2
toma formation or laceration with massive hemorrhage. ~ Other struc- tures that have been reported injured include the thoracic duct, the brachial plexus and the phrenic nerve. Addi- tional problems which have been de- scribed involve inability to catheter- ize, mis-direction of the catheter and late consequences of the procedure such as vein thrombosis and infection. 1-7 Infraclavicular subclavian ven- ipuncture is likely to create a problem if the patient is uncooperative, as in the case under discussion. If rapid ac- cess to a vein to infuse glucose is tech- nically difficult or hazardous, three al- ternatives are available: 1. hypodermoclysis of hypotonic glucose. 2. instillation of glucose through a retention enema. 3. instillation of glucose through a nasogastric tube. All the above means have advan- tages and disadvantages with respect to one another. 11 Absorption with hypodermoclysis occurs by diffusion and is slower than that from the stomach or the intestines. The con- centration of glucose must be approp- riately lower to avoid irritation of the tissue and the procedure must be per- formed with strict asepsis. Absorption of glucose administered in a retention enema bypasses the portal system, thus achieving a rapid onset of effect. However, the absorpiton is often Jr- regular and incomplete. Monosac- charides are completely absorbed in the stomach and small intestine s-l° with the rate of absorption diminish- ing at the lower levels of the intestine. The amount and concentration enter- ing the intestines have comparatively little effect on the rate of absorp- tion. s-l° Hypertonic and hypotonic solutions are both brought to approx- imate isotonicity prior to absorption. The rate of absorption of glucose aver- ages 1 gram per kilogram of body weight per hour. The selection of an alternative to the intravenous route for glucose ad- ministration should be considered in light of the above factors and the specific problems presented by the pa- tient. REFERENCES 1. Moosman D: The anatomy of infra- clavicular subclavian vein catheterization and its complications. Surg Gynedol Obstet 136:71-74, 1973. 2. Parsa M, Habib D, Fever J: Techniques for placement of long term ia. dwelling superior vena cava catheters. 56th Annual Clinical Congress, Amerlca~ College of Surgeons, October, 1970. 3. Henzel J, DeWeese MS: Morbid a~d mortal complications associated with pro. longed central venous cannulation. Am Surg 121:602-605, 1971. 4. Borja AR: Current status of intYa. clavicular subclavian vein catheteriza. tion. Ann Thorac Surg 13:615-624, 1973. 5. Lefrak EA, Noon G: Management of arterial injury secondary to attempted subclavian vein catheterization. Ann Thorac Surg 14:294-298, 1972. 6. Manny J, Haruzi I, Yosipovitch Z: Os- teomyelitis of the clavicle following sub- clavian vein catheterization. Arch Surg 106:342-343, 1973. 7. James P Jr, Myers R: Central venous monitoring -- misinterpretations, abuses, indications and a new technique. Ann Surg 175:693-701, 1972. 8. Cantarow A, Schepartz B: Textbook of Btochemistry, ed 3. Philadelphia, WB Saunders, 1967, pp 409-410. 9. West E, Todd W: Textbook of Biochemistry, ed 3. New York, Macmillan, 1969, p. 471. 10. Best CH, Taylor NB: The Physiologi- cal Basis of Medical Practice, ed 8. Balti. more, William & Wilkins, 1966, p 1334. 11. Goodman LS, Gilman A: The Phar- macological Bas~s of Therapeutics, ed 4. New York, Macmillan, 1970, p 528. correspondence REBUTTAL TO NESBITT ARTICLE To the Editor: I have just read Dr. William Nesbitt's article (Emergency Medicine and Family Practice) published in the March/ April 1974 issue of JACEP and wish to take exception to several points made by him. Dr. Nesbitt's concept that subspecialty is based upon shared percentages of ~common ground" can be extended to include most traditional specialties, making them sub- specialties of family medicine. Indeed, most of medicine could be considered as a subspe- cialty of one or the other primary physician specialties. A legitimate argument could be raised in many quarters for some education of all specialists to be gained in family medicine prior to further specialization. This would, how- ever, make family medicine a nonspecialty. Many of our specialist colleagues, as was pointed out by Dr. Nesbitt, provide primary care. A significant percent of the internist's practice, the obstetrician's practice, the pediatrician's practice, the psychiatrist's practice, and perhaps even the surgeon's practice could conceivably be rendered by a well-trained, competent family physician. But shared percentages are not what separate out spe- cialists. It is the "unshared" percentages that make the difference. If indeed Dr. Nesbitt believes that the ACEP and the AAFP should develop a primary health care system that integrates the functions, responsibilities and duties of each into a comprehensive emergency health care plan, should not our internal medicine colleagues, our surgical col- leagues and our pediatric colleagues, among others, be included? If emergency medicine, because it shares with family practice the commonality of providing primary health care, Page 260 Journal of the American College of Emergency Physicians July/August 1914

