CORRESPONDENCE

assurance, can provide a high level of care to all trauma patients. We might find this high level of care comparable to that delivered by a Level I hospital for an individual trauma patient, and at a much lower cost. We, as clinicians, do not know these facts because we are too involved in a debate about "trauma centers."

We must make every effort not to spend our time and resources on unnecessary debate, but rather to organize ourselves to tackle the real problem.

The Trauma Commit tee of the American College of Emergency Physicians and the Committee on Trauma of the American College of Surgeons have had a very worth- while, although informal, dialogue this past year between their chairmen. It is my hope that the two committees will develop in the near future an even closer working rela-

tionship, so that we might realize how close our respective opinions regarding the care of the trauma patient really are. I believe that the logical and caring minds involved in this controversy will prevail, and that an effective, realistic, and financially feasible system will be developed.

John C. Sacra, MD Director of Emergency Medicine Saint Francis Hospital TUlsa, Oklahoma Chairman, Trauma Committee American College of Emergency Physicians

1. Thompson CT: Trauma center development. Ann Emerg Med 10:662-665, 1981.

Disease Entities In Homosexual Population

To the Editor: Since publication of the article on gay bowel syndrome by

HeUer (9:487-493, September 1980) and my letter to the edi- tor (10:499-500, September 1981), there has been increased recognition of other disease entities occurring In the homo- sexual population.

Enteric protozoa and helminthes (giardiases, amebiasis, pin worms, eysticercus and strongloides) appear to be trans- missible through the sexual practices of anilingus and fel- latio after anal intercourse; however, any sexual activity resulting in fecal oral contamination may cause transmis- sion. 1

Twenty-six cases of Kaposi's sarcoma (KS) and 15 cases of pneumocystis carinii pneumonia (PCP) among previously hea l thy homosexua l men were recen t ly reported. 2,3 Pneumocystis pneumonia in the United States is almost ex- clusively limited to severely immunosuppressed patients. Many of the KS and PCP patients have had positive cultures or serologic evidence of infection with cytomegalovirus (CMV). Although the role of CMV infection in the patho- genesis of PCP remains unknown, the possibility of P cari- nii infection should be considered in the diagnosis for pre- viously hea l thy homosexua l m e n wi th dyspnea and

pneumonia. Therapy is specific, and verification requires biopsy. The majority of cases have been reported from New York and California.

KS, a rare, malignant neoplasm seen predommantly in elderly men and rarely fatal, has been reported to occur in young to middle-aged homosexual men with 20% fatality. In many instances PCP preceded the tumor. The apparent clustering of both these diseases among homosexual men suggests a common underlying factor.

Donald Forester, MD, Chief Section on Emergency Medicine Mount Vernon Hospital Mount Vernon, New York

1. Phillips SC, Mildvan D, William DC, et al: Sexual transmission of enteric protozoa and helminthes in a venereal disease-clinic population. N Engl l Med 305:603-606, 1981. 2. CDC pnemnocystis pneumonia - - Los Angeles. MMWR 30:250- 252, 1981.

3. CDC follow-up on Kaposi's sarcoma and pneumocysfis pnettmo- nia. MMWR 30:409-410, 1981.

Emergency Medicine Residencies: The Problems with Two-Year Programs

To the Editor: The time has come to change the application procedure

for emergency medicine residencies. As a fourth-year medical student, planning to do an emergency medicine res- idency, I was dismayed to discover that only about half the available programs offer three-year residencies. Even more distressing was the fact that none of the two-year programs would accept applications from students still in medical school.

Students who opt for a two-year program are therefore placed at a disadvantage, as are the programs themselves.

In the first place, such students are at a loss as to exactly

what type of internship is most suitable. Judging by the cur- ricula of most three-year programs a flexible internship would be most appropriate. Unfortunately, these are few and far between. Straight medical or surgical intemships in- clude many rotations which will be irrelevant to the stu- dent's future career, and furthermore, good one-year pro- grams are hard to find.

