(Correspondence Xylocaine Viscous for Diagnosis of Chest Pain To the Editor:

It was wi th considerable a m u s e m e n t tha t I read Dr. Schwartz ' s a r t ic le ~'Xylocaine Viscous as an Aid in the Di f fe ren t i a l D iagnos i s of Ches t P a i n " (Dec. 1976). I t seems tha t the ~Schwartz test" has been a round a good deal longer t han Dr. Schwartz in t imates . In 1974 while t a k i n g an emergency depa r tmen t elect ive dur ing my in- t e rnsh ip a t Georgia Bapt i s t Hospi ta l in A t l an ta , Georgia, I was in t roduced to the del ightful concoction dubbed by the emergency nurses as the "GI cocktail ." This delicious mix ture consis ted of 20 cc Maalox, 5 cc Xylocaine Vis- cous, 5 cc e l ix i r of phenobarbi ta l , and 5 drops of t inc ture of be l ladonna.

Af te r phys ica l examina t ion was performed, a pa t i en t c o m p l a i n i n g of a t y p i c a l ches t p a i n w i t h or w i t h o u t ep igas t r i c d i scomfor t would f r equen t l y be g iven a GI cocktai l and the resu l t s observed. Not inf requent ly , w i th some prodding, the pa t i en t would give a h is tory of dys- pepsia and over indulgence of food or alcoholic beverages. I can r e m e m b e r severa l occasions, af ter hav ing reques ted an e lec t rocard iogram, (EKG) and the GI cocktai l a t the same t ime, when the E K G technic ian appeared (usual ly in 10 to 15 minutes ) the pa t ien t was ~cured" and asked us why we were doing an EKG.

We have no contro l led s tudies but I am sure m a n y examples could be found in old emergency d e p a r t m e n t records. My amusement , too, comes from my assumpt ion tha t everyone knew of the good old GI cocktail . Pe rhaps the "Schwar tz test" would work as well as our GI cocktai l wi th one q u a r t e r the dose of Xylocaine Viscous by adding the e l ix i r of phenoba rb i t a l and t inc ture of bel ladonna.

Albert D. Friday, Jr, MD Channelview, Texas

Author's Reply The pa r t i cu l a r GI cocktai l wi th Xylocaine Viscous as

an ingred ien t is new to me and could not be found in the medical l i t e r a tu re over the past ten years . Perhaps , as wi th o ther s imple innovat ions and techniques , nobody felt i t was necessary to ~spread the word." I contacted As t r a Pha rmaceu t i ca l Products, Inc. and they were also unaware of such use.

The dosage of Xylocaine Viscous used (20 cc) was a de- cision based on experience. I t h ink it l ike ly tha t 5 or 10 cc might work as well, a t leas t in some people. Thus, if the re is concern t h a t dosage be minimized, 5 cc should be t r ied. Dr. F r i d a y ' s exper ience ce r t a in ly sugges ts effec- t iveness at a lower dosage.

The addi t ion of phenobarb i t a l and be l l adonna is un-

necessary since the response to the Xylocaine Viscous i~ so rap id i t is un l ike ly t ha t the re is much absorption i~ the other agents . Also, there has been concern about us~ of a t ropine- l ike subs tances in the presence of a myocar? dial infarction.

The use of Xylocaine Viscous as a diagnost ic aid s e e ~ to be re la ted to i ts topical and no t systemic effects.

George R. Schwartz, MI) Mount Holly, New Jersey

Statewide EMT Training To the Editor:

I r e a d w i t h g r e a t i n t e r e s t Dr. M c S w a i n ' s article "Sta tewide Approach to E m e r g e n c y Medical Training" ( Janua ry 1977). This art icle, I believe, is of particular~ re levance as EMT-paramed ics p l ay an ever-increasing role in the de l ivery of hea l th care.

Es t ab l i sh ing s ta tewide t r a i n i n g for emergency medical technic ians is a s ignif icant task. The experience at Kan. sas Univers i ty Medical Center , I am certain, wil l lay the groundwork for s imi la r programs.

At the Un ive r s i ty of Oregon Hea l th Sciences Center we are p lann ing to begin our EMT-paramedic program based on the 16-module P i t t sburgh plan. Wi th funding from a p r iva te foundat ion, we wil l be able to t r a in 14 to 15 paramedics every six months under the supervis ion of a ful l - t ime phys ic ian-d i rec tor and pa ramedic coordinator. O u r p r o g r a m wi l l i n i t i a l l y t r a i n a s m a l l n u m b e r of paramedics , but we hope these people, wi th local physi- c ian guidance, will be able to es tab l i sh sa te l l i te programs in more ru ra l areas. E s t a b l i sh ing a cadre of profession- a l ly t r a ined personnel in the de l ivery of emergency care is essent ia l to our h e a l t h care system.

Marc J. Bayer, MD Associate Director

Emergency Services University of Oregon

Triage and Vital Signs To the Editor:

In reply to the ar t ic le '~Effectiveness of Nurse Triage in the Emergency D e pa r tme n t of an U r b a n County Hospi- ta l ," by John Mills, MD (November 1976), I would ada- m a n t l y oppose a t r i a g e sys tem for emergency depart- men t s not based on the pa t i en t ' s v i ta l signs.

Lord Kelv in s t a ted ~When you can measure wha t you are speak ing a b o u t . . , you know someth ing about it, but when you cannot measure it, your knowledge is of a very meage r kind."

