Local Anesthesia
a t the expense of t h o r o u g h scientific procedure, as classically defined by Koch. The practice of sending a g a n g r e n o u s a p p e n d i x from t h e o p e r a t i n g room to the l a b o r a t o r y is also not n e c e s s a r y for the successful outcome of most patients, y e t few would r e c o m m e n d t h e abolition of t h a t procedure. Lest m y c o m m e n t a p p e a r couched only in t h e context of medical t r a d i t i o n or classic microbiology, I would p o i n t out t h a t both retrospective and prospective epidemiologic studies of infectious disease processes depend on d a t a recovered from s t a n d a r d i z e d s c i e n t i f i c p r a c t i c e , often a t mom e n t s far removed from the t i m e of the a c t u a l infectious event. C l i n i c a l l y speaking, the exceptional pat i e n t is often best served in the course of an a t y p i c a l t h e r a p e u t i c response w h e n definitive microbiological d a t a are r e a d i l y available.
To the Editor: H a v i n g observed m a n y of m y colleagues at work in e m e r g e n c y d e p a r t m e n t s in several states, I have noted that, w i t h r e g a r d to local a n e s t h e s i a , most are in need of some simple advice in the i n t e r e s t of their p a t i e n t s and themselves. Tell t h e p a t i e n t , if he is old enough to u n d e r s t a n d , w h e r e and w h e n you are about to inject, t h a t it will h u r t a little, and w a r n h i m not to move, p a r t i c u l a r l y if t h e injection is to be m a d e into the h a n d or the foot. 1 I u s u a l l y touch the point of the needle l i g h t l y to the skin, at the same t i m e s a y i n g "On t h e count of t h r e e you will feel a prick a t this spot. Do not move or I m a y have to stick you a second time." The idiomatic English, well understood by patients, is t h u s acceptable. In t h e case of local a n e s t h e s i a to the sole of the foot, I tell the p a t i e n t t h a t it w i l l be very painful. If you don't believe me, a s k a colleague to t r y it on your foot. It should not be necessary to add, b u t I have observed t h a t it is, t h a t t h e s m a l l e s t size needle possible should be used a n d t h a t the slower the r a t e of the injection, the less the pain. F u r t h e r m o r e , if epinephrine is contained in t h e a n e s t h e t i c solution, r e m e m b e r t h a t a n e s t h e s i a occurs more slowly: T a k e two m i n u t e s of A C E P m e d i t a t i o n before s t a r t i n g to suture. Physicians, likewise, do not all know t h a t r i n g block of a finger does not produce i n s t a n t a n e o u s anesthesia. Even longer m e d i t a t i o n m a y be necessary.
W. C. Anderson, MD Chapman General Hospital Emergency Department Orange, California
Author's Reply Koch, in his quest to isolate the etiologic a g e n t of tuberculosis, de~eloped his now famous p o s t u l a t e s to isolate a n d identify a n offending pathogen. These four p o s t u l a t e s h a v e provided t h e basis for m o d e r n d a y microbiologic isolation and identification. O u r s t u d y w a s done in t h e s t r i c t e s t s c i e n t i f i c method w i t h as few v a r i a b l e s as possible in order to properly identify the bacteriologic pathogens sden in cutaneous abscesses from various regions of t h e body. As t h i s d a t a was b e i n g collected, the i n v e s t i g a t o r s realized t h a t antibiotics w e r e not indicated to i n s u r e healing. A l t h o u g h h e a l i n g t i m e s with or w i t h o u t ant i b i o t i c s w e r e not m e a s u r e d , a l l abscesses t r e a t e d w i t h o u t antibiotics c o m p l e t e l y healed. Dr. Anders~n m a k e s the point t h a t w h e t h e r or not antibiotics are needed, c u l t u r i n g should still exist. His reason s e e m i n g l y is t h a t we somehow violate the classic postulates of Koch and have voided some p o t e n t i a l d a t a of undefined, futuristic, retrospective studies. I object to both of t h e s e points. We suggested a very cost-effective a p p r o a c h to t h e t r e a t m e n t of localized, cutaneous abscesses. In those p a t i e n t s where antibiotics are indicated, a p r e s u m p t i v e indication of t h e bact e r i a involved can be had to choose the proper i n i t i a l antibiotic needed to e r a d i c a t e the offending bacteria. In those patients, c u l t n r i n g can be done t h a t can l a t e r be compared to the i n i t i a l d r u g use as to efficacy. It is u n f a i r to the p a t i e n t in t h i s world of severely r i s i n g medical costs to c u l t u r e wounds unnecessarily, simply for the sake of some futuristic epidemiologic study. W h y culture or G r a m stain the purulence of a n abscess if antibiotics are not indicated for h e a l i n g to occur in a p a t i e n t w i t h n o r m a l host defenses? I see no reason for u n n e c e s s a r y culturing. P e r h a p s Koch m a y have agreed as he h i m s e l f s t a t e d "The l i t e r a t u r e on b a c t e r i a h a s b e e n a l l o w e d to s w e l l into a m u d d y stream."1
Cyril T. M. Cameron, MD, FRCS, FACS Director, Emergency Department Samaritan Hospital, Troy, New York 1. Cameron CTM: The treatment of superficial lacerations of the hand. Med J Aust 1:244, 1967.
