EPITOMES-GENERAL AND FAMILY PRACTICE

illness-associated sense of helplessness in an tracheal intubation with an emphasis on naso-

asthmatic patient. Preliminary experience with tracheal intubation. Students must show satisfac-
the Mini-Wright Peak Flow Meter indicates that tory knowledge and technical performance of these
selected patients can use this PEFR sliding- skills to their instructor to pass the course. An-
scale regimen to improve daily control, resulting esthetized dogs are used for teaching some of the
in fewer visits for emergency medical care and, invasive skills. The initial skill assessment station
perhaps, fewer admissions to hospital. is particularly noteworthy in that it gives students
DAVID N. KATZ, MD a chance to practice their skills and to be tested
REFERENCES on the ability to initially assess and treat a mul-
Gregg I: The measurement of peak expiratory flow rate and its
application in general practice. J Coll Gen Pract 1964 Mar; 7:
199-214
tiply injured patient. Well-coached persons with
Henderson WR, Shelhamer JH, Reingold DB, et al: Alpha- appropriate simulated injuries are used as patients
adrenergic hyper-responsiveness in asthma. N Engl J Med 1979 for students to assess. The students review case
Mar 22; 300(12):642-647
Turner-Warwick M: On observing patterns of airflow obstruc-
tion in chronic asthma. Br J Dis Chest 1977 Apr; 71(2):73-86
histories and appropriate physical findings. The
chaos of the typical emergency room is created by
the "'patients" and the supportive nursing staff. A
Advanced Trauma Life Support student must systematically examine a patient,
TRAUMA IS SURPASSED only by arteriosclerosis perform lifesaving interventions, order and inter-
and cancer as the leading cause of death in the pret the appropriate laboratory and x-ray studies
United States and is the leading cause of death in a specified time; otherwise the "patients" will
in the first three decades of life. Primary care die of their injuries.
physicians are often responsible for the initial Instructor level courses are also available for
care of trauma victims. those interested in teaching ATLS courses. At the
Trauma care training previously had been car- University of California, Los Angeles (UCLA), the
ried out by preceptorship and lectures, neither of Family Practice Group has found this training
which allowed a "hands on" learning experience. especially useful for physicians in rural sites and
Standards for resuscitation of a trauma victim an adjunct to ACLS courses for physicians with an
such as those set forth by the American Heart active hospital practice. The ATLS course is now
Association for advanced cardiac life support available nationally through several groups.
(ACLS) did not exist before 1977. In 1977 a RICHARD A. JOHNSON, MD
course in advanced trauma life support (ATLS) REFERENCES
Carveth SW, Burnap TK, Bechtel J, et al: Training in advanced
was developed and revised by the Lincoln Medical cardiac life support. JAMA 1976 May 24; 235(21):2311-2315
Education Foundation, Physicians' Committee on Collicott PE: Advanced trauma life support course: An im-
provement in rural traumna care. Nebr Med J 1979 Sep; 64(9):
Trauma, Southeast Nebraska Emergency Medical 279-280
Collicott PE, Hughes I: Training in advanced trauma life sup-
Services, the American College of Surgeons, The port. JAMA 1980 Mar 21; 243(11):1156-1159
University of Nebraska School of Medicine and
a number of practicing surgeons. The course was Preoperative Preparation of Patients
presented statewide in Nebraska to practicing pri-
mary care physicians, who were overwhelmingly ABOUT 18 YEARS AGO Egbert and co-workers re-
in favor of the format. As a result, improvement ported that preoperative visits were beneficial in
in the condition of severely injured patients was that they gave support and information to patients
noted. having elective surgical procedures. The study
The ATLS course is quite similar in format to showed substantial reduction in the use of nar-
the ACLS course. It is designed for family practi- cotics, earlier resumption of activities and short-
tioners and emergency room physicians. There are ened hospital stays in addition to subjective bene-
ten lecture and slide presentations and ten prac- fit. Other studies have suggested relaxation
tical skill stations. With these skill stations and techniques taught to patients having an elective
lectures, physicians learn various lifesaving tech- operation reduced incisional pain and the need
niques, such as chest tube insertion, pericardio- for analgesics postoperatively. Furthermore, in-
centesis, cricothyroidotomy, peritoneal lavage, forming surgical patients about sensations that
application of an antishock garment, application will be experienced during the perioperative
of splints and spinal boards, radiographic inter- period effectively reduced stress and the length
pretation, patient assessment, intravenous catheter of hospital stay.
placement technique, fluid replacement and endo- Despite this evidence, routine preoperative
THE WESTERN JOURNAL OF MEDICINE 55
 EPITOMES-GENERAL AND FAMILY PRACTICE

visits by an anesthesiologist or surgeon continue In proved ectopic pregnancy, culdocentesis yields

