to make useful conclusions is because authors far too oftenfail to separate the effects of confounding variables. Second,our understanding of the specific issue of optimal prehos­pital care for trauma victims is not furthered by biased andunsupported speculation such as is found in this otherwisevery useful article. Whether or not these authors' bias willbe ultimately validated is not the issue; the fair and accuratereporting and interpretation of data is.

JERmlE R. HOFFMAN, !\toDepartment of EmergencyMedicineUCLA Medical CenterLos Angeles

The authors reply:-Dr. Hoffman states that our recommen­dation not to implement emergency department thora­cotomy (EDT) in our Group IV ("dead on the scene")' pa­tients is a measure not supported by the trauma literature. Abrief review of the recent trauma literature would seem tosupport our contention, not refute it as Dr. Hoffman implies.Mattox and Feliciano? reported 100% mortality in 63 victimsof penetrating thoracic trauma undergoing EDT after re­quiring greater than three minutes of CPR prior to arrival ata hospital. Cogbill et aP reported that, of 177 patients withblunt or penetrating trauma who had no vital signs at thescene of injury and then underwent EDT, the lone survivorwas a patient who had sustained a severed brachial artery.These authors state that in their study the ratio of pene­trating to blunt injuries was 2: I to 3: I. Thus, in that study,even at the more conservative 2: I ratio, over one-hundredpatients with penetrating trauma and no vital signs at thescene were not successfully resuscitated with EDT. Flynn etat' reported on seven patients with penetrating trauma whopresented without signs of life on arrival and had receivedCPR during air transport; again. none in this group survived.Rohman et afS reported no survivors among 18 victims ofpenetrating thoracic injuries who showed no signs of life inthe field and subsequently underwent EDT. We have re­ported nine such cases in our study.' Thus, the trauma litera­ture documents over 200 such cases since 1980. One canonly wonder at how many more such cases would be re­ported if all articles on EDT utilized a patient classificationsystem similar to ours to enable identification of those pa­tients devoid of signs of life in the field. That application ofEDT in trauma victims should be selective is a view sharedby many authors with considerable experience in the field oftrauma resuscitation.l-"

Dr. Hoffman further states that our transportation anal­ysis with respect to survival is faulty because of no "attemptto evaluate similarity of patients on the basis of other criticalfactors, such as weapon used, site of injury, and condition inthe field." On the contrary, patients in our study were evalu­ated with regard to type of weapon used, site of injury, andstatus of vital signs at the scene, in transit, and upon arrivalat the emergency department as outlined in Table 5 of ourstudy. I The data from Table 5 demonstrate remarkable clin­ical similarity between the ambulance-transported patientsand the "scoop and run" group in all parameters exceptnumbers of survivors. We have never stated categoricallythat "scoop and run" is the definitive answer to field man­agement of penetrating thoracic injuries. Rather, we haveadvocated the inclusion of pertinent transportation data in

CORRESPONDENCE

future studies of EDT in trauma victims to help resolve theoverall impact, if any, of rapid transportation Upon ultimatesurvival. We continue this advocacy.

RAYMOND J. RODERGE. !\IORAO R. IVATURY, xmLincoln Medical and Mental

Health Center and theNell' York Medical College

Nell' York

References

1. Roberge RJ, Ivatury Rr, Stahl W, et al. Emergency depart­ment thoracotomy for penetrating injuries: Predictivevalue of patient classification. Am J Emerg Med 1986;4:129-135.

2. Mattox KL, Feliciano DV. Role of external cardiac compres­sion in truncal trauma. J Trauma 1982;22:934-936.

3. Cogbill TH, Moore EE. Millikan JS, et al. Rationale for selec­tive application of emergency department thoracotomy intrauma. J Trauma 1983;23:453-460.

4. Flynn TC, Ward RE, Miller PW. Emergency department tho­racotomy. Ann Emerg Med 1982;11:413-416.

5. Rohman M, Ivatury RR, Steichen FM, et al. Emergency roomthoracotomy for penetrating cardiac injuries. J Trauma1983;23:570-576.

6. Moore EE. Moore JB, Galloway AC, et al. Postinjury thora­cotomy in the emergency department: A critical evalua­tion. Surgery 1979;86:590-598.

