO2 of 31 will yield a pH of 7.422 while a HCO3 of 22 would decrease the pH 0.03 to a net v a l u e of 7.469. Again, no l a b o r a t o r y error was involved. In t h e pH d a t a presented, two of the three v a l u e s reported as l a b o r a t o r y errors a r e indeed correct by calculation.
John C. Johnson, MD Emergency Services Department The Methodist Hospital of Indiana Indianapolis, Indiana 1. Advanced Cardiac Life Support (manual), American Heart Association, 1975, pp IX-4 - - IX-5.
Author's Reply Dr. Johnson is correct in his calculations, but inappropriate in t h e i r application. The A H A c r i t e r i a were i n t e n d e d to allow a rough calculation of the influence of acute blood gas changes on pH values in humans. By a p p l y i n g t h e m rigidly to all the d a t a from my dog e x p e r i m e n t s , Dr. Johnson could also demonstrate t h a t the results we a s s u m e d were r e a s o n a b l e are also incorrect. The r e a l i t y is t h a t if one m a k e s a dog anoxic, his pH drops, acidosis develops, and his PO~ falls. W i t h v e n t i l a t i o n t h a t m a r k e d l y i m p r o v e s his PO2, t h e
7:11 (November) 1978
Roland B. Clark, MD Paramedic Coordinator Paradise Valley Hospital National City, California
JACEP
416/59
acidosis i m p r o v e s , ie, lessens, as well. At the end of a period of total apnea, the pH will not be h i g h e r t h a n a pH d u r i n g ventilation. I'm sure the A H A c r i t e r i a were not intended to Substitute for common sense. A l t h o u g h t h e r e are a g r e a t m a n y problems w i t h my paper, D r . J o h n s o n h a s n ' t r e a l l y addressed a n y of them. Instead, he h a s used an A H A calculation t h a t r e a l l y isn't a p p r o p r i a t e to dog e x p e r i m e n t a t i o n to justify e x p e r i m e n t a l values t h a t do not m a k e a n y logical sense. At the s a m e time, I a m gratified by his close r e a d i n g of the paper.
To the Editor: R e g a r d i n g Dr. Dunlap's article, ~'A Modified, Simple Device for the E m e r g e n c y A d m i n i s t r a t i o n of Percutaneous T r a n s t r a c h e a l Ventilation" (7:42-46, 1978), in Tables 1 and 2 a footnote reads ~'tUnderlined results a r e p r o b a b l e l a b o r a t o r y e r r o r s . " I n c l u d e d in these t a b l e s are five u n d e r l i n e d values, t h r e e pertaining to pH. U s i n g A m e r i c a n H e a r t Association (AHA) criteria 1 in its advanced cardiac life support course, two of these three a p p a r e n t pH errors can be found to be correct a n d the t h i r d can be approximated.
Larry Dunlap, MD Sacred Heart General Hospital Eugene, Oregon
Table 1. Dog 3
pH 7.69 pO2 24 pCO2 53 HCO3 ?
Disaster Drills
Based on the subsequently reported values for dog 3, the u n m e a s u r e d HCO~ would probably be 18 to 20. A pCO2 of 53 will yield a p H of 7.30. The p H of 7.69 (if it were true) would require a HCO3 of 46 which seems unlikely. Therefore, l a b o r a t o r y error is likely. The pH by calculation was probably 7.30.
To the Editor: I m u s t disagree with Dr. Holloway's position in "The EMS S y s t e m a n d D i s a s t e r Planning: Some Observations," (7:60-61, 1978) t h a t d i s a s t e r "drills" function p r i m a r i l y to appease officialdom, promote good public relations, a n d test the s t r u c t u r e of a multiple c a s u a l t y incident response. C e r t a i n l y our older concepts of simple drills are of limited use. In t h e i r stead, I propose t h a t we consider four levels of "drill." 1) Conventional drills involving the entire hospital staff, w i t h r e p e a t e d notification of the date and t i m e of drill. 2) U n a n n o u n c e d telephone surveys in which key respondents of the d i s a s t e r p l a n are called a t a given time and asked t h r e e questions: a) W h a t is your disast e r a s s i g n m e n t ? b) In addition to yourself, how m a n y skilled personnel would you be able to b r i n g to a disaster? c) W h a t would y o u r response t i m e be if this were an a c t u a l disaster? 3) Announced mock d i s a s t e r s e n l i s t i n g community resources to produce a s i m u l a t e d p a t i e n t load sufficient to t e s t t h e c a p a b i l i t i e s of the hospital. 4) U n a n n o u n c e d mock d i s a s t e r s c o n d u c t e d in such a fashion t h a t t h e r e s p o n d i n g staff is u n a w a r e of the fact t h a t it is a mock d i s a s t e r u n t i l t h e i r actual a r r i v a l at the hospital. Such a d i s a s t e r r e h e a r s a l m u s t be conducted with the i n v o l v e m e n t of t h e entire hospital staff, and cert a i n l y with t h e i r approval. Once such cooperation and support is secured, the above drills can be carried out in such a fashion as. to both orchestrate the r e h e a r s a l of i n d i v i d ~ M ~ o l e s in the d i s a s t e r plan, and to test the d i s a s t e r p r e p a r e d n e s s of the hospital. D i s a s t e l~ P l a n n e r s f r e q u e n t l y f i n d t h e m s e l v e s o p e r a t i n g in a ~ c U u m , w i t h only episodic i n t e r e s t on the p a r t of t h e i r Colleagues. A p p r o p r i a t e d i s a s t e r drills are an excellent d e v i c e for:reminding the hospital staff t h a t a m u l t i p l e c a s u a l t y incident m a y overwhelm the existing facilities at a n y time.
Table 2. Dog 1
pH 7.48 pO2 20 pCO2 29 HCO3 22 A n isolated pCO2 of 29 would yield a pH of 7.488. An isolated HCO3 of 22 would decrease the p H by 0.03 yielding a n e t pH of 7.486. There was no l a b o r a t o r y error involved.
Table 2. Dog 2
pH 7.46 p02 24 pCO2 31
HCO322
An isolated pCO2 of 31 will yield a pH of 7.422 while a HCO3 of 22 would decrease the pH 0.03 to a net v a l u e of 7.469. Again, no l a b o r a t o r y error was involved. In t h e pH d a t a presented, two of the three v a l u e s reported as l a b o r a t o r y errors a r e indeed correct by calculation.
John C. Johnson, MD Emergency Services Department The Methodist Hospital of Indiana Indianapolis, Indiana 1. Advanced Cardiac Life Support (manual), American Heart Association, 1975, pp IX-4 - - IX-5.
Author's Reply Dr. Johnson is correct in his calculations, but inappropriate in t h e i r application. The A H A c r i t e r i a were i n t e n d e d to allow a rough calculation of the influence of acute blood gas changes on pH values in humans. By a p p l y i n g t h e m rigidly to all the d a t a from my dog e x p e r i m e n t s , Dr. Johnson could also demonstrate t h a t the results we a s s u m e d were r e a s o n a b l e are also incorrect. The r e a l i t y is t h a t if one m a k e s a dog anoxic, his pH drops, acidosis develops, and his PO~ falls. W i t h v e n t i l a t i o n t h a t m a r k e d l y i m p r o v e s his PO2, t h e
7:11 (November) 1978
Roland B. Clark, MD Paramedic Coordinator Paradise Valley Hospital National City, California
JACEP
416/59