AHA Guidelines for
Hospital Based Physicians To the Editor: The article e n t i t l e d " P o s t g r a d u a t e Realities: Surv i v i n g in E m e r g e n c y Medicine Practice," published in t h e J u n e 1978 issue of y o u r j o u r n a l , w a s r e c e n t l y b r o u g h t to our attention. Because m u c h of t h e article deals with the American Hospital Association's
Guidelines on Contractual Relationships Between Hospitals and Physicians, we feel t h a t a response is indicated. The author of the article, K a r l G. Marigold, MD, h a s b a s e d his c o n c e r n s on t h e " i n e q u i t i e s a n d inapplicability" of the A H A ' s guidelines, p a r t i c u l a r l y as t h e y r e l a t e to hospital approval of fees of emergency physicians u n d e r contract w i t h t h e hospital. However, t h e guidelines, as t h e y refer to hospital approval of fees, are not i n t e n d e d to apply to all m e m b e r s of the h o s p i t a l medical staff, b u t only to t h o s e who receive exclusive or s h a r e d exclusive contracts. Hospital review and approval of charges of p h y s i c i a n s who hold such contracts is considered appropriate, because the p a t i e n t who seeks t h e i r services at the h o s p i t a l has no a l t e r n a t i v e choice of physician. We should point out t h a t since the publication of t h e Guidelines in 1976,
Harvey W. Meislin, MD UCLA Emergency Medicine Center Los Angeles, California 1. Knight DC: Robert Koch, Father of Bacteriology. London, Chatto and Windus, Ltd, 1978, p 67.
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a t the expense of t h o r o u g h scientific procedure, as classically defined by Koch. The practice of sending a g a n g r e n o u s a p p e n d i x from t h e o p e r a t i n g room to the l a b o r a t o r y is also not n e c e s s a r y for the successful outcome of most patients, y e t few would r e c o m m e n d t h e abolition of t h a t procedure. Lest m y c o m m e n t a p p e a r couched only in t h e context of medical t r a d i t i o n or classic microbiology, I would p o i n t out t h a t both retrospective and prospective epidemiologic studies of infectious disease processes depend on d a t a recovered from s t a n d a r d i z e d s c i e n t i f i c p r a c t i c e , often a t mom e n t s far removed from the t i m e of the a c t u a l infectious event. C l i n i c a l l y speaking, the exceptional pat i e n t is often best served in the course of an a t y p i c a l t h e r a p e u t i c response w h e n definitive microbiological d a t a are r e a d i l y available.
To the Editor: H a v i n g observed m a n y of m y colleagues at work in e m e r g e n c y d e p a r t m e n t s in several states, I have noted that, w i t h r e g a r d to local a n e s t h e s i a , most are in need of some simple advice in the i n t e r e s t of their p a t i e n t s and themselves. Tell t h e p a t i e n t , if he is old enough to u n d e r s t a n d , w h e r e and w h e n you are about to inject, t h a t it will h u r t a little, and w a r n h i m not to move, p a r t i c u l a r l y if t h e injection is to be m a d e into the h a n d or the foot. 1 I u s u a l l y touch the point of the needle l i g h t l y to the skin, at the same t i m e s a y i n g "On t h e count of t h r e e you will feel a prick a t this spot. Do not move or I m a y have to stick you a second time." The idiomatic English, well understood by patients, is t h u s acceptable. In t h e case of local a n e s t h e s i a to the sole of the foot, I tell the p a t i e n t t h a t it w i l l be very painful. If you don't believe me, a s k a colleague to t r y it on your foot. It should not be necessary to add, b u t I have observed t h a t it is, t h a t t h e s m a l l e s t size needle possible should be used a n d t h a t the slower the r a t e of the injection, the less the pain. F u r t h e r m o r e , if epinephrine is contained in t h e a n e s t h e t i c solution, r e m e m b e r t h a t a n e s t h e s i a occurs more slowly: T a k e two m i n u t e s of A C E P m e d i t a t i o n before s t a r t i n g to suture. Physicians, likewise, do not all know t h a t r i n g block of a finger does not produce i n s t a n t a n e o u s anesthesia. Even longer m e d i t a t i o n m a y be necessary.