OPEN-CHEST CPRTo the Editor:-The May 1986 article by Rosenthal and Tur­biak (AJEM 1986;4:248-258) was a fascinating review of"Open-Chest Cardiopulmonary Resusitation." My com­ment is directed toward their opening statement:

"The history of cardiac resusitation begins with thework of Professor Schiff in the latter half of the nine­teenth century.'>"

In this article, and other reviews, I have not seen any creditgiven to Dr. William Harvey, a great name in English medi­cine and experimental science. In 1628, his treatise "DeMotu Cordis et San Guinis (on the-Motion of the Heartand Blood), states:

"Experimenting with a pigeon upon on occasion, afterthe heart had wholly ceased to pulsate, and the auriclestoo had become motionless, I kept my finger wettedwith saliva and warm for a short time upon the heart,and observed, that under the influence of this fomenta­tion it recovered new strength and life, so that bothventricles and auricles pulsated, contracting and re­laxing alternately, recalled as it were from death tolife ..."I am not a medical historian. I respectfully submit this

view-point for consideration to give Dr. William Harvey rec­ognition as not just "father of cardiology and embryology"but also as a founding father of cardiac resusitation.

RANDALL WILLIS, Ml)Emergency DepartmentClaiborne County HospitalTazewell, Tennessee

ACADEMIC ASPIRATIONS OF RESIDENTS

To the Editor:-The academic evolution of the specialty ofemergency medicine includes the training of future faculty to

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AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 4, Number 6 • November 1986

bring forth new progeny. As a clinical specialty. emergencymedicine residency programs have largely emphasized clin ­ical training. This emphasis has been in part caused by theclinical. rather than academic, orientation and responsibili­ties of the early emergency medicine residency directors. J

Interest in laboratory and clinical research ha s subsequentlyevolved in these training programs. Research interest inemergency medicine residency programs is in part to fulfillthe academic charge of blending service , education and re­search. Few emergency medicine faculty view research astheir primary academic activity.

To characterize the clinical and research aspirations ofresidency applicants having the goal of an ac ademic careerin emergency medicine , applicants to the Uni versity of Cin­cinnati Emergency Medicine Residency Pro gram were sur­veyed regarding factors contributing to their interest inemergency medicine, their interest in certain research andeducational activities, prior research activities, and their fu­ture career plans . The results of this survey suggest impor­tant implications regarding the future of academic emer­gency medicine.

AU survey respondents were first-year residency appli­cants to the University of Cincinnati four-y ear emergencymedicine residency program . Applicants were asked toanonymously complete a survey form wh ile interviewing fora residency position in the program. Of 549 potential appli­cants, 104 individuals were granted an interview for a resi­dency position. Of these, 94 applicants were ultimately in­terviewed. Survey sheets were completed by 79 of the 94(84%) applicants.

Data from the survey were analyzed anonymously by anonfaculty member. Applicants were as sured at the timethey completed the survey that the material would be re­viewed anonymously following assignment of the residencyprogram match rank list. The applicants were instructed thatthe survey was to "help us better understand the back­ground and interests of residency applicants." The appli­cants were also encouraged to be "candid." Comparison ofapplicant subgroups was performed by Chi-square analysisor Fisher's exact test with a P-value of 0.05.

The residency applicants had a mean (± standard devia­tion) age of 26.6 (±2.3) years with a range of 23-35 years.There were 54 male and 25 female applicants. The majorityof applicants (89%) had a bachelors degree (Bachelors ofArts or Bachelors of Science). There were five applicantswith MOs at the time of application and two applicantswith PhOs at the time of application. There were 49 appli­cants who were married or had a "significant other." Mostapplicants developed an interest in emergency medicine be­cause of their "enjoyment of constant diagnostic chal­lenges" (96%) , the "variety of patient age and illness"(96%), and because of the "subject matter" (92%).

AU but one applicant expressed limited to definite.interestin "participating" in a clinical research project (Table I). Infact . only three applicants indicated disinterest in " devel­oping" a clinical research project. Of the educational activi­ties suggested . the applicants indicated least interest in "de­veloping" an animal laboratory research project with "par­ticipation" in an animal laboratory project a close second.Interestingly, 57% of the applicants reported prior basicscience research experience.

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TABLE 1. Interest in Educational Activities during Residency

Percentageof Applicants'

Educational Activity 0 L M

Participate in a clinicalresearch project 81 18 1

Develop a clinical research project 49 47 4Present a Grand Rounds topic 65 30 5Write a case report for a journal 68 28 4Write a review article for a journal 43 44 13Participate in an animal laboratory

research project 32 50 18Develop an animal laboratory

research project 19 57 24

• Applicants used the following rating scale: D = definite (willdo regardless of residency location); L = limited (likelyonly if ina supportive environment); M = minimal (not interested at thistime). Applicants responded to each activity.

When questioned about career goals, the majority of ap­plicants planned "some affiliation with a teaching hospital ina clinical role" (81%) . A minority planned a pure clinicalcareer (9%) . Interestingly, no applicants planned to committhemselves to a predominately research-oriented career. Anadministrative or mixed clinical/research career was plannedby 28% and 59%, respectively. Fellowships were planned by38 (48%) of the applicants; 29 planned clinical fellowships,and nine planned research fellowships.

