CORRESPONDENCE Opinions expressed in the Correspondence Section are those of the authors, and not necessarily of the Journal editors, ACEP, 6r UA/EM.

Combination Aspirator and Hemostat: "Aspistat" ® To the Editor:

Although blood loss dur ing surgery or t r a u m a can u sua l l y be contro l led by the cau te r i za t ion of sma l l vessels, vascu la r t r a u m a with d is rupt ion of a la rger a r t e ry may be present . Hemostas is requi res a two-step motion: blood must be removed from the field th rough an asp i ra to r to find the source, and a hemos ta t mus t be used to clamp off the vessel. Both the surgeon 's hands are required, or an a s s i s t an t (whose view is genera l ly not as opt imal) is necessary.

I have developed an asp i ra to r combined with a hemos ta t (Figure A) tha t e l imina tes this in terval . The device offers economy of motion and rap id hemostasis ; i t is best sui ted to control deep abdominal bleeding.

The asp i ra tor sl ides smoothly onto the hemos ta t and does not lock into place. Thus the possibi l i ty of a sudden motion which migh t cause fu r the r b leed ing and injury to the vessel is reduced. Because the as- p i ra to r lies along the blade of the hemosta t , interfer- ence with the surgeon 's vision and change in ba lance of the ins t rument is minimal . A s ingle f inger can con- trol aspi ra t ion (Figure B). and cessat ion of asp i ra t ion (Figure C) by covering or uncovering a smal l hole in the aspirator .

Removal of ' the asp i ra tor leaves the field unclut- • t e red by tubing. T h e ' h e m o s t a t r emains in place, per-

mi t t ing the vessel to be t ied off by the surgeon. A dis- posable plas t ic uni t e l imina tes the need for c leaning and re tu rn ing to storage.

James Simon, MD Annals Contributing Editor

Department of Emergency Services Herrick Memorial Hospital

Berkeley, California

Fig . A. The aspirator-hemostat (Aspistat®). Fig . B. Aspirator valve closed. Fig . C. Aspirator valve open.

MAST Trouser Use for Head-Injured Patients

To the Editor:

The author ' s rep ly by Cleve Trimble, MD, in the J a n u a r y issue of Annals ut i l i zed a p a p e r recen t ly presented a t the UA/EM annua l mee t ing to make a point . As one of the authors of this paper I would l ike to clear up any misconceptions caused by Dr. Trim- ble 's remarks .

The paper involved a s tudy of the re la t ionship be- t w e e n h e m o d y n a m i c p a r a m e t e r s and i n t r a c r a n i a l p ressu re in normovolemic and hypovolemic conditions both wi th and wi thout s imula ted space occupying le- sions. Dr. Tr imble reports t ha t the s t imulus for the s tudy was paramedics who refuse to follow the wr i t t en wa rn ing Of the vendor and apply compression t rousers to head in jury victims. Actual ly , the s t imulus for the paper was the fact t ha t vict ims of mul t ip le t r a u m a in hypovolemic shock were not being t rea ted with MAST t rousers dur ing the prehospi ta l phase of care because of the manufac tu re r ' s warn ing regard ing the use of the device in head in jury pat ients . In many cases, the head injur ies were minor, and because of t ime and dis- tance problems encountered in a rura l EMS t ranspor- t a t ion system, the pa t ien t ' s u l t ima te cause of death was " i r revers ible" shock. ~

We thought the manufac tu re r ' s warn ing was not jus t i f ied in many of these s i tua t ions and could find no evidence in the l i t e ra tu re to support the concept tha t p reserva t ion of perfusion to the vi ta l organs systems would be de t r imen ta l to pa t ien ts with head injuries. Da ta from the s tudy showed s ignif icant improvement in cen t ra l hemodynamics and cerebral perfusion pres- sure with c l inical ly ins ignif icant increases in in t ra- c rania l pressure. I t was our conclusion tha t EMT-As t ra ined in the proper use of the compression t rousers should be told by on-l ine medical control physic ians to use the device in those ins tances in which other mech- an isms to support the hypovolemic shock pa t i en t had been ineffective.

In a l l f a i rness , I ag ree wi th Dr. T r imb le t h a t equ ipmen t in the prehospi ta l se t t ing has the potential for abuse. Simply moving the pa t i en t from the scene of his injury to the ambulance cer ta in ly has the potential for fur ther ha rm to the pat ient . The only safeguard aga ins t such a poss ibi l i ty is proper in i t ia l and ongoing educat ion of prehospi ta l care providers coupled with on-line phys ic ian medical supervis ion and prompt re- view of prehospi ta l care ambulance runs. In a proper ly designed prehospi ta l care sys tem EMTs are not "per- mit ted," in a passive sense, t o ca r ry out the i r activi- t ies, but are ordered by the on-line supervis ing physi- c ian to ca r ry out those procedures which he deems proper and necessary for the well-being of the pat ient .

Albert E. Cram, MD Assistant Professor of Surgery

The University of Iowa School of Medicine

Iowa City

68/386 Ann Emerg Med 9:7 (July) 1980