to be mainly perfunctory; rarely is an attempt nonclotting blood with up to 82 percent accuracy.
made by a busy physician to understand a pa- Accuracy increases to 97 percent when combined
tient's anxieties or to teach simple pain-control with radioreceptor assay (RRA) pregnancy test. In
techniques. In some hospitals nursing services acute salpingitis purulent peritoneal fluid can be
have taken over this task. examined directly with greater accuracy than
Though program formats vary, efforts are being endocervical fluid.
made to offer all patients this preoperative prepa- Careful patient selection and good fundamental
ration. At the San Jose Hospital (San Jose, Cali- technique are critical to success. In both suspected
fornia), for example, the program is run by the ectopic pregnancy and acute salpingitis there
recovery room nursing staff to ensure continuity should be signs of peritoneal irritation- that is,
during the early postoperative period. During the pain on cervical motion, rebound tenderness, a
early evening before operation an audiovisual bulging cul-de-sac or shoulder pain. If a patient
program, prepared by the nursing service, is shown has none of these, culdocentesis is less likely to
to all available preoperative patients. This is fol- be useful. Similarly, a fixed mass or a fixed retro-
lowed by a session in which leg and breathing verted uterus that fills the cul-de-sac conmraindi-
exercises are taught. Each patient is then visited cates culdocentesis.
by a nurse who asks open-ended questions (that The essential equipment are a speculum, a
is, designed to permit spontaneous responses). A tenaculum, an 18-gauge spinal needle, a 1O-ml
summary nursing record sheet is prepared, listing syringe (a three-finger control syringe is more
special problems that should be considered during convenient), sterile sponges and ring forceps,
the operative procedure or in the immediate post- iodine preparatory solution and gloves. Good
operative period. This record includes issues sterile technique should be used.
elicited during the interview, such as special fears The technique includes the following steps:
or anxieties. The summary sheet is reviewed by (1) a thorough pelvic examination, including
the nursing staff in the operating room, recovery careful bimanual examination (for cervical ten-
room and on the surgical floor. derness, uterine position, adnexal or cul-de-sac
The available evidence is quite convincing that masses or tenderness); (2) speculum placement
this type of program should be encouraged in all and preparation of cervix and vagina; (3) appli-
of our hospitals. WILLIAM C. FOWKES, MD cation of the tenaculum to the lower lip of the
REFERENCES
cervix (caution patients about cramps) and posi-
Egbert LD, Battit GE, Welch CE, et al: Reduction of post- tioning of the cervix to allow access to the cul-
operative pain by encouragement and instruction of patients-A de-sac; (4) draw 2 to 3 ml of air into the syringe;
study of doctor-patient rapport. N Engi J Med 1964 Apr 16; 270:
825-827 (5) puncture the vaginal mucosa in the midline 1
Flaherty GG, Fitzpatrick JJ: Relaxation technique to increase
comfort level of postoperative patients: A preliminary study.
Nurs Res 1978 Nov-Dec; 27(6):352-355
cm below its posterior reflection away from the
Johnson JE, Fuller SS, Endress MP, et al: Altering patients' cervix. The needle should penetrate below the
responses to surgery: An extension and replication. Res Nurs
Health 1978 Oct; 1(3):111-121 cervix and uterus and above the rectum; (6) hold
the needle and syringe horizontally and advance 3
to 4 cm through the mucosa; (7) inject the 2 to
Culdocentesis to Diagnose Ectopic 3 ml of air. If there is resistance the needle has
Pregnancy and Pelvic Inflammatory entered solid tissue and should be repositioned;
Disease (PID) (8) aspirate, and (9) the procedure,is terminated
PROMPT AND ACCURATE DIAGNOSIS of ectopic preg- after aspiration of fluid or three dry taps. Bleeding
nancy and acute salpingitis is critical for timely will be minimal.
and appropriate treatment. Delay and misdiag- Complications are very rare and are primarily
nosis can result in an unnecessary surgical pro- the result of penetration of pelvic organs, cysts or
cedure, delay in necessary surgical or antibiotic tumors. They should be avoidable with good
treatment and increased patient morbidity and technique. J. TIMOTHY MURPHY, MD
mortality.
REFERENCES
Culdocentesis is a simple, safe and efficient Brenner PF, Roy S, Mishell DR Jr: Ectopic pregnancy-A study
diagnostic tool that allows direct examination of of 300 consecutive surgically treated cases. JAMA 1980 Feb 15;
243(7):673-676
free intraperitoneal fluid and provides immediate, Eisinger SH: Culdocentesis. J Fam Pract 1981 Jul; 13(1) :95-101
accurate and readily interpretable information. Quan M, Rodney WM, Puffer JC: Ectopic pregnancy: A clinical
review. J Fam Pract 1982 Mar; 14(3):561-566

56 JULY 1982 * 137 * 1