There were 39 (46%) applicants who stated that theywould use a "fourth year to prepare for an academic career"(positive response). These applicants had a mean (±SO) ageof 26.8 (± 2.3), with a range of 24 to 35 years . The onlystatistically significant difference in factors influencing theirinterest in emergency medicine was that a larger percentageof positive respondents sensed the "opportunity for rapidacademic advancement" as a motivation for choosing a ca­reer in em ergency medicine.

The only difference between the two response groups withrespect to interest in performing educational projects was agreater interest in "presenting a grand rounds lecture" bythe positive response group. More of the positive responsegroup had been primary author on a scientific publication(28% versus 10%). Otherwise, there was no statistically sig­nificant difference between the groups with respect to theirprior research, writing, or EMT training . Of the 39 appli­cants with positive responses, 18 planned clinical fellow­ships and eight planned research fellowships. No applicantwith a positive response stated that a pure clinical careerwas desired .

This survey of applicants to a university hospital emer­gency medicine residency program raises important issuesfor the future of academic emergency medicine . First, theobservations that 81% of the applicants planned some affilia­tion with a teaching ho spital in a clinical role, that 59% ofthe applicants planned a mixed clinical/research career, andthat none of the applicants planned a career predominatelyoriented towards research implies that emergency medicineacademicians in the near future will probably remain pri­marily clinically oriented.

Second. the observation that 11% of the applicants

planned research fellowships and that 37% of the applicantsplanned clinical fellowships implies that saturation filling ofclinical postresidency training positions in emergency medi­cine may occur much sooner than anticipated. Again, thepredominate interest in a clinical academic role is evident.

Third, the observation that 81% of applicants definitelyplanned to participate in a clinical research project duringtheir residency indicates that emergency medicine residencyapplicants are interested in clinical research. Although theinterest in an animal laboratory research project is less thanfor clinical research, the interest in laboratory research inemergency medicine is still probably greater than for mostclinical specialties.

This limited research interest suggests there is potentialfor developing future laboratory-based career scientists inemergency medicine despite the applicants' denial of a-'re­search-oriented career at this time. The realization of thispotential will depend upon emergency medicine program di­rectors and their fellow faculty, as it is up to them to estab­lish an environment conducive to productive research. Col­laborative preceptors, encouraging program directors, andadequate time for research positively correlate with residentresearch productivity,"

Finally, the majority of the applicants participated in re­search prior to applying for an emergency medicine resi­dency. This impressive research exposure may reflect a per­ception on the part of the applicants that prior research ex­perience will enhance their application for a position inhighly competitive residency programs. Competitive spe­cialties including emergency medicine tend to place moreimportance upon prior research experience during residentselection.' This survey also suggests that academic careerplans do not necessarily correlate with prior research andpublishing experience.

This survey has several inherent biases. Despite assur­ances to the contrary, the applicants may have believed thattheir responses would affect their residency match. Further­more, the applicants had been preselected for their interviewby the residency director. Preselection favored applicantswho had multiple achievements during their premedical and

CORRESPONDENCE

medical school experiences. These factors are expected toincrease the proportion of applicants with academic aspira­tions and prior research experience. Nonetheless, it is ex­pected that a similar selection process is performed at otheruniversity hospital residencies; the results of this surveyshould apply for those programs as well.

Verification of the impressions stated previously will re­quire prospective evaluation of subsequent career choices ofapplicants after completion of their emergency medicine res­idency. The last multiprogram survey of emergency medi­cine residency graduates' career choices was performed ap­proximately ten years ago. I Because research in emergencymedicine has become a more important aspect of academicemergency medicine since the initial multiprogram survey,the current interest in research as a component of trainingshould significantly alter the career choice results indicatedpreviously. Finally, the impact of university emergencymedicine residencies upon medical students aspiring to anacademic career must be assessed. Since productive scien­tists have been found to be highly socialized to research andto have had early association with productive senior re­searchers, the development of predominately research-ori­ented academicians in emergency medicine may require fac­ulty contact with research-oriented students during the basicscience years of medical school or even sooner."

THmlAs LUNDBERG, BAJERRIS R. HEDGES, MD, MSUniversity ofCincinnati College ofMedicineCincinnati, Ohio

REFERENCES1. Anwar RAH. Trends in training : Focus on emergency medi­

cine. Ann Emerg Med 1980;9:60-71 .2. Hinman F. Resident research, part-time. J Urol 1984;131 :

358-362.3. Wagoner NE. Suriano JR, Stoner JA. Factors used by pro­

gram directors to select residents. J Med Educ 1986;61:10-21.

4. Bland CJ, Schmitz CC. Characteristics of the successful re­searcher and implications for faculty development. J MedEduc 1986;61 :22-31.

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