of us involved in the field of tobacco abuse have an enormous amount of compassion for those who have not yet been able to quit. Waugh notes that the tone of the arguments against smoking have changed. It is a real pity that he has not taken the time to read these arguments. If he had, he would have seen that the content has also changed. Virtually all of the analysis today concerns how best to prevent children from starting to smoke. The elimination of advertising, the educational campaigns, the encouragement of price increases and the efforts to limit access to tobacco are all specifically designed to discourage smoking among children. Does Waugh disagreee that this is important? I wish Waugh were correct when he says that the battle over smoking is just about over. Children are taking up smoking at distressingly high rates, and this is particularly true for girls. A 1986 study by the Department of National Health and Welfare found that 329 164 Canadians between 15 and 19 years of age were regular smokers. I We are destined to not be free of tobacco-caused disease for at least one more generation. A recent study from the World Health Organization2 has estimated that tobacco will kill 500 million people around the world in the next 25 years and that smoking will be the number one cause of death in the world by the turn of the century. Today 8000 people a day die from smoking-related disease. When today's children reach middle age the figure will be 28 000 a day. The battle is far from over. The contention that the poor tobacco companies are losing money is patently absurd. Tobacco remains the most profitable product available, with a captive market of millions of addicts. These companies will stay alive by
finding new strategies to create child addicts. The notion that each of us has the right to self-destruct is interesting. If another ubiquitous substance - for example, aspartame - were shown conclusively to have killed 35 000 Canadians last year, as tobacco did,3 would Waugh advocate the right of each person to continue to use it if he or she wished? I contend that the government would immediately ban the substance, and the manufacturer would face massive lawsuits. I recommend that Waugh review the data that led to the banning of saccharin and compare it with the data on tobacco. Since more than 5.5 million Canadians remain addicted to tobacco' a total ban would be impractical as well as unkind, but we should all be moving as quickly as possible to eliminate this lethal substance. Let us portray the tobacco companies in their true light, as drug pushers whose survival depends on turning our children into addicts. So there. Mark C. Taylor, MD Nova Scotia representative Physicians for a Smoke-Free Canada PO Box 9530, Stn. A Halifax, NS
tionally inept as a missionary, but I do what I can. So there. Douglas Waugh, MD 183 Marlborough Ave. Ottawa, Ont.
Abortion as mayhem D r. Catherine Ferrier ("CMA's response to
abortion bill" [Can Med Assoc J 1990; 142: 515]) may well have no love of British common law, but the criminalization of abortion in Britain stemmed from the crime of mayhem. Any act that left the victim less able to serve the monarch was mayhem. Thus, removing a man's front teeth left him unable to eat army rations and so unable to serve in the British army. Hence the cockney threat "I'll kick your back [my emphasis] teeth in", which would avoid the crime of mayhem, although it must be difficult to
achieve. Abortion might deprive the monarch of a future British soldier, so it was considered mayhem. Its criminalization had little to do with the sanctity of life. R.H. Boardman, MD Box 1000 Ponoka, Alta.
References 1. Smoking Behaviour of Canadians, 1986 (cat no H39-66/1988E), Dept of Na-
tional Health and Welfare, Ottawa, 1988:28 2. Lopez A, Peto R: Paper presented at 7th World Conference on Tobacco and Health, Perth, Australia, Apr 1-5, 1990 3. The Active Health Report on Alcohol, Tobacco and Marijuana (cat no H39-145/1989E), Dept of National Health and Welfare, Ottawa, 1989: 7
[Dr. Waugh responds.]
A
Dr. Taylor is right: he and I agree on tobacco addiction. The difference between us is that he approaches it with missionary zeal, whereas my style is the lampoon. I cannot help it that I am constitu-
Acute asthma: emergency department management and prospective evaluation of outcome I was disappointed to read the paper by Drs. J. Mark Fitzgerald and Frederick E. Hargreave (Can Med Assoc J 1990; 142: 591-595). The authors offer opinion as fact, with little objective evidence from their own study to support it. Because the portion of the CAN MED ASSOC J 1990: 142(I 1)
1183
study involving patient management was retrospective there were no rigid criteria for entry, no standardized treatment protocols and, of course, no control groups. Owing to incomplete objective criteria for severity of illness (or lack of charting of such) we have no clear idea of the grouping of patients according to their presentation (mild, moderate or severe) or of the treatments used for each group. Without this information we cannot assess whether these patients' outcomes were below an acceptable standard and if so why these failures occurred. The authors base their opinion of "suboptimal" management of asthma patients in the emergency department on a relapse rate of 37% and a subsequent admission rate of 13%, without demonstrating better outcomes in a control group following their treatment protocols. They claim that these rates are higher than those in other studies that included "the routine use of corticosteroids", without showing that the patient populations or their overall management were similar. Fitzgerald and Hargreave criticize multiple aspects of the management of these patients, including the histories taken, underuse of spirometry, and inadequate use of anticholinergic and steroid therapy, without linking any of these directly to patient outcome. Their statement that for "all patients with acute asthma" presenting to an emergency department (presumably regardless of severity) "the use of corticosteroids is routinely indicated" is not supported by their findings. They admit that there is controversy regarding the value of spirometry in deciding whether to admit or discharge asthma patients; however, they "continue to recommend it", without adding new, objective evidence to support this practice. Some of the authors' recommendations (the use of spirometry 1186
