CORRESPONDENCE

A t t e n d i n g C o v e r a g e .

To the Editor: The September 1985 issue featured views on attending

coverage ('~ttending Coverage" by Rosen and Markovchick) and on quantity of patients ("Residency Essentials: Quan- tify to Assure Quality," by Dailey) at emergency medicine training sites. Because these are controversial opinions ap- pearing in the pages of the journal representing two major societies of our specialty, differing perspectives are war- ranted.

Rosen and Markovchick present several salient argu- ments for the presence of an experienced teacher and clini- cian in the ED at all times. Their chastisement of those who attempt to shirk the around-the-clock responsibilities of medicine is especially appropriate. However, the authors blithely ignore the fact that for many emergency medicine educators this is an academic issue, rather than one of life- style or economics.

The growth process of a medical specialist traditionally has included a period late in training of semiautonomous responsibility for patient care on the service. The senior res- ident gradually assumes a greater role, but with regular re- view of care and ready availability of assistance from faculty when necessary. This maturation must occur at some point, ff not during residency then after its completion, when guidance and advice on decision making are not as easily obtained. Medical educators regularly witness the transition of a capable but unassured resident to one ready to assume independent practice after completing this important final step in training. The Residency Review Commi t t ee for Emergency Medicine recognizes this need by requiring graded responsibility, and it is a mistake to add a require- ment that is in direct c o n f l i c t . 1

The authors argue that this autonomous responsibility can be achieved by working simultaneously with an attend- ing during busy periods. I disagree, for that system is little different than the role of junior residents, and deprives the senior resident of a supervisory and teaching role. In some institutions, dual coverage also would not be justified or, conversely, the attending would be too busy to provide thoughtful assistance.

Despite their casual dismissal of an on-call attending sys- tem, this has worked with a conscientious faculty encour- aging calls, assisted by written guidelines and the nursing staff. Verbal "drawing and quartering" at daily rounds for failing to call when appropriate tends to make a lasting im- pression on the resident involved and his peers. Further- more, the role of consultant to senior residents is consistent with that of other attendings within the teaching hospital setting, and helps to reduce a damaging distinction between us and other specialists.

It would be inappropriate to limit this supervisory role of the senior resident to the nighttime, and it is equally incor- rect to state that this is always the case. At some centers, shifts are rotated among all attendings and the senior resi- dent(s), with an attending always on ~ site or on call. The advent of 24-hour on-site attending coverage will encourage schemes that actually reduce faculty availability for teach-

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ing and consulting. Rather than mandat ing easily verifiable requirements

such as 24-hour attending coverage, the more difficuk is- sues of faculty qualifications, quality of teaching, and the true degree of supervision of residents must be addressed. Ignoring the successful techniques of other specialties in phased trainee responsibility will not enhance the resident's education, his future clinical capabilities, or the academic contribution and stature of our faculty.

In the editorial on residency essential requirements, Dailey argues for quantifying ED patient volume. Advocates of this approach are also guilty of oversimplification, for they ignore the issues of patient:physician ratios, degree of illness, extent of resident participation in each case, and proportion of "private" patients. I am encouraged that at least this author has obliquely addressed some of these questions by introducing the concepts of numbers of signifi- candy ill patients and patients treated per resident.

However, I must take issue with his statements that most speciakies quantify exposure, and that greater patient quan- tity equates with excellence in medical education. A review of other residency essential requirements reveals that very few even recommend, much less require, specific numbers of patients or procedures for each residentA This is obvious by his need to refer to one minor specialty's requirements. Furthermore, no other specialty lists total patient volume on the service as a requirement. This speaks well for their wisdom and is an absurd idea of ours that is unfounded in fact. The only emergency medicine study comparing pa- tient volume to educational quality showed an inverse rela- tionship between total ED volume and scores on the ABEM Examination.a

Dr Dailey quotes Sir William Osler's aphorism that "to study books without patients is not to go to sea at all." This must be taken in the proper historical perspective of argu- ing for a balance between study and clinical exposure, a goal not always achieved when overwhelmed by patient care du- ties. When discussing criteria unsupported by data, I prefer to quote Osier from the Montreal Medical Journal in 1902: "The greater the ignorance, the greater the dogmatism."

J Ward Donovan, MD Royal Infirmary of Edinburgh Edinburgh, Scotland 1. Director of Residency Training Programs, Special Require- ments for Residency Training in Emergency Medicine. Chicago, American Medical Association, 1985-86;20-21.

2. Directory of Residency Training Programs, The Essentials of Accredited Residencies in Graduate Medical Education. Chicago, American Medical Association, 1985-8617-13.

