- Email: [email protected]
Role of the SARS nurse
CORRESPONDENCE
3. Isenschmid DS, Levine BS, Caplan YH: A comprehensive study of the stability of cocaine and its metabolites. J Anal Toxicol 1989;13:250-256. 4. Brogan WC III, Lange RA, Glamann B, etal: Recurrent cornary vasoconstriction caused by intranasal cocaine: Possible role for metabolites. Ann Intern Med 1992;116:556-561. 5. Madden JA, Powers RH: Effect of cocaine and cocaine metabolites on cerebral arteries in vitro. Life Sci 1990; 47:1109-1114. 6. SandbergJA, Olsen GD: Cocaine pharmacokinetics in the pregnant guinea pig. J Pharmacol Exp Therap 1991;258:477-482. 7. Schreiber D, Torgerson LJ, Covert RF, et al: Effects of cocaine and its metabotites on isolated pressurized cerebral arteries from perinatal lambs. Pediatr Res 1992;31:221. 8. Konkol RJ, DoerrJK, Madden JA: Effects of benzoylecgonine on the behavior of suckling rats: A preliminary report. J Child NeuroI 1992;7:87-92. 9. Konkot RJ, Erickson BA, Doerr JK, etal: Seizues induced by the cocaine metabolite benzoylecgonine in rats. Epilepsia 1992;33:420-427.
In Reply: We appreciate Drs Kenkoland Olson's insightful review of our data, especiallytheir sharing of recent work from their own laboratory.1,2 Thekey point of our article was to alert emergencyphysiciansto the importanceof ascertainingthe specific construction of packets in body stuffers. The rate of release of cocainein vitro is clearly affected by packetdesign.The effect of raising the pH was twofold: it lowered the rateof release of material from the packets,and it resulted in rapid conversionof releasedcocaine to BZEin the simulated gastric medium. Drs Konkoland Olson's data suggestthat BZE may be an active rnetabolite.If they are correct, then we needto considerboth the bioavailabilityof BZE in the gastrointestinaltract and the relative toxicity of BZEversus cocaine. The current treatment of cocaine packetingestion in adults includes whole-bowelirrigation with polyethyleneglycol electrolyte lavagesolution (PEG-ELS)3,4 at a rate of 1 to 2 L/hr. The pH of PEG is 8. While we have not studied the effect of PEG-ELSadministration on gastric pH in human beings, it seems likelythat its effect would be to raisegastric pH. Our study of the effect of pFI on packet integrity and
JULY 1983
22:7
release of cocaine has important implications for current therapy. The bioavailability of BZE in the gastrointestinal tract has not been studied extensively.BZE is an amphetericcompound,5 which implies that it may be poorly absorbedover a wide range of pH. The studies performedand cited by Drs Konkeland Olson looked at the toxicity of 8ZE from the intravenous and intraventricular (central nervous system) routes and not from the oral route. Kenkolet al commentthat "Since BZE is relatively hydrophilic and does not really cross the bloodbrain barrier, the build-up of brain BZE has been attributed to the rapid conversion of cocaineto BZE by hydrolysis in the brain.'q Misra observedno pharmacologiceffects in rats after doses of 250 mg/kg of BZE.6 Konkolet al concludedthat Misra's data "provide additional evidencethat peripherallyderived BZE does not affect the central nervous system."I We appreciate Drs Konkoland Olsen's concerns regardingthe effect of BZE-inducedvasoconstriction in in vitro feline and lamb cerebral artery models.Whether this can be applied clinically for oral administration is unclear. We hope that Annals readerswill not take any leaps and will await further data before undertakingalkalinizatien beyondthe current recommendation of using PEG-ELSin the setting of the body stuffer.3.4 It is hopedthat this useful discussion will inspire subsequentwork en the following questions: What is the oral absorption of cocaine versus BZE?Can an amphoteric compoundsuch as BZE be well absorbedorally? Are there in vivo vasoconstrictiveeffects directly due to BZE?