CAN MED ASSOC J 1990: 142 ( 11)
contacted at various intervals after the emergency department visit also makes the conclusions suspect. The lack of information from a comparison group makes it difficult to accept as valid the authors' recommendations regarding treatment. Assessment in a "respiratory clinic" is not shown Trevor Gilkinson, MD, FRCPC to be necessary. Department of Emergency Medicine At best this paper presents a Victoria Hospital descriptive study pointing to the London, Ont. need for reassessment of patients Drs. Fitzgerald and Hargreave re- with asthma after emergency detrospectively examined charts partment visits. At worst it is an with the diagnosis of "asthma" unfounded criticism of the quality after the patient's discharge from of care provided in the emergency the emergency department. This department by researchers with method is fraught with recording little knowledge of the reality of error and underrepresentation of care in this setting. Further reclinical findings. Busy emergency search in this area needs to be physicians may provide care first methodologically sound and withand document later. Thus, the out bias to be helpful in manageconclusions regarding asthma as- ment decisions. sessment with this technique are Brian Rowe, MD, CCFP (EM) highly questionable. Gajdowski, MD The authors' insistence on Richard Michael Shuster, MD, FRCPC, DABEM documentation of pulsus paradox- Stephen Lloyd, MD, CCFP (EM), us and on spirometry reflects their DABEM personal preferences, not the view Chedoke-McMaster Hospitals supported by current emergency Hamilton, Ont. medicine research.' The validity of spirometry in the patient with References acute asthma depends on the pa- 1. Worthington JR, Ahuja J: The value of tient's ability to comprehend the pulmonary function tests in the management of acute asthma. Can Med instructions and then comply with 1989; 140: 153-156 them. The reproducibility of the 2. .4ssocJ Feinstein AR, Josephy BR, Wells CK: results with hand-held equipment Scientific and clinical problems in inin this kind of patient in an emerdexes of functional disability. Ann Intern i Med 1986: 105: 413-420 gency department is unproven and questionable. Innuendo regarding the choice of a nebulizer [Drs. Fitzgerald and Hargreave reover a metered-dose inhaler is un- spond.justified by any scientific evidence that one is more efficacious than Our study was an audit with the the other. objective of assessing the current The main weaknesses of this emergency management of asthma study are the inappropriate out- in our hospital. The assessment of come assessment and the lack of a investigation and treatment in the comparison group. Despite abun- emergency department had to be dant measurement tools in the retrospective, but the outcomes field of disability research2 the were assessed prospectively. authors selected a simple, poorly The outcomes of treatment described outcome that provides were poor. Apart from the relapse an assessment that is less than and admission rates cited by Dr. reliable or valid. The fact that Gilkinson, which are significant, only 72% of the patients were we also demonstrated that 2 for all patients and more aggressive use of steroids) have support from existing literature for certain patient populations. From the study presented by the authors, however, we have no way of knowing if their conclusions are valid.
finding new strategies to create child addicts. The notion that each of us has the right to self-destruct is interesting. If another ubiquitous substance - for example, aspartame - were shown conclusively to have killed 35 000 Canadians last year, as tobacco did,3 would Waugh advocate the right of each person to continue to use it if he or she wished? I contend that the government would immediately ban the substance, and the manufacturer would face massive lawsuits. I recommend that Waugh review the data that led to the banning of saccharin and compare it with the data on tobacco. Since more than 5.5 million Canadians remain addicted to tobacco' a total ban would be impractical as well as unkind, but we should all be moving as quickly as possible to eliminate this lethal substance. Let us portray the tobacco companies in their true light, as drug pushers whose survival depends on turning our children into addicts. So there. Mark C. Taylor, MD Nova Scotia representative Physicians for a Smoke-Free Canada PO Box 9530, Stn. A Halifax, NS
tionally inept as a missionary, but I do what I can. So there. Douglas Waugh, MD 183 Marlborough Ave. Ottawa, Ont.
Abortion as mayhem D r. Catherine Ferrier ("CMA's response to
abortion bill" [Can Med Assoc J 1990; 142: 515]) may well have no love of British common law, but the criminalization of abortion in Britain stemmed from the crime of mayhem. Any act that left the victim less able to serve the monarch was mayhem. Thus, removing a man's front teeth left him unable to eat army rations and so unable to serve in the British army. Hence the cockney threat "I'll kick your back [my emphasis] teeth in", which would avoid the crime of mayhem, although it must be difficult to
achieve. Abortion might deprive the monarch of a future British soldier, so it was considered mayhem. Its criminalization had little to do with the sanctity of life. R.H. Boardman, MD Box 1000 Ponoka, Alta.
