in reply
TRANSCRIPT
Correspondence
Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article that might createany potential conflict of interest. The authors have stated that nosuch relationships exist. See the Manuscript Submission Agree-ment in this issue for examples of specific conflicts covered by thisstatement.
1. Bozeman WP, Hauda WE, 2nd, Heck JJ, et al. Safety and injuryprofile of conducted electrical weapons used by law enforcementofficers against criminal suspects. Ann Emerg Med. 2009;53:480-489.
2. Vilke GM, Sloane CM, Bouton KD, et al. Physiological effects of aconducted electrical weapon on human subjects. Ann Emerg Med.2007;50:569-575.
3. Strote J, Range Hutson H. Taser use in restraint-related deaths.Prehosp Emerg Care. Oct-Dec 2006;10:447-450.
4. Lee BK, Vittinghoff E, Whiteman D, et al. Relation of taser(electrical stun gun) deployment to increase in in-custody suddendeaths. American Journal of Cardiology. 2009;In Press.
5. Koscove EM. Physiological effects of the taser. Ann Emerg Med.2008;52(1):85; author reply 85-86.
In reply:We appreciate the opportunity to respond to the comments
of Drs. Strote and Hutson. We wholeheartedly agree that therisks associated with conducted electrical weapons must bebroadly considered, both medically and in the context of therisks of other force options available to police officers. Ourstudy represents the first large independent assessment of theepidemiology of injuries associated with these weapons whenused in real world conditions against criminal suspects, ratherthan experimental conditions using volunteers. Our results shedlight on the important question of the actual risk of adverseoutcomes after conducted electrical weapon use by lawenforcement officers. 1
As stated in the methods section, direct injuries were thoseassessed by the physician site investigators to be related to themetal barbs or electrical current, while indirect injuries were dueto falls or other effects of the conducted electrical weapons. Fivecontusions and one case of rhabdomyolysis were listed as havingan uncertain relationship to conducted electrical weapon use.Due to the small number these injuries were conservativelyincluded in the analysis as being due to conducted electricalweapon use. Our study is the first to include expert physicianassessment of the nature and severity of conducted electricalweapon injuries, rather than relying solely on police officerimpressions.
The question of whether acidosis may have been present onlaboratory studies raises the distinction between patient-orientedoutcomes research and disease-oriented investigations oflaboratory values. As discussed in the methods and limitationssections of our manuscript, we tracked injuries and outcomesafter conducted electrical weapon use in an observational trialdesign and could not mandate laboratory investigations as part
of the medical screening process. While distinctly different fromVolume , . : August
the patient-oriented outcomes reported in our manuscript,laboratory studies will nevertheless be another importantcomponent in understanding the potential risks of conductedelectrical weapons.
We, like others, query whether there might be a subgroup ofcriminal suspects with a markedly abnormal physiologic state orother risk factors that could be adversely affected by conductedelectrical weapon exposure. However, we note that there iscurrently no experimental human evidence to support suchconcerns, including studies of prolonged conducted electricalweapon exposures and studies incorporating extreme physicalexertion to model the acidosis and other physiologic effects ofstruggling with police. We look forward to publication of thedata that Drs. Strote and Hutson mention that includeslaboratory studies in 1000 criminal suspects after conductedelectrical weapon use. We hope this report will includecomparative data in a group of control subjects who requirephysical restraint or less lethal force other than conductedelectrical weapons, as only this will provide the broadcomparison they (and we) advocate.
The 2 in-custody deaths that occurred in our case series arediscussed at some length. These cases were investigated in detailby the medical examiners and law enforcement agenciesinvolved, and determined by them to be unrelated to conductedelectrical weapon use. By a priori study design decisions, theinvestigators did not presume to “second guess” either theappropriateness of conducted electrical weapon use or the resultsof the medical examiners’ investigations. Rather than dismissingthese in-custody death cases, our intended approach was todescribe them in detail, acknowledge the current controversiesregarding conducted electrical weapon effects, and discuss theemerging literature that explores the known physiologicconsequences of conducted electrical weapon exposure.
We also endorse a national database of deaths that occurafter conducted electrical weapon use but point out that such adatabase should include all unexpected in-custody deaths, notjust the minority that occurs after conducted electrical weaponuse. This is necessary to provide appropriate comparative dataand broad consideration of all pertinent information.
William P. Bozeman, MDJames E. Winslow, III, MD, MPHDepartment of Emergency MedicineWake Forest UniversityWinston Salem, NC
William E. Hauda, II, MDDepartment of Emergency MedicineInova Fairfax HospitalFairfax, VA
doi:10.1016/j.annemergmed.2009.03.015
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationshipsAnnals of Emergency Medicine 311
Correspondence
in any way related to the subject of this article that might createany potential conflict of interest. The authors have stated that nosuch relationships exist. See the Manuscript Submission Agree-ment in this issue for examples of specific conflicts covered by thisstatement.