Steven Aks, DO Daniel Hryhorczuk, MD fan Tebbett, PhD Mercy Hospital and Medical Center The Toxikon Consortium University of Illinois Chicago 1. Konkol RJ, Doerr JK, Madden Jh: Effects of benzoylecgonine on the behavior of suckling rats: A preliminary report. J Child Neurol 1992; 7:87-92. 2. Konkol RJ, Erickson BA, Doerr JK, et al: Seizures induced by !he cocaine metabolite benzoytecgonine in rats. Epilepsia 1992;33:420-427.
ANNALS OF EMER6ENCY MEDICJNE
3. Hoffman RS, Smilkstein MJ, Goldfrank LR: Whole bowel irrigation and the cocaine body stuffer: A new approach to a common problem. AmJ Ernerg Med 1986;4:24-27. 4. Cocaine. Poisondex System 1992 Vol 75, Micromedex Corporation, Denver, Colorado. 5. Moffat AC: Clarke's Isolation and Identification oI Drugs. London, The Pharmaceutical Press, I986, p 385. 6. Misra AL, Nyak PK, Bloch R, etal: Estimation and disposition of 3H benzoylecgonine and pharmacological activity of some cocaine metabolites. J Pharnz Pharmacol 1975;27:784-786.
Role of the SARS Nurse To the Editor: I read with interest "Female Sexual Assault: Medical and Legal Implications" by Rainbowet al [June 1992;21:727-731].The article states that victim counselingwas provided through the SexualAssault Resource Service (SARS).The relative contributions and responsibilities of nurses and physiciansare not described. Two recent articles from this same emergencyservice, however, indicated that the SARS is exclusivelya nursing service.1,2According to this author, the role of the SARSnurse clinician in that setting extends beyondcounselingand includes evidentiary examination,administration of pregnancypreventionand sexuallytransmitted diseasetreatment based on standing orders, and follow-up care. Rainbowet al state "Total professional time for the inital visit averages 4.33 hours, including20 minutes of physiciantime, two hours of ED nursingtime, and two hours of nurse-counselortime." If the SARS nurses have been functioning in this same setting as sexual assault case managersfor 15 years, I am concerned that their role was not acknowledgedadequately. Successful collaborative programs should be describedaccurately in the literature so that emergencycare can improvenationally. Furthermore, in developingour knowledge base regarding care for the victim of sexual assault, I wonder how much farther along we would be if the respective researchershad bridged the discipline gap and conducted
and publishedtheir researchcollaboratively.
Jane KozioI-McLain, RN, MS Colorado EmergencyMedicine Research Center University of Colorado Health Sciences Center Denver 1. Ledray LE: The sexual assault nurse clinician: A fifteen-year experience in Minneapolis. J Emerg Nurs 1992;18:217-222. 2. Ledray LE: The sexual assault examination: Overview and lessons learned in one program. J Emerg Nuts 1992;18:223-230.
In Reply: I agree with Ms KozioI-McLainthat successful collaborative programs should be describedaccurately in the literature. Her concernthat the SARS nurse role was not appropirately acknowledgedin our article is easily put to rest. Although the SARSprogramwas initiated in Minneapolis in 1977 and based at HennepinCountyMedical Center (HCMC), SARSnurses did net do evidentiary or physical examinations for victims of sexual assault there until late 1988. Duringthe period reviewed in this study, the role of the SARSnursewas to provide counselingand follow-up. The interview, examination,evidence collection, and medical treatment were performed by emergency department nursing and physician staff. As the focus of our paper was not on who was performing different portions of the sexual assault examination, but rather on the medical and legal usefulnessof that examination, contributions of the various health care workers were acknowledged simply and truthfully in the statement, "Total professionaltime for the initial visit averages4.33 hours, including 20 minutes of physician time, two hours of ED nursing time, and two hours of nurse-counselor time." The reader might be interested to know that the role of the SARS nurse at HCMChas changedsince t988. Largelybecauseof the ED's commitmentto training emergency medicine residents in sexual assault examination,HCMCwas slow to adopt the nurse-clinicianmodel offered by SAILS.However,what has evolved over the last four years is a rule for SARSat HCMCthat is much