Equally important is 'the onus of having to reapply. Most interns, especially in the beginning of the year, barely have time to go to the bathroom and eat, let alone fill out ap- plications and go on interviews. There is also the expense of

98/456 Annals of Emergency Medicine 11:8 August 1982

traveling to see the programs, which because of a tight schedule must be done one at a time rather than on a re- gional basis, not to mention the possibility of relocating to an entirely different part of the country. If students were notified far enough in advance of the match deadline, they would be able to apply for internships in the same city or even in the same hospital.

The current system encourages a certain amount of dis- honesty, on the part of both the students and the program directors. Students may choose to go to a three-year pro- gram simply to receive more relevant training during the internship, but with the intent of transferring to a two-year program. Directors, on the other hand, may offer an excep- tionally qualified applicant an "early acceptance," thus forc- ing the student to make a decision before he has heard from other programs. This, of course, could be obviated by requir- ing all emergency medicine residencies to participate in a match program.

As of December 1978, 38% of all emergency medicine residencies included an internship year. In 1979 this rose to 40%, and in 1980 to 52%. I hope this trend continues.

The two-year program need not become extinct. Many special t ies , such as neurology, oph tha lmology , and orthopedics, require some prior "general" training, yet all accept applicants while still in medical school. Following their example would not only attract those students who are reluctant to apply to two-year programs, but would make it considerably easier for those who do.

Marc Nelson, MS New York, New York

[Editor's note: A t the time of submission, the author was a fourth-year medical student at the Mount Sinai School of Medicine and a student member of ACEP.)

To the Editor: Mr. Nelson has nicely summarized the difficulties and

frustrations of the medical student applying for a residency

in emergency medicine. He has focused on the two-year programs which provide the greatest problem to students who are secure in emergency medicine as a career goal. Tracing the evolution of the application process may pro- vide some insight into these problems.

When emergency medicine graduate education began in earnest 10 years ago, the applicant pool consisted almost entirely of second-career physicians who had, of course, already served an internship. Two-year programs were the answer to this applicant's need. As emergency medicine be- came a recognized specialty and a primary career choice of medical students, the need for three-year programs surfaced. The gradual change from two-year to three-year programs in the last few years has been a natural response to these mar- ketplace pressures. But because emergency medicine con- tinues to attract applicants from practice, other residencies, and recent intern graduates, the need for some two-year programs persists.

The problem of "dishonesty" in the current process re- sults not so much from two-year programs, but rather from the lack of a formal system that discourages abuse. But help is on the way. The establishment of the Residency Review Committee in Emergency Medicine augnres inclusion of our specialty in the NIRMP matching program this year. And next year, the NIRMP plans to provide three choices for medical students:

1) To match with a three-year integrated program; 2) To match with a two-year program after internship; or 3) To allow deferral to match with a two-year program at

a distant future date. Interestingly, an overwhelming majority of residency

directors polled at a recent conference of the Society of Teachers of Emergency Medicine favored participation in the NIRMP.

This action will mark yet another step in the ordering of administrative process within our new specialty, and we all shall benefit.

Robert H. Dailey, MD, Member American Board of Emergency Medicine 1979-1982

Avoiding Aspiration Following Inadvertent To the Editor:

Emergency endotracheal intubation is a procedure carried out frequently. Inevitably, no matter how skilled the physi- cian, inadvertent esophageal intubation will occur. It is hoped this will be recognized early when attempts at ven- tilation produce gastric distension and no air entry into the lungs. Often the misplaced tube is deflated and removed, a second attempt at endotracheal intubation is carried out, and there is massive gastric regurgitation and aspiration be- fore a secure airway can be achieved.

When the error is recognized the ET tube should be left in place, inflated. A renewed attempt at endotracheal intuba-

Esophageal Intubation

tion with a second ET tube should occur. The procedure is no more difficult with the esophageal tube in place; in fact, it may help because it marks the hypopharyr~ and esopha- gus. Regurgitation may still occur, but it does so via the esophageal tube and out of harm's way. Once a secured, cuffed ET tube is in place, the first tube can be deflated and withdrawn, and a nasogastric tube can be inserted. Brian D, Steinhart, MD Department of Emergency Care Hamilton Civic Hospitals Hamilton, Ontario, Canada

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