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L~sing hospi tal based emergency medical technic ians (~Ts) to t ake v i ta l s igns can allow the phys ic ian and ~ursi~g personnel more t ime for the cognit ive processes 0f triage. Use of an electronic t h e r m o m e t e r g rea t ly re- duces the t ime requ i red to obta in v i ta l signs. The child ¢ith high fever (thus prone to seizures), the hyper tens ive patient, the dizzy pa t i en t wi th an a r r h y t h m i a , and the -^ung girl wi th a pu lmonary embolus and unexpla ined Y~ ~.,,ardia, are a few examples of pa t i en t s who m a y look essential!y well , b u t do fal l in the c a t e g o r y of '~true

emergencms- proper t r i age by pa ramedica l and nur s ing personnel

~ill allow the emergency phys ic ian to meet the demands placed on the emergency depar tment .

Jerry Goddard, MD Emergency Physician's Group, PC

Tacoma, Washington

Author's Reply I appreciate Dr. Goddard 's comments r ega rd ing our ar-

ticle. Basically, I agree tha t i t would be op t imal to ob ta in vital signs on every person coming to the emergency de- partment, and as I pointed out in the paper , th is would, in fact, modera te ly increase the precis ion of nurse t r iage . It was my opinion, however, t h a t the increase in t ime necessary to ob ta in complete v i ta l s igns was not cost ef- fective for the nurse t r iage process.

John Mills, MD Chief, Division of Infectious Diseases

University of California, San Francisco

Schizophrenia Defined To the Editor:

Michael E l i a s t am, MD, wrote you ( Janua ry 1977) con- coming his desire to " improve the qua l i ty of scientif ic evaluation . . . "

I would beg of him, and of you, please allow those of us in psychia t ry the same privi lege.

Schizophrenia is admi t t ed ly a vague ly def ined diag- nosis but i t is not a synonym for "confusing," " improper ," or "unscientific," a l l of which could have been used in Dr. Eliastam's l e t t e r to more por t ray his feelings.

J. F. Hooper, MD Department of Psychiatry

University of Kentucky

Author's Reply Dr. Hooper ' s comments a re obvious ly app rop r i a t e . I

have a l r e a d y been v e r b a l l y a s s a u l t e d by m y wife, a psychiatry res ident , who pointed out t~a t I was us ing an entirely incorrect cl inical defini t ion.

In a t t emp t ing to hold an emba t t l ed posit ion, I would like to point out t ha t I used the word schizophrenic to SUggest t h a t the author ' s comments on the va lue of the

esophagea l ob tu ra to r a i rway ref lected a form of dissocia- t ion or "spl i t t ing." The d i s s o c i a t i o n r e l a t e d to the absence of good cl in ical s tudies to suppor t the c la ims about the "proven" appl icab i l i ty of t r achea l in tuba t ion in the pre- hospi ta l care set t ing.

Michael Eliastam, MD Director of Emergency Services

Stanford University Medical Center

Complications of G-Suit To the Editor:

"Clinical Use of the G-Suit ," by Soler, et al (August 1976) does much to exp la in some of the theore t ica l as- pects of the G-sui t and is ce r t a in ly t imely. There are two areas, however, I m u s t d isagree with.

"A drop of 40-60 m m Hg or more in blood pressure can be expected on deflat ion." This is t rue if the t rousers are rap id ly deflated. However , they should never be r ap id ly deflated. The a u tho r s s ta te t h a t in r a r e cases of pro- longed use wi thout surgery , def la t ion should proceed step by step. I bel ieve s tep by step def la t ion should t a k e place in al l cases. Step by step def la t ion and moni to r ing the blood pressure as the var ious compar tmen t s (beginning wi th the abdominal ) are def la ted, wil l give adequa te re- t u rn of blood pressure before anes thes ia is induced. This can f requent ly be accomplished over a period of 20 to 40 minutes , while a pa t i e n t is be ing prepared for surgery . If complete def la t ion cannot be accomplished pr ior to ini t ia- t ion of anes thes ia , the abdomina l segment at l eas t usu- al ly can be def la ted and g r a d u a l def la t ion of the leg seg- m e n t s accompl i shed i n t r a o p e r a t i v e l y . No hypo tens ion should occur.

"Sudden increase in i n t r a - a b d o m i n a l pressure can pro- duce dyspnea, f r ank r e sp i r a to ry embar r a s smen t , emesis , defecation and/or u r ina t ion ." Al though these complica- t ions are ment ioned i n the l i t e r a tu r e 1 and in the man- ufac turer ' s in format ion (David Clark) , in our recent ex- perience of 50 cases repor ted in September to the Amer i - can Associa t ion for the Surgery of Trauma, 2 we had none of these complicat ions. In only th ree cases was there a drop in blood pressure in the r ange of 30-60 m m Hg. This was due to someone i n e x p e r i e n c e d in the use of the t rouse r s not p rope r ly r e p l a c i n g f luids and m o n i t o r i n g blood pressure dur ing the i r deflat ion.

I would l ike to compl imen t the authors on the i r work but do not feel t h a t compl ica t ions are of the f requency commonly bel ieved bu t do feel t hey are theoret ical . I em- phasize t h a t they do not need to produce severe hypoten- sive problems.

Norman E. McSwain, Jr, MD, FACS Department of Surgery

Kansas University Medical Center

REFERENCES 1. Kaplan BC, _Civetta TM, Nagel EL, et al: The military anti- shock trouser in civilian pre-hospital emergency care. J Trauma 13:843-848, 1973.

2. McSwain NE: Report of 50 cases of G-suit use. J Trauma (to be published).

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