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167
3. Isenschmid DS, Levine BS, Caplan YH: A comprehensive study of the stability of cocaine and its metabolites. J Anal Toxicol 1989;13:250-256. 4. Brogan WC III, Lange RA, Glamann B, etal: Recurrent cornary vasoconstriction caused by intranasal cocaine: Possible role for metabolites. Ann Intern Med 1992;116:556-561. 5. Madden JA, Powers RH: Effect of cocaine and cocaine metabolites on cerebral arteries in vitro. Life Sci 1990; 47:1109-1114. 6. SandbergJA, Olsen GD: Cocaine pharmacokinetics in the pregnant guinea pig. J Pharmacol Exp Therap 1991;258:477-482. 7. Schreiber D, Torgerson LJ, Covert RF, et al: Effects of cocaine and its metabotites on isolated pressurized cerebral arteries from perinatal lambs. Pediatr Res 1992;31:221. 8. Konkol RJ, DoerrJK, Madden JA: Effects of benzoylecgonine on the behavior of suckling rats: A preliminary report. J Child NeuroI 1992;7:87-92. 9. Konkot RJ, Erickson BA, Doerr JK, etal: Seizues induced by the cocaine metabolite benzoylecgonine in rats. Epilepsia 1992;33:420-427.
In Reply: We appreciate Drs Kenkoland Olson's insightful review of our data, especiallytheir sharing of recent work from their own laboratory.1,2 Thekey point of our article was to alert emergencyphysiciansto the importanceof ascertainingthe specific construction of packets in body stuffers. The rate of release of cocainein vitro is clearly affected by packetdesign.The effect of raising the pH was twofold: it lowered the rateof release of material from the packets,and it resulted in rapid conversionof releasedcocaine to BZEin the simulated gastric medium. Drs Konkoland Olson's data suggestthat BZE may be an active rnetabolite.If they are correct, then we needto considerboth the bioavailabilityof BZE in the gastrointestinaltract and the relative toxicity of BZEversus cocaine. The current treatment of cocaine packetingestion in adults includes whole-bowelirrigation with polyethyleneglycol electrolyte lavagesolution (PEG-ELS)3,4 at a rate of 1 to 2 L/hr. The pH of PEG is 8. While we have not studied the effect of PEG-ELSadministration on gastric pH in human beings, it seems likelythat its effect would be to raisegastric pH. Our study of the effect of pFI on packet integrity and
JULY 1983
22:7
release of cocaine has important implications for current therapy. The bioavailability of BZE in the gastrointestinal tract has not been studied extensively.BZE is an amphetericcompound,5 which implies that it may be poorly absorbedover a wide range of pH. The studies performedand cited by Drs Konkeland Olson looked at the toxicity of 8ZE from the intravenous and intraventricular (central nervous system) routes and not from the oral route. Kenkolet al commentthat "Since BZE is relatively hydrophilic and does not really cross the bloodbrain barrier, the build-up of brain BZE has been attributed to the rapid conversion of cocaineto BZE by hydrolysis in the brain.'q Misra observedno pharmacologiceffects in rats after doses of 250 mg/kg of BZE.6 Konkolet al concludedthat Misra's data "provide additional evidencethat peripherallyderived BZE does not affect the central nervous system."I We appreciate Drs Konkoland Olsen's concerns regardingthe effect of BZE-inducedvasoconstriction in in vitro feline and lamb cerebral artery models.Whether this can be applied clinically for oral administration is unclear. We hope that Annals readerswill not take any leaps and will await further data before undertakingalkalinizatien beyondthe current recommendation of using PEG-ELSin the setting of the body stuffer.3.4 It is hopedthat this useful discussion will inspire subsequentwork en the following questions: What is the oral absorption of cocaine versus BZE?Can an amphoteric compoundsuch as BZE be well absorbedorally? Are there in vivo vasoconstrictiveeffects directly due to BZE?
