Active Compression-Decompression CPR, Quinn et al. 467

amine would have been the best choice in hindsight. The dose used was 0.1 mg/kg, the minimum recommended anesthetizing dose for rapid-sequence induction.24 Given the uniqueness of this situation, the proper dosage is uncertain. While the dose used in this setting of hypoten- sion may still have been excessive, the patient’s degree of agitation suggested the need for a full induction dose.

The magnesium sulfate used in this case, while not recommended for asystole, was used for the underlying acute myocardial i n f a r ~ t i o n . ~ The hemodynamic effects of magnesium are minimal, and despite its potential to de- crease general vasomotor tone, magnesium has been sug- gested to improve coronary perfusion.6 Earlier pacing in this patient would have been ideal .’ We considered early pacing in this patient. but difficulty controlling the arrest scene delayed its use.

We believe this case demonstrates some of the challeng- ing dilemmas faced when resuscitation efforts produce effective cerebral perfusion that cannot be sustained when CPR is halted.

IREFERENCES 1.

2.

3 .

4.

5 .

6.

7.

Merriman CS, Kalbfleisch ND. Thrombolysis in acute myocardial infarction following prolonged cardiopulmonary resuscitation. Acad Emerg Med. 1994; 1:61-6. Dronen SC. Pharmacologic adjuncts to intubation. in: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 2nd ed. Philadelphia: W.B. Saunders, 1991: 37. Danzl DE Advanced airway support. In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine. A Comprehensive Study Guide. 3rd ed. New York: McGraw-Hill, 1992: 18-9. Walls RM. Rapid sequence intubation: a primer for physicians in the emergency department. In: Emergency Update 92: Airway Manage- ment and Pain Control. Ottawa, Ontario: Canadian Association of Emergency Physicians, 1992: 10-5. Finkelstein JA, O’Keefe KP, Butzin CA. Magnesium in acute myocar- dial infarction. Ann Emerg Med. 1993; 22:754-6. Yusuf S, Teo K, Woods K. Intravenous magnesium in