References 1. Smoking Behaviour of Canadians, 1986 (cat no H39-66/1988E), Dept of Na-
tional Health and Welfare, Ottawa, 1988:28 2. Lopez A, Peto R: Paper presented at 7th World Conference on Tobacco and Health, Perth, Australia, Apr 1-5, 1990 3. The Active Health Report on Alcohol, Tobacco and Marijuana (cat no H39-145/1989E), Dept of National Health and Welfare, Ottawa, 1989: 7
[Dr. Waugh responds.]
A
Dr. Taylor is right: he and I agree on tobacco addiction. The difference between us is that he approaches it with missionary zeal, whereas my style is the lampoon. I cannot help it that I am constitu-
Acute asthma: emergency department management and prospective evaluation of outcome I was disappointed to read the paper by Drs. J. Mark Fitzgerald and Frederick E. Hargreave (Can Med Assoc J 1990; 142: 591-595). The authors offer opinion as fact, with little objective evidence from their own study to support it. Because the portion of the CAN MED ASSOC J 1990: 142(I 1)
1183
study involving patient management was retrospective there were no rigid criteria for entry, no standardized treatment protocols and, of course, no control groups. Owing to incomplete objective criteria for severity of illness (or lack of charting of such) we have no clear idea of the grouping of patients according to their presentation (mild, moderate or severe) or of the treatments used for each group. Without this information we cannot assess whether these patients' outcomes were below an acceptable standard and if so why these failures occurred. The authors base their opinion of "suboptimal" management of asthma patients in the emergency department on a relapse rate of 37% and a subsequent admission rate of 13%, without demonstrating better outcomes in a control group following their treatment protocols. They claim that these rates are higher than those in other studies that included "the routine use of corticosteroids", without showing that the patient populations or their overall management were similar. Fitzgerald and Hargreave criticize multiple aspects of the management of these patients, including the histories taken, underuse of spirometry, and inadequate use of anticholinergic and steroid therapy, without linking any of these directly to patient outcome. Their statement that for "all patients with acute asthma" presenting to an emergency department (presumably regardless of severity) "the use of corticosteroids is routinely indicated" is not supported by their findings. They admit that there is controversy regarding the value of spirometry in deciding whether to admit or discharge asthma patients; however, they "continue to recommend it", without adding new, objective evidence to support this practice. Some of the authors' recommendations (the use of spirometry 1186
CAN MED ASSOC J 1990: 142 ( 11)
contacted at various intervals after the emergency department visit also makes the conclusions suspect. The lack of information from a comparison group makes it difficult to accept as valid the authors' recommendations regarding treatment. Assessment in a "respiratory clinic" is not shown Trevor Gilkinson, MD, FRCPC to be necessary. Department of Emergency Medicine At best this paper presents a Victoria Hospital descriptive study pointing to the London, Ont. need for reassessment of patients Drs. Fitzgerald and Hargreave re- with asthma after emergency detrospectively examined charts partment visits. At worst it is an with the diagnosis of "asthma" unfounded criticism of the quality after the patient's discharge from of care provided in the emergency the emergency department. This department by researchers with method is fraught with recording little knowledge of the reality of error and underrepresentation of care in this setting. Further reclinical findings. Busy emergency search in this area needs to be physicians may provide care first methodologically sound and withand document later. Thus, the out bias to be helpful in manageconclusions regarding asthma as- ment decisions. sessment with this technique are Brian Rowe, MD, CCFP (EM) highly questionable. Gajdowski, MD The authors' insistence on Richard Michael Shuster, MD, FRCPC, DABEM documentation of pulsus paradox- Stephen Lloyd, MD, CCFP (EM), us and on spirometry reflects their DABEM personal preferences, not the view Chedoke-McMaster Hospitals supported by current emergency Hamilton, Ont. medicine research.' The validity of spirometry in the patient with References acute asthma depends on the pa- 1. Worthington JR, Ahuja J: The value of tient's ability to comprehend the pulmonary function tests in the management of acute asthma. Can Med instructions and then comply with 1989; 140: 153-156 them. The reproducibility of the 2. .4ssocJ Feinstein AR, Josephy BR, Wells CK: results with hand-held equipment Scientific and clinical problems in inin this kind of patient in an emerdexes of functional disability. Ann Intern i Med 1986: 105: 413-420 gency department is unproven and questionable. Innuendo regarding the choice of a nebulizer [Drs. Fitzgerald and Hargreave reover a metered-dose inhaler is un- spond.justified by any scientific evidence that one is more efficacious than Our study was an audit with the the other. objective of assessing the current The main weaknesses of this emergency management of asthma study are the inappropriate out- in our hospital. The assessment of come assessment and the lack of a investigation and treatment in the comparison group. Despite abun- emergency department had to be dant measurement tools in the retrospective, but the outcomes field of disability research2 the were assessed prospectively. authors selected a simple, poorly The outcomes of treatment described outcome that provides were poor. Apart from the relapse an assessment that is less than and admission rates cited by Dr. reliable or valid. The fact that Gilkinson, which are significant, only 72% of the patients were we also demonstrated that 2 for all patients and more aggressive use of steroids) have support from existing literature for certain patient populations. From the study presented by the authors, however, we have no way of knowing if their conclusions are valid.