1. Bozeman WP, Hauda WE 2nd, Heck JJ, et al.Safety and injuryprofile of conducted electrical weapons used by law enforcementofficers against criminal suspects. Ann Emerg Med. 2009;53:480-489.
Time to First Antibiotic Dose Measurement inCommunity-Acquired Pneumonia: Time for aChange
To the Editor:I read with interest the article by Cheng & Buising titled,
“Delayed Administration of Antibiotics and Mortality inPatients With Community-Acquired Pneumonia.”1 In oneAustralian hospital, the authors reported an inverse relationshipbetween time to first antibiotic dose and mortality in patientswith community-acquired pneumonia: patients who diedexperienced shorter time to first antibiotic dose (1.5 hours) thansurvivors (2.9 hours). Their findings stand in sharp contrast toprevious studies in Medicare patients where antibiotic delays of4- or 8-hours were associated with a higher likelihood ofdeath.2,3
The salient question for the frontline emergency physician is:do early antibiotics really matter in community-acquiredpneumonia? The authors argue that early antibiotics actually domatter in sick patients (ie, with septic shock) and point to anICU-based study where delayed antibiotics were associated withdramatically higher mortality rates.4 But in the generalpopulation with mild to moderate community-acquiredpneumonia, “. . .overinterpretation of small differences in timeto first antibiotic dose in which the majority are receiving timelytherapy is probably not justified.”
All of this makes sense, but I would go one step further. Ipropose that we, as emergency physicians, use this evidence tomake a change in practice. We need to go back to practicingthoughtful medicine, and do what we did before Centers forMedicare & Medicaid Services announced that time to firstantibiotic dose � 4 hours was a care standard (as an aside, nowit’s time to first antibiotic dose � 6 hours which is supported byeven less evidence). Wait until a diagnosis of community-acquired pneumonia is made, then give the antibiotics, not theopposite, unless the patient is in shock. And ensure theemergency department is run efficiently so diagnoses can bemade in a timely manner (in the authors’ study, �90% receivedantibiotics within 8 hours).
The bigger question is: why are we still having thisdiscussion? Do we need more evidence demonstrating that in
otherwise stable community-acquired pneumonia patients who312 Annals of Emergency Medicine
have been sick for days to weeks that giving antibiotics at hour 3versus hour 7 doesn’t cause fewer deaths?
My message to the group that continues to support themeasurement of time to first antibiotic dose in community-acquired pneumonia: undo the damage. Time to first antibioticdose in community-acquired pneumonia needs to just go away.The failed promise of this measure to improve community-acquired pneumonia outcomes is only worsened by thecontinued measurement of a clinically meaningless entity thatclearly promotes antibiotic misuse.5,6 In the inaugural words ofour new President Barack Obama, now is time for a “. . .new eraof responsibility.” This not only applies to governmentspending, but also how Centers for Medicare & MedicaidServices influences the practice of emergency care. 1-6
Jesse M. Pines, MD, MBA, MSCEDepartment of Emergency MedicineCenter for Clinical Epidemiology and BiostatisticsLeonard Davis Institute for Health EconomicsUniversity of Pennsylvania School of MedicinePhiladelphia, PA
doi:10.1016/j.annemergmed.2009.02.020
Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article that might createany potential conflict of interest. The author has stated that nosuch relationships exist. See the Manuscript Submission Agree-ment in this issue for examples of specific conflicts covered by thisstatement.
1. Cheng AC, Buising KL. Delayed Administration of Antibiotics andMortality in Patients With Community-Acquired Pneumonia. AnnEmerg Med. 2009;53:618-624.
2. Houck PM, Bratzler DW, Nsa W, et al. Timing of antibioticadministration and outcomes for Medicare patients hospitalizedwith community-acquired pneumonia. Arch Intern Med. 2004;164:637-644.
3. Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process,and outcomes in elderly patients with pneumonia. JAMA. 1997;278:2080-2084.
4. Kumar A, Roberts D, Wood KE, et al. Duration of hypotensionbefore initiation of effective antimicrobial therapy is the criticaldeterminant of survival in human septic shock. Crit Care Med.2006;34:1589-1596.
5. Kanwar M, Brar N, Khatib R, et al. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics:side effects of the 4-h antibiotic administration rule. Chest. 2007;131:1865-1869.
6. Welker JA, Huston M, McCue JD. Antibiotic timing and errors indiagnosing pneumonia. Arch Intern Med. 2008;168:351-356.
In reply:We thank Dr. Pines for his lucid comments. In contrast to
the US Joint Commission, the time to first antibiotic dosecriterion is not used in Australia as a marker of the quality of
care. We further note that in a recent systematic review, theVolume , . : August