tal se t t ing is pa r t of the protocol for all pa t ien ts in hypovolemic shock. Since sudden def la t ion of the sui t is s t r ic t ly con t ra ind ica ted , the p rox ima l saphenous vein would not be avai lab le for cutdown. The pneuma- tic t rouser sui t does not cover the ankles . However, once the sui t is inflated, IV t ransfusion may often be ex- t remely slow. For t ha t reason lower ex t r emi ty cut- downs should be avoided. In my ar t ic le I ment ioned increas ing use of the pneumat ic t rouser sui t as one reason emergency phys ic ians m u s t become fami l i a r with upper ex t r emi ty cutdowns.

In conclusion, Dr. Nowak and Dr. Tomlanovich use a technique for lower ex t remi ty cutdown which, in thei r hands and in the proper s i tuat ion, is simple, safe r a p i d and ef fec t ive . However , in a r e a s u s i n g the pneumat ic t rouser suit , physicians should concentra te on deve lop ing expe r t i s e wi th upper e x t r e m i t y cut- downs.

This technique appears to be a reasonable a l te rna- t ive to cutdown at the ankle in pa t ien ts wi th exsan- gu ina t ing hemorrhage.

Robert Knopp, MD Assistant Chief of Emergency Medicine

Valley Medical Center Fresno, California

Profesco Clarification Received

To the Editor:

The purpose of th is le t te r is to clarify the issues evolving around the art icle on page 87, ~'ACEP En- dorsed In su rance Reviewed," in t he A p r i l i ssue of JACEP.

In our l e t t e r of J a n u a r y 4, 1979, addressed to George Podgorny, MD, ACEP Pres ident , we addressed the issues which caused Vigi lan t Insurance Company, not Profesco Corporat ion, to change its underwr i t ing profiles. The JACEP art icle incorrect ly a t t r ibu ted this decision to Profesco Corporation.

F u r t h e r m o r e , Profesco Corpora t ion h i s t o r i c a l l y e s t a b l i s h e d i t s i n d e p e n d e n t agency r e p r e s e n t a t i o n wi th each insured who purchased coverage under the ACEP Endorsed Professional L iab i l i ty Insurance Pro- gram. This' re la t ionship was implemented th rough a "Let ter of Unders tanding" between Profesco Corpora- t ion and each insured. There never was a "le.tter of u n d e r s t a n d i n g wi th the College." In our "Le t t e r of U n d e r s t a n d i n g , " b e t w e e n A g e n t and I n s u r e d , we spelled out cer ta in agreements r ega rd ing membersh ip in ACEP. There is no le t ter of unde r s t and ing wi th the College.

In response to objections ra ised by Dr. Podgorny and o the r ACEP officers, Profesco Corpora t ion has agreed, as ACEP's Endorsed Agent, to accept applica- t ions only from ACEP members . We are now t ak ing the steps necessary to implement th is commitment .

We would apprecia te your ass is tance in c lar i fying the factual inconsistencies in the ar t ic le in quest ion . . . .

We respect and enjoy our re la t ionship wi th ACEP, i ts officers and members , and we look forward_to en- joying a long- term and mutua l ly profi table re la t ion- ship.

I. David Gordon Vice President, Profesco Corporation

8:6 (June) 1979 JACEP

Mediocolegal Skull X-ray To the Editor:

In the i n t e r e s t i ng case repor t by Wilson et al, ' ~Embedded F o r e i g n Body in t h e F a c i a l B o n e s " (7:444-447, 1978), a s t a t emen t in the introduct ion was d is turb ing to me. The authors s ta te tha t the i r case '~reinforces the fact t ha t rout ine skul l x-ray performed for 'mediocolegal ' reasons is somet imes of great use."

However, in the i r case there were at leas t two medical indicat ions for skul l x-ray. One was the al- tered men ta l s ta tus of the pat ient . The other was the presence of an i n t r a c r a n i a l foreign body tha t sure ly would have been discovered dur ing proper explorat ion of the facial wound.

I object to the phrase ~routine skul l x- ray per- formed for 'medicolegal ' reasons." Whether i t be one, four or six views, I bel ieve tha t we should s t r ive to e l imina te unneces sa ry rou t ine x-rays, and per form them for medical , but not medicolegal , reasons.

Lionel Edwards Weeks, MD Albany, New York

Author's Reply Dr. Weeks ' point is indeed well taken. Unfortu-

nate ly , in th is imperfec t world, the a l te red m e n t a l s ta tus of the pa t i en t was ascr ibed more to his blood alcohol of 169mg/100 ml t h a n to his head injury. Also, the Wound should indeed have been properly explored. However, the amoun t of project ing steel was min ima l and the gap in the f rontal bone was not at al l obvious unt i l the wound had been ex tended on formal explora- t ion in the opera t ing room.

I quite under s t and t ha t x-ray films for medicole- gal reasons are, in th is cost-conscious world, some- th ing which should be avoided if at all possible.

Neal Wilson, MD Division of Plastic Surgery

Wayne State University School of Medicine

Detroit, Michigan

1. Condon RE, Nyhus LM (eds): Manual of Surgical Therapeutics, ed 2. Boston, Little Brown & Co, 1972, p 144.

Emergency Medical Care in China To the Editor:

I recent ly had the oppor tun i ty to observe medical care in the Peoples Republic of China and would l ike to share th is experience wi th your readers.

Emergency medical care in China is not a high p r i o r i t y i t em. W h i l e C h i n a has made i m p r e s s i v e s tr ides in prevent ive medic ine and basic hea l t h care, the medica l sy s t em has not ye t reached a level of sophis t ica t ion where widesp read deve lopment of or appl icat ion of emergency medical technology can be just if ied.

China has more immed ia t e needs and programs on which to concentrate . Hea l th care is avai lable , free for all workers and peasants , and at a m in i mum cost for a l l f a m i l y m e m b e r s . P e r s o n a l and c o m m u n i t y hygiene is impress ive . Disease p reven t ion t h r o u g h immun iz a t i on p rog rams and e l imina t ion of d isease vectors (carr iers such as rats , snails , flies, mosquitoes) is an effective ongoing project. Almost a l l d r i n k i n g water , for example , is f i rs t boiled. In a developing na-

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