Steven Aks, DO Daniel Hryhorczuk, MD fan Tebbett, PhD Mercy Hospital and Medical Center The Toxikon Consortium University of Illinois Chicago 1. Konkol RJ, Doerr JK, Madden Jh: Effects of benzoylecgonine on the behavior of suckling rats: A preliminary report. J Child Neurol 1992; 7:87-92. 2. Konkol RJ, Erickson BA, Doerr JK, et al: Seizures induced by !he cocaine metabolite benzoytecgonine in rats. Epilepsia 1992;33:420-427.
ANNALS OF EMER6ENCY MEDICJNE
3. Hoffman RS, Smilkstein MJ, Goldfrank LR: Whole bowel irrigation and the cocaine body stuffer: A new approach to a common problem. AmJ Ernerg Med 1986;4:24-27. 4. Cocaine. Poisondex System 1992 Vol 75, Micromedex Corporation, Denver, Colorado. 5. Moffat AC: Clarke's Isolation and Identification oI Drugs. London, The Pharmaceutical Press, I986, p 385. 6. Misra AL, Nyak PK, Bloch R, etal: Estimation and disposition of 3H benzoylecgonine and pharmacological activity of some cocaine metabolites. J Pharnz Pharmacol 1975;27:784-786.
Role of the SARS Nurse To the Editor: I read with interest "Female Sexual Assault: Medical and Legal Implications" by Rainbowet al [June 1992;21:727-731].The article states that victim counselingwas provided through the SexualAssault Resource Service (SARS).The relative contributions and responsibilities of nurses and physiciansare not described. Two recent articles from this same emergencyservice, however, indicated that the SARS is exclusivelya nursing service.1,2According to this author, the role of the SARSnurse clinician in that setting extends beyondcounselingand includes evidentiary examination,administration of pregnancypreventionand sexuallytransmitted diseasetreatment based on standing orders, and follow-up care. Rainbowet al state "Total professional time for the inital visit averages 4.33 hours, including20 minutes of physiciantime, two hours of ED nursingtime, and two hours of nurse-counselortime." If the SARS nurses have been functioning in this same setting as sexual assault case managersfor 15 years, I am concerned that their role was not acknowledgedadequately. Successful collaborative programs should be describedaccurately in the literature so that emergencycare can improvenationally. Furthermore, in developingour knowledge base regarding care for the victim of sexual assault, I wonder how much farther along we would be if the respective researchershad bridged the discipline gap and conducted
and publishedtheir researchcollaboratively.
Jane KozioI-McLain, RN, MS Colorado EmergencyMedicine Research Center University of Colorado Health Sciences Center Denver 1. Ledray LE: The sexual assault nurse clinician: A fifteen-year experience in Minneapolis. J Emerg Nurs 1992;18:217-222. 2. Ledray LE: The sexual assault examination: Overview and lessons learned in one program. J Emerg Nuts 1992;18:223-230.
In Reply: I agree with Ms KozioI-McLainthat successful collaborative programs should be describedaccurately in the literature. Her concernthat the SARS nurse role was not appropirately acknowledgedin our article is easily put to rest. Although the SARSprogramwas initiated in Minneapolis in 1977 and based at HennepinCountyMedical Center (HCMC), SARSnurses did net do evidentiary or physical examinations for victims of sexual assault there until late 1988. Duringthe period reviewed in this study, the role of the SARSnursewas to provide counselingand follow-up. The interview, examination,evidence collection, and medical treatment were performed by emergency department nursing and physician staff. As the focus of our paper was not on who was performing different portions of the sexual assault examination, but rather on the medical and legal usefulnessof that examination, contributions of the various health care workers were acknowledged simply and truthfully in the statement, "Total professionaltime for the initial visit averages4.33 hours, including 20 minutes of physician time, two hours of ED nursing time, and two hours of nurse-counselor time." The reader might be interested to know that the role of the SARS nurse at HCMChas changedsince t988. Largelybecauseof the ED's commitmentto training emergency medicine residents in sexual assault examination,HCMCwas slow to adopt the nurse-clinicianmodel offered by SAILS.However,what has evolved over the last four years is a rule for SARSat HCMCthat is much
1 239/
167