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Transferring patients without doing burr holes
AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 6, Number 6 n November 1988
den on our literature for rigor and vigilance in its peer review. But these are the challenges of a healthy specialty struggling with the “vices” of sophisticated medical science and investigation. It is far better to confront these issues than to have our specialty restricted and entirely derivative. As a participating member of the International Committee of Medical Journal Editors, AJEM subscribes to this organizations’ guidelines for authorship.3 Authorship is a privilege reserved for those who have substantially participated in the creative process of investigation and composition. Participation solely in a technical manner, collecting data, or providing resources, support, or facilities does not justify authorship. Furthermore, all authors must be able to assume responsibility for the integrity of all aspects of the research and its reporting. Powers and others raise the specter of the problems of success for this specialty, and while this journal has not had to retract publications because of fraud, it will
be the shared task of our reviewers and audience, as well as our contributors, to maintain our literature’s scientific and ethical standards to ensure the veracity and validity even more than its immediate relevance and interest. J. DOUGLAS WHITE, MD Editor REFERENCES 1. Powers RD: Multiple authorship, basic research, and other trends in the emergency medicine literature (1975 to 1986). Am J Emerg Med 1988;6:647-650 2. Mills ML: An analysis of the emergency medicine literature: 1982-1985. Ann Emerg Med 1988;17:501-506 3. Huth EJ: Abuses and uses of authorship. Ann Intern Med 1986;104:266-267 4. Huth EJ: Guidelines for authorship of medical papers. Ann Intern Med 1986;104:269-274 5. Freisinger GS: Who should be an author? J Am Coll Cardiol 1986;8:1240-42
TransferringPatientsWithoutDoingBurr Holes Ten years ago there were major referral and tertiary care regional trauma centers without computed axial tomography (CAT) scanners. In the face of obvious trauma the choice at that time was clear: a lengthy cerebral angiogram or immediate craniotomy with burr holes. The hope was of finding the lesion and decompressing subdural or epidural hematoma. The search for the lesion was made easier by playing the statistical odds. The epidural hematoma was usually, but not invariably, on the side of the injury; 80% to 90% of the time ipsilateral to a dilated pupil; and 70% of the time contralateral to a hemiparesis. Still, placing exploratory burr holes is itself time consuming, particularly when four to six holes have to be drilled to find the epidural. Clearly the “head CT” was a miraculous improvement, and the incidence of exploratory burr holes precipitously fell to almost zero. The standard of care did a total “flip flop” over the ten years from 1976 to 1986. In 1976 it was reasonable and not unusual for a general surgeon or even an emergency physician in an outlying hospital to place burr holes on a severely head-injured patient before transferring the patient, and a good outlying emergency physician was expected to have the necessary skills. By 1986 the identical course of action was considered heroically aggressive and uncommon. Because CT is such an excellent diagnostic tool no one wants to operate without it. In essence, the standard of care for outlying hospitals has become to transport the patient to the nearest CT machine and neuro678
surgeon rather than even try to intervene, even when the patient is herniating and the transport means almost certain deterioration and/or death. The report by Springer and Baker’ in this issue calls for a long overdue reevaluation of the current practice. They point out that a relatively quick procedure, which is easily taught, can cause dramatic, almost immediate improvement in selected patients who almost certainly would have a rapid, tragic, downhill course if subjected to the usual transport delays. As the authors prudently point out, it isn’t yet clear which patients to perform the procedure on, nor is it clear exactly what procedure to perform. Nevertheless, we owe our thanks to Springer and Baker. They have now said what a number of us have thought. They have written not “The emperor has no clothes,” but an equivalent “We are routinely transporting people and delivering them into the hands of certain deterioration when there are quick and easy procedures that would provide almost immediate improvement for many of them.” HOWARD A. FREED, MD Department of Emergency Albany Medical College Albany, New York
Medicine