Rebuttal to nesbitt article

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toma format ion or lacera t ion with mass ive hemorrhage . ~ Other struc- tures tha t have been repor ted in jured include the thoracic duct, the brachia l plexus and the phrenic nerve. Addi- t ional problems which have been de- scribed involve inab i l i t y to catheter- ize, mis-direct ion of the ca the te r and la te consequences of the procedure such as ve in t h r o m b o s i s and infection. 1-7

I n f r a c l a v i c u l a r s u b c l a v i a n ven- ipuncture is l ike ly to c rea te a problem if the pa t i en t is uncooperat ive , as in the case under discussion. I f rap id ac- cess to a vein to infuse glucose is tech- n ica l ly difficult or hazardous , three al- t e rna t ives a re avai lab le :

1. hypodermoclys is of hypotonic glucose.

2. ins t i l l a t ion of glucose th rough a re ten t ion enema.

3. ins t i l l a t ion of glucose th rough a nasogas t r ic tube.

Al l the above means have advan- tages and d i sadvan tages wi th respect to one another . 11 Absorpt ion with hypodermoclys is occurs by diffusion and is slower than t ha t from the s tomach or the in tes t ines . The con- cen t ra t ion of glucose mus t be approp-

r i a te ly lower to avoid i r r i t a t ion of the t issue and the procedure mus t be per- formed wi th s t r ic t asepsis. Absorpt ion of glucose admin i s t e red in a re ten t ion enema bypasses the por ta l system, thus achieving a r ap id onset of effect. However, the absorpi ton is often Jr- r egu la r and incomplete. Monosac- char ides are complete ly absorbed in the s tomach and smal l in tes t ine s-l° wi th the ra te of absorpt ion diminish- ing at the lower levels of the intest ine. The amount and concentra t ion enter- ing the in tes t ines have compara t ive ly l i t t l e effect on the r a t e of absorp- t ion. s-l° H y p e r t o n i c and hypo ton ic solut ions are both brought to approx- ima te isotonici ty pr ior to absorption. The ra te of absorpt ion of glucose aver- ages 1 g r a m per k i l o g r a m of body weight per hour.

The select ion of an a l t e rna t ive to the in t ravenous route for glucose ad- min i s t r a t ion should be considered in l ight of the above factors and the specific problems presented by the pa- t ient .

REFERENCES 1. Moosman D: The anatomy of infra-

clavicular subclavian vein catheterization and its complications. Surg Gynedol Obstet 136:71-74, 1973.

2. Parsa M, Habib D, Fever J: Techniques for placement of long term ia. dwelling superior vena cava catheters. 56th Annual Clinical Congress, Amerlca~ College of Surgeons, October, 1970.

3. Henzel J, DeWeese MS: Morbid a~d mortal complications associated with pro. longed central venous cannulation. Am Surg 121:602-605, 1971.

4. Borja AR: Current status of intYa. clavicular subclavian vein catheteriza. tion. Ann Thorac Surg 13:615-624, 1973.

5. Lefrak EA, Noon G: Management of arterial injury secondary to attempted subclavian vein catheter izat ion. Ann Thorac Surg 14:294-298, 1972.

6. Manny J, Haruzi I, Yosipovitch Z: Os- teomyelitis of the clavicle following sub- clavian vein catheterization. Arch Surg 106:342-343, 1973.

7. James P Jr, Myers R: Central venous monitoring - - misinterpretations, abuses, indications and a new technique. Ann Surg 175:693-701, 1972.

8. Cantarow A, Schepartz B: Textbook of Btochemistry, ed 3. Philadelphia, WB Saunders, 1967, pp 409-410.

9. West E, Todd W: Textbook of Biochemistry, ed 3. New York, Macmillan, 1969, p. 471.

10. Best CH, Taylor NB: The Physiologi- cal Basis of Medical Practice, ed 8. Balti. more, William & Wilkins, 1966, p 1334.

11. Goodman LS, Gilman A: The Phar- macological Bas~s of Therapeutics, ed 4. New York, Macmillan, 1970, p 528.

c o r r e s p o n d e n c e

REBUTTAL TO NESBITT ARTICLE

To the Editor:

I have jus t r ead Dr. Wi l l i am Nesbi t t ' s a r t ic le (Emergency Medicine and F a m i l y Practice) publ ished in the March/ Apr i l 1974 issue of J A C E P and wish to t ake exception to severa l points made by him.

Dr. Nesbi t t ' s concept t ha t subspecia l ty is based upon shared percentages of ~common ground" can be extended to include most t r ad i t i ona l specialt ies, m a k i n g them sub- special t ies of fami ly medicine.

Indeed, most of medicine could be considered as a subspe- c ia l ty of one or the other p r i m a r y physic ian special t ies. A leg i t imate a r g u m e n t could be ra ised in many quar te r s for some educat ion of al l special is ts to be gained in fami ly medicine pr ior to fu r the r special izat ion. This would, how- ever, make fami ly medic ine a nonspecial ty.

