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painlessly and with minimal muscle contraction has been developed. This pacemaker has been tested in monkeys and dogs and has not produced clinically significant cardiac damage. 2 Transcutaneous pacemakers have recently been licensed for use in human beings by the Food and Drug Administration. 3 We would like to report the successful use of a transcutaneous pacemaker in the resuscitation of a bradyarrhythmic patient. A 39-year-old man was found unconscious, and paramedics were summoned to the scene. The patient was in ventricular fibrillation that was refractory to initial defibrillation. Treatment followed standard advanced cardiac life support guidelines. The patient was given 44.5 mEq (1 amp) sodium bicarbonate and 10 cc 1:10,000 (1 amp) epinephrine followed by two defibrillations without effect. Lidocaine 100 mg followed by an infusion of 4 mg/min with another countershock was unsuccessful In producing conversion. Bretylium 350 mg and another i mg (1 amp) of epinephrine was followed by defibrillation, without a rhythm change. A 750-mg bolus of bretylium with a repeat defibrillation resulted in the development of complexes with a rate of 30 to 40; however, there was no pulse. Another 1 mg (1 amp) of epinephrine was given, but the patient became asystolic and was then transported to the University of Cincinnati Emergency Department. On arrival the patient had electrical complexes with a rate of 30 to 40, but no palpable pulse. He received a total of 1.5 mg atropine and 135.5 mEq (3 amps) sodium bicarbonate, and he was placed in a pneumatic antishock garment. A 4-mg% dopamine infusion was used without a change in complex rate or development of pulses. Transcutaneous cardiac pacing was initiated using a Pace*Aid transcutaneous pacemaker and antero-posterior electrodes delivering a current of 100 mA with a pulse duration of 20 ms at a rate of 80/min. The pacing current captured a rate of 80, with the development of a pulse and systolic blood pressure of 100 m m Hg. The transcutaneous pacemaker was used to support pulse and blood pressure for approximately 15 minutes until an intravenous pacemaker was inserted. During this time the patient had return of spontaneous respirations. The intravenous pacemaker captured and also supported a

systolic blood pressure of 100 m m Hg. Altemating the method of pacIng demonstrated that both systems were equally effective In capturing and maintaining a systolic blood pressure of 100 m m Hg. Without pacIng, the patient was unable to sustain a pulse or blood pressure. The patient was paced for approximately 90 minutes, but subsequently developed refractory pulmonary edema. The transvenous pacemaker failed to capture, but the patient was subsequently successfully paced by transcutaneous pacLug for a few minutes. This method then failed, and the patient died in refractory ventricular fibrillation. Postmortem examination confirmed an acute anteroseptal myocardial infarction, preexisting myocardial damage from two prior infarctions, and pathological changes secondary to hypertension. Evidence of both acute and chronic heart failure was present, but no damage attributable to pacing was noted. We write this report to call attention to transcutaneous cardiac pacIng, the original method used to electrically pace the heart. This technique has been overlooked as a temporary means to pace the heart until alternative pacing techniques can be applied. It is simple and easy to use. It requires placement of two contact electrodes in an anteroposterior position, which can be done quickly, and offers the ability to initiate pacing within seconds.

William C Dalsey, MD Scott A Syverud, MD David S Ross, MD Frank Yeiser, MD Bryan Carducci, MD Division of Emergency Medicine University of Cincinnati College of Medicine Cincinnati 1. Zoll PM: Resuscitation of the heart in ventricular standstill by external electric stimulation. N EngI J Med 1952;247:768-771. 2. Syverud SA, Dalsey WC, Hedges JR, et al: Transcutaneous cardiac pacing: Determination of myocardial injury in a canine model. Ann Emerg Med 1983;12:745-748. 3. Dalsey WC, Syverud SA, Trott A: Transcutaneous cardiac pacing. Journal of Emergency Medicine 1984;1:201-205.

Emergency Medicine and the University Trauma Center To the Editor: In December 1979, the emergency medicine residency at. San Francisco General Hospital was abruptly terminated. At that time I had responsibility for the program. Even though four years have passed, a number of issues raised by the events surrounding the termination of this program merit national discussion, if emergency medicine is to compete successfully in the university trauma center environment. Let me briefly outline those events. In early November 1979 I tendered my resignation as director of emergency services, with a tentative date of July 1, 1980. At that time I expressed to both the dean and the chief of surgery the necessity of supporting and maintaining the emergency medicine residency while recruiting my replacement. I was a s 13:5 May 1984

sured that the entire emergency medicine program would be thoroughly evaluated, including the use of outside consultation. On the afternoon of December 5, 1979, I was called to the dean's office and told of a meeting that had been held on December 4. Based on those discussions and several prior phone calls with the incoming chief of medicine and the dean of the university, the decision had been made not to seek an emergency-medicine-trained individual to replace me. Rather the decision was to divide the responsibility for running the emergency department between the departments of medicine and surgery. Because neither of the representatives of these departments had an interest in running an emergency medicine residency, the program was to