3. Certification data. American Board of Emergency Medicine presentation in Dallas, June 1983.

In Reply: We fail to understand the authors' statement that "The

advent of 24-hour on-site attending coverage will encourage schemes that actually reduce faculty availability for teach-

Annals of Emergency Medicine 15:6 June 1986

ing and consulting." This seems to imply that more is less and that because

faculty are ubiquitously available you will therefore stop teaching and consulting. The argument further suggests that because an attending is present, the resident cannot function autonomously. This may well be true in an ED that sees few patients, but it is definitely not true in a high- volume, high-acuity ED.

Anybody who has ever studied the educational process, especially where technical manipulative skills are involved, has formed the same conclusions; namely, repetition and high volume of exposure will result in gradually improving manual dexterity and technical skills. Moreover, unless one is exposed to a wide variety of situations in which to apply those technical skills, the judgment as to when and how to use them will be difficult to acquire. There is no substitute for the knowledge of the literature, but it has long been observed in every educational process that there must be actual experience integrated into the theoretical knowledge.

There is no substitute in clinical medicine for the years of clinical experience that can only be acquired by living them, and that is part of the learning process of the young physician who is in the process of acquiring that experi- ence. We believe that the presence of 24-hour attending cov- erage enhances rather than detracts from this experience. Furthermore, it enhances the overall quality of patient care in an ED. Oscar Wilde said "experience is the name men give their mistakes," but in the process of acquiring experi- ence, it is the patient who suffers from our mistakes. We must work to minimize these mistakes through adequate supervision of emergency medicine residents.

We will match our residents' clinical expertise, indepen- dent judgment-making, technical skills, and theoretical knowledge with any program that fails to provide the same

24-hour attending coverage that our residents have received.

Peter Rosen, MD Vincent J Markovchick, MD Department of Emergency Medical Services Denver General Hospital Denver, Colorado

In Reply: By raising such germane issues as patient acuity and resi-

dent/patient ratios, Dr Donovan addresses how we assess quantification; I am glad that he does not question whether we should. I did not say nor did I mean to imply that "most" specialties quantify exposure; indeed, most do not. This may well be due to the obvious difficulties of doing so in most specialties. Emergency medicine is almost unique in lending itself to such examination. This opportunity should not be passed up by us or others.

I am well aware of the negative correlation between total ED visits and ABEM examination scores; this is not surpris- ing when one considers that the largest EDs often have the poorest supervision and teaching. Certainly, beyond a cer- tain point more is not better.

By Dr Donovan's closing quote from Osier, I sincerely hope he is not characterizing editorial opinions expressed in Annals as ignorant or dogmatic. Especially in such an im- portant area as our specialty's residency essentials, we must hear and heed the thoughtful and concerned opinions of our colleagues.

Robert H Dailey, MD Department of Emergency Medicine Highland Hospital Oakland, California

Unibase ® and Triple Antibiot ic O in tment for Hardened Tar Removal

To the Editor: Removal of hardened tar from the skin surface without

causing any further injury can be difficult. Methods of tar extraction have been reported in the literature with varying degrees of success noted. 1-6 The following case illustrates a modified method of tar removal that has not been pre- viously reported in the literature.

A 40-year-old roofer presented to the ED 30 minutes after being splattered on the left eyebrow, palmar aspect of the left thumb, and the lower portion of the thumb with hot tar from a heated caldron. Initial treatment consisted of the ap- plication of cold water to the affected areas and the removal of superficial dirt. An attempt using mayonnaise to remove the solidified tar proved to be ineffective. Subsequently, a mixture of topical triple antibiotic o in tment (Fougera) (bacitracin zinc 400 units, neomycin sulfate 5 mg [equiv- alent to 3.5 mg neomycin base], and polymyxin B sulfate 5,000 units}, and Unibase ® was extemporaneously com- pounded in an approximately 50:50 mixture. Several ap- plications of this mixture to affected areas were successful in softening the hardened tar, allowing for complete and painless removal of the substance without causing any inju-

ry to the skin. The literature describes several modali t ies/or removing

tar from skin surfaces. 1-6 Organic solvents such as alcohol, acetone, kerosene, and gasoline have been used.6-s In addi- tion to the inconsistent results achieved in removing tar with these agents, however, there may be further damage to the skin as well as toxic effects from systemic absorption.6 The successful use of petroleum-based products such as De- Solv-it ® has been documented in the literature. 2 Mayon- naise also has been reported to be a pain-free convenient tar removal agent when used in repeated applications to the skin without scrubbing; 4 however, this emulsion was used ombiacessfully in our case.

Polysorbate ® and Tween-80 ® have been described as ideal emulsifying agents in removing tar.l,2,5, 6 These surface-ac- tive agents have excellent lipophilic and hydrophilic proper- ties that facilitate the removal of tar by promoting micelle formation. These micelles allow for the bond between the cell surface and the adherent material to be cleaved and washed off with water.9

Because Polysorbate ® and Tween-80 ® were not immedi- ately available, both the literature and the hospital formu-

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