Many of our specia l i s t colleagues, as was pointed out by Dr. Nesbi t t , provide p r ima ry care. A s igni f icant percent of the in te rn is t ' s practice, the obs te t r ic ian ' s pract ice, the ped ia t r i c ian ' s pract ice, the psych ia t r i s t ' s practice, and perhaps even the surgeon 's pract ice could conceivably be rendered by a wel l - t ra ined, competent fami ly physician. But shared percentages are not wha t sepa ra te out spe- cial ists . I t is the "unshared" percentages t h a t make the difference.

I f indeed Dr. Nesb i t t bel ieves tha t the ACEP and the A A F P should develop a p r i m a r y hea l th care system that in tegra tes the functions, responsibi l i t ies and dut ies of each into a comprehensive emergency hea l t h care plan, should not our in te rna l medicine colleagues, our surgical col- leagues and our pedia t r ic colleagues, among others, be included?

If emergency medicine, because i t shares with family pract ice the commonal i ty of providing p r i m a r y hea l th care,

Page 260 Journal of the American College of Emergency Physicians July/August 1914

Page 2: Rebuttal to nesbitt article

be made a subspec ia l ty of fami ly medicine, should not all the special t ies which also provide p r i m a r y hea l th care be made subspecia l t ies of fami ly medicine?

The deve lopment of solut ions to common problems is fine. The absorpt ion, however, of emergency medicine into family medic ine will be the dea th knel l of the emergency medicine movement and represen ts l i t t le more t han the a t tempt to b roaden the scope of f ami ly medic ine and empire-build.

Ronald L. Krome, MD, FACS Associate Professor of Surgery

Director, Emergency De pa r tme n t Detroi t General Hospi ta l

EMESIS TABLE PROPOSED

To the Editor:

The a r t i c l e on A p o m o r p h i n e - N a l o x o n e C o n t r o l l e d Rapid Emes is [Raus ten DS, Ochs MA: Jacep 2:1, 44-5, 1973] was a welcome addi t ion to the therapeut ic protocol of any busy emergency center . However , i ts fo rmat was somewhat awkward for quick calculat ions, especia l ly at the ext remes of body weight. The accompanying table al- lows for r ap id age-weight-dose de te rmina t ions when delay in t r ea tmen t may be cri t ical . I t has been inva luab le in our emergency center.

In our l imi ted series, the t ime to achieve emesis averaged ten minutes compared with 20 minutes with the use of ipecac. Res i s t an t pa t ien t s usua l ly respond to tongue de- pression af ter ten minutes . The only fa i lures in achieving emesis have occurred in phenoth iaz ine in toxicat ions when t rea tment has been delayed for severa l hours.

F. E. Picklow, Jr . , MD Wil loughby, Ohio

Ed.'s Note: Dr. Picklow's suggestion was forwarded to Dr. Rausten, whose response appears below.

To the Editor:

Regarding the s t a t emen t by F. E. Picklow, Jr . , MD re- garding the awkwardness of calculat ions for dosages on

Age

years pounds

2 28 3 32 4 37 5 42 6 49 7 54 I 100

125 Over 7 150

175 2OO 225 250

Apomorphine-Naloxone Controlled Rapid Emesis

Weight Apomorphine* Naloxone** 30/4g/Ib 4.5Fg/Ib

CC CC

0.85 0.33 1.0 0.38 1.1 0.43 1.25 0.45 1.5 0.51 1.6 0.61 3.0 1.1 3.75 1.4 4.5 1.7 5.25 2.0 6.0 2.3 6.75 2.6 7.5 2.9

* Dissolve 6 mg tablet in 6.0 cc H20; administer sub- cutaneously. Do not repeat.

**0.4 m g = 1.0 cc. May be administered IV, IM, or, sub- cutaneously, prn with complete safety.

apomorphine and naloxone - - control led rap id emesis.

I have found tha t calculat ions of dosage for chi ldren based on age were considered inaccura te . The only basic dosage calculat ion considered, therefore, was based on weight. The calculat ion of 0.03 mg/lb or 0.066 mg/kg for apomorphine, and 0.01 mg/kg of naloxone is very easy and basic for any s tuden t nurse or doctor to calculate . Based on these calculat ions, a char t was developed.

The char t which accompanied the ar t ic le gave ranges of pre-ca]culated doses. Wha t else could one want? The ar t ic le speaks for itself!

Corresponding calculat ions a t e i ther range of body weight are easy to calculate. I bel ieve Dr. Picklow has offered no advantage .

David S. Rausten, MD Director of Emergency Service

Pa rad i se Val ley Hospi tal Na t iona l City, Cal ifornia

July/August 1974 Journal of the American College of Emergency Physicians Page 261