W. C. Anderson, MD Chapman General Hospital Emergency Department Orange, California
Author's Reply Koch, in his quest to isolate the etiologic a g e n t of tuberculosis, de~eloped his now famous p o s t u l a t e s to isolate a n d identify a n offending pathogen. These four p o s t u l a t e s h a v e provided t h e basis for m o d e r n d a y microbiologic isolation and identification. O u r s t u d y w a s done in t h e s t r i c t e s t s c i e n t i f i c method w i t h as few v a r i a b l e s as possible in order to properly identify the bacteriologic pathogens sden in cutaneous abscesses from various regions of t h e body. As t h i s d a t a was b e i n g collected, the i n v e s t i g a t o r s realized t h a t antibiotics w e r e not indicated to i n s u r e healing. A l t h o u g h h e a l i n g t i m e s with or w i t h o u t ant i b i o t i c s w e r e not m e a s u r e d , a l l abscesses t r e a t e d w i t h o u t antibiotics c o m p l e t e l y healed. Dr. Anders~n m a k e s the point t h a t w h e t h e r or not antibiotics are needed, c u l t u r i n g should still exist. His reason s e e m i n g l y is t h a t we somehow violate the classic postulates of Koch and have voided some p o t e n t i a l d a t a of undefined, futuristic, retrospective studies. I object to both of t h e s e points. We suggested a very cost-effective a p p r o a c h to t h e t r e a t m e n t of localized, cutaneous abscesses. In those p a t i e n t s where antibiotics are indicated, a p r e s u m p t i v e indication of t h e bact e r i a involved can be had to choose the proper i n i t i a l antibiotic needed to e r a d i c a t e the offending bacteria. In those patients, c u l t n r i n g can be done t h a t can l a t e r be compared to the i n i t i a l d r u g use as to efficacy. It is u n f a i r to the p a t i e n t in t h i s world of severely r i s i n g medical costs to c u l t u r e wounds unnecessarily, simply for the sake of some futuristic epidemiologic study. W h y culture or G r a m stain the purulence of a n abscess if antibiotics are not indicated for h e a l i n g to occur in a p a t i e n t w i t h n o r m a l host defenses? I see no reason for u n n e c e s s a r y culturing. P e r h a p s Koch m a y have agreed as he h i m s e l f s t a t e d "The l i t e r a t u r e on b a c t e r i a h a s b e e n a l l o w e d to s w e l l into a m u d d y stream."1
Cyril T. M. Cameron, MD, FRCS, FACS Director, Emergency Department Samaritan Hospital, Troy, New York 1. Cameron CTM: The treatment of superficial lacerations of the hand. Med J Aust 1:244, 1967.
AHA Guidelines for
Hospital Based Physicians To the Editor: The article e n t i t l e d " P o s t g r a d u a t e Realities: Surv i v i n g in E m e r g e n c y Medicine Practice," published in t h e J u n e 1978 issue of y o u r j o u r n a l , w a s r e c e n t l y b r o u g h t to our attention. Because m u c h of t h e article deals with the American Hospital Association's
Guidelines on Contractual Relationships Between Hospitals and Physicians, we feel t h a t a response is indicated. The author of the article, K a r l G. Marigold, MD, h a s b a s e d his c o n c e r n s on t h e " i n e q u i t i e s a n d inapplicability" of the A H A ' s guidelines, p a r t i c u l a r l y as t h e y r e l a t e to hospital approval of fees of emergency physicians u n d e r contract w i t h t h e hospital. However, t h e guidelines, as t h e y refer to hospital approval of fees, are not i n t e n d e d to apply to all m e m b e r s of the h o s p i t a l medical staff, b u t only to t h o s e who receive exclusive or s h a r e d exclusive contracts. Hospital review and approval of charges of p h y s i c i a n s who hold such contracts is considered appropriate, because the p a t i e n t who seeks t h e i r services at the h o s p i t a l has no a l t e r n a t i v e choice of physician. We should point out t h a t since the publication of t h e Guidelines in 1976,
Harvey W. Meislin, MD UCLA Emergency Medicine Center Los Angeles, California 1. Knight DC: Robert Koch, Father of Bacteriology. London, Chatto and Windus, Ltd, 1978, p 67.
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