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be phased out after meeting commitments to existing residents. All decisions were finalized without any input or review from any individuals representing emergency medicine and without any formal review of the residency itself. As one might expect, the monies spent for emergency medicine reverted to the departments of medicine and surgery for "redistribution." What factors really precipitated this decision? Certainly, the personal disdain of the principal players toward emergency medicine was important. More important was the fiscal impact of emergency medicine on San Francisco General and the University of California, San Francisco. The "marketplace" that emergency medicine entered at the University of California, San Francisco, in the late 1970s is best analogized to that which existed in the American auto industry in the early 1970s. The university medical complex had been geared up to produce massive numbers of specialty and subspecialty residents, the Cadillacs of medicine. At San Francisco General Hospital, the 60 flexible internships had been remodeled into specialty and subspecialty intern and resident positions. Each time a new subspecialty rotation was developed, funded residency positions were required and often internship slots were necessary Finally, each new subspecialty service required at least one faculty member. Each new layer of subspecialty care treated fewer and fewer patients per week. To make matters worse, a large family practice program had been started requiting a significant allocation of monies. This world of medical "gas guzzlers" was running out of fuel by the late 1970s. House staff salaries had gone up and the house staff was increasingly unable or unwilling to cover rotations "outside" their field of primary interest. Faculty salaries were also rising, and Proposition 13 had eliminated significant state and local tax funds. Part-time private practice was impractical for most faculty because San Francisco is oversupplied with physicians and the hospital's environm e n t discourages private patient visits. In this fiscal environment emergency medicine began. Every dollar spent for emergency medicine was money that the traditional departments wished to (or were) spending on themselves. As important as the fiscal issues were, there were philosophical problems of almost equal significance. There was a strong belief among some senior faculty members that it was impossible to adequately train any physician to perform the skills required of an in-breadth specialist such as an emergency physician. Obviously a lack of understanding becomes self sustaining as long as the university refuses to allow trained emergency physicians to perform in the university environment. Another philosophical clash evolved around the aggressive marketing of the "mega" trauma center concept. In theory, emergency medicine and the university trauma center concept should be able to coexist peacefully. In fact, at the emergency department level, emergency medicine residents and medicine and surgery residents did function well together. But at the faculty and university levels there were, and are, serious problems. Although the large university trauma center concept can be justified on clinical grounds, there are some fundamental economic forces behind the concept. The University of Cal148/412

ifomia, San Francisco, and San Francisco General Hospital specifically retooled during the past 20 years to produce great numbers of specialty and subspecialty house officers and faculty. This resulted in the fragmentation of the general patient population into a number of subgroups. In addition, since the late 1960s, the Medi-Cal program in California has allowed patients to choose private providers for many health care needs. The combination of these two factors has resulted in significantly fewer patients presenting to the General Surgery Service at San Francisco General Hospital. Clearly a hospital fighting to get enough patients to maintain existing services cannot be interested in creating a new service, however appropriate to the environment. Are there national implications to these issues? The fiscal and philosophical problems that existed at the University of Califorma, San Francisco, and San Francisco General Hospital are not unique, and exist in a number of medical schools, in which there are excessive n u m b e r s of specialty faculty surrounded by an excessive number of specialty house staff in increasing competition with an excessive number of private physicians in geographic areas of stable or decreasing population. A careful reading of recent articles in Journal of Trauma I and New England Journal of Medicine 2 suggest that there is a strong feeling in some university centers that emergency physicians and/or residents are unnecessary and that emergency medicine itself is a short-lived field. Of particular interest is Geis's article delineating "an integrated university emergency medicine/trauma program" that is, in fact, a staffing pattern very similar to that chosen by San Francisco General Hospital after the elimination of emergency medicine. All academic emergency physicians should read this article. It delineates physician staffing patterns that will reappear in those university centers seeking to avoid developing departments of emergency medicine. The use of the surgeon attending in the emergency department, as described by Geis, is interesting and somewhat innovative. Unfortunately the rest of the staffing pattern seems to be a return to the 1950s pattern of using young specialists in the community as moonlighting emergency physicians until their practice becomes fiscally sound. The article by Leitzell z is familiar to most. Even to a casual reader of the New England Journal, this article is not of the quality usually found in this prestigious journal. The obvious question is why would an article of so little substance be published? It was published, I suspect, because it fulfills the preconceived opinions of the academic medical community in Boston concerning emergency medicine. The emergency medical residents at San Francisco General Hospital showed clearly in their brief stay that such residents can perform successfully in the trauma center environment, and in fact are necessary. There is no emergency department that needs full-time emergency physicians and emergency medicine residents more than the large public hospital trauma center. The compartmentalization of care into specialty categories makes for an extremely costly and inefficient emergency department and trauma resuscitation center. It was the unanimous opinion of all emergency-medicine-trained faculty exposed to the emergency service at San Francisco

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