and thick, we managed never to miss the duty roster in the pit. Each shift brought the thrill of anticipation of the life that we knew we would save in the next 12 or 24 or 36 hours - - whatever the shift length happened to be.

Somehow or other over the years we also learned to de- rive as much satisfaction from the simple laceration neatly sutured, the snotty nose dried up, and the subungual hema- toma relieved.

So years have passed. Where they went so quickly I don' t know. The adrenalin surge prompted by a GSW to the chest at 3 AM has now become less welcome than the turned- down covers that will welcome me at 8:30 AM. A 24-hour

shift requires 48 hours of recovering instead of six hours and catnaps on an airplane on the way to another meeting.

So it's appropriate and it's time to move on. Goodbye, emergency depar tment! Hello, minor emergicenter. But still, not wi thout a tear.

Do you suppose the AMA could use a Section on Minor Emergicenters? Maybe they need Minor paramedics? Maybe we need a Journal of Minor Emergencies? Nah, I'll let the kids do it - - they need some fun, too.

William T Haeck, MD Deerfield Beach, Florida

Out.of.Hospital Cardiac Arrest

To the Editor: This is to compl iment Drs Roth, Stewart, Rogers, and

Cannon on their most important and timely article remind- ing us of the success of out-of-hospital cardiac arrest ("Out- of-Hospital Cardiac Arrest: Factors Associated wi th Sur- vivaL" April 1984;13:237-243). Their excellent study did em- phasize the factors associated with survival.

Twenty-four years ago, m y brother and I maintained a man who died in our office with mouth- to-mouth respira- tions and external massage for more than one hour. All dur- ing this time we maintained a normal small pupil which encouraged us to persist with our efforts. When the am- bulance finally arrived, I accompanied the ambulance and maintained CPR. This was the first successful case of car- diac arrest treated with external massage outside the hospi- t a d

I applaud their report and their firm suggestion of public education toward prompt CPR.

Asher Black, MD Syracuse, New York

1. Black A, Black M: Cardiac resuscitation from recurrent ven-

tricular fibrillation occurring in a physician's office. Am J Cardiol 1964;13: 71-76.

In Reply: The letter from Dr Black reminds us of the debt we owe

the "pioneers" who laid many of the foundations on which emergency medicine is built. I was aware of the description of his successful resuscitation published only four years fol- lowing the landmark article by Kouwenhoven, Knicker- bocker, and Jude3

Dr Black's experience, as well as our own, serves well to underscore the importance of basic CPR and lay education in the approach to the problem of sudden cardiac death in the community.

We would pay tribute to the contribution of Dr Black and the others who have been our teachers and mentors.

Ronald D Stewart, MD Center for Emergency Medicine Pittsburgh

1. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac massage. JAMA 1960;173:1064-1067.

Amniotic Fluid Embolism and Emergency

To the Editor: The article by Sterner et al on amniotic fluid embolism

(May 1984;13:343-345) posed the ques t ion of wha t else could have been done in managing the case described.

It is evident, since the work of Del Guercio, Feins and Cohn,1 that there are patients who are not good candidates for closed-chest cardiac compression (CCCC) and whose successful resusci ta t ion wil l require open-ches t cardiac massage (OCCM). The patient in the third trimester of preg- nancy is not a good candidate for closed-chest resuscita- tion. 2

OCCM can empty the ventricle more completely, reduc- ing the circulation time and improving the cardiac index. Secondly massive pulmonary embolism may virtually elim- inate effective cardiac output despite correct closed-chest compression. 2 Tissue perfusion is only 30% of normal with ideal closed-chest compression.

Cardiac Care

Patients w h o d e m o n s t r a t e cardiac per fus ion dur ing closed-chest compression but lose cardiac function once compression stops should be considered for OCCM. This patient had palpable pulses and atrial flutter on ECG which disappeared after CPR was stopped. Hypovolemia, tension pneurnothorax, or cardiac tamponade should be suspected. 3 In view of the fact that this patient was so young and did not respond to the conventional ALS modalities, opening the chest, in m y opinion, was indicated.

Finally, use of a transverse pacemaker should have been considered early in the cardiac arrest when an atropine-re- sistant b radyar rhy thmia was evident. Whe the r ut i l iz ing both approaches would have changed the clinical outcome is now a moot point. Survival of a patient in cardiac arrest is related to both the time at which treatment is initiated and the time to definitive care.

13:12 December 1984 Annals of Emergency Medicine 1172/141