REFERENCE 1. Springer MFB, Baker FJ: Cranial burr hole decompression in the emergency department. Am J Emerg Med 1988; 6640-650
den on our literature for rigor and vigilance in its peer review. But these are the challenges of a healthy specialty struggling with the “vices” of sophisticated medical science and investigation. It is far better to confront these issues than to have our specialty restricted and entirely derivative. As a participating member of the International Committee of Medical Journal Editors, AJEM subscribes to this organizations’ guidelines for authorship.3 Authorship is a privilege reserved for those who have substantially participated in the creative process of investigation and composition. Participation solely in a technical manner, collecting data, or providing resources, support, or facilities does not justify authorship. Furthermore, all authors must be able to assume responsibility for the integrity of all aspects of the research and its reporting. Powers and others raise the specter of the problems of success for this specialty, and while this journal has not had to retract publications because of fraud, it will
be the shared task of our reviewers and audience, as well as our contributors, to maintain our literature’s scientific and ethical standards to ensure the veracity and validity even more than its immediate relevance and interest. J. DOUGLAS WHITE, MD Editor REFERENCES 1. Powers RD: Multiple authorship, basic research, and other trends in the emergency medicine literature (1975 to 1986). Am J Emerg Med 1988;6:647-650 2. Mills ML: An analysis of the emergency medicine literature: 1982-1985. Ann Emerg Med 1988;17:501-506 3. Huth EJ: Abuses and uses of authorship. Ann Intern Med 1986;104:266-267 4. Huth EJ: Guidelines for authorship of medical papers. Ann Intern Med 1986;104:269-274 5. Freisinger GS: Who should be an author? J Am Coll Cardiol 1986;8:1240-42
TransferringPatientsWithoutDoingBurr Holes Ten years ago there were major referral and tertiary care regional trauma centers without computed axial tomography (CAT) scanners. In the face of obvious trauma the choice at that time was clear: a lengthy cerebral angiogram or immediate craniotomy with burr holes. The hope was of finding the lesion and decompressing subdural or epidural hematoma. The search for the lesion was made easier by playing the statistical odds. The epidural hematoma was usually, but not invariably, on the side of the injury; 80% to 90% of the time ipsilateral to a dilated pupil; and 70% of the time contralateral to a hemiparesis. Still, placing exploratory burr holes is itself time consuming, particularly when four to six holes have to be drilled to find the epidural. Clearly the “head CT” was a miraculous improvement, and the incidence of exploratory burr holes precipitously fell to almost zero. The standard of care did a total “flip flop” over the ten years from 1976 to 1986. In 1976 it was reasonable and not unusual for a general surgeon or even an emergency physician in an outlying hospital to place burr holes on a severely head-injured patient before transferring the patient, and a good outlying emergency physician was expected to have the necessary skills. By 1986 the identical course of action was considered heroically aggressive and uncommon. Because CT is such an excellent diagnostic tool no one wants to operate without it. In essence, the standard of care for outlying hospitals has become to transport the patient to the nearest CT machine and neuro678
surgeon rather than even try to intervene, even when the patient is herniating and the transport means almost certain deterioration and/or death. The report by Springer and Baker’ in this issue calls for a long overdue reevaluation of the current practice. They point out that a relatively quick procedure, which is easily taught, can cause dramatic, almost immediate improvement in selected patients who almost certainly would have a rapid, tragic, downhill course if subjected to the usual transport delays. As the authors prudently point out, it isn’t yet clear which patients to perform the procedure on, nor is it clear exactly what procedure to perform. Nevertheless, we owe our thanks to Springer and Baker. They have now said what a number of us have thought. They have written not “The emperor has no clothes,” but an equivalent “We are routinely transporting people and delivering them into the hands of certain deterioration when there are quick and easy procedures that would provide almost immediate improvement for many of them.” HOWARD A. FREED, MD Department of Emergency Albany Medical College Albany, New York
Medicine
REFERENCE 1. Springer MFB, Baker FJ: Cranial burr hole decompression in the emergency department. Am J Emerg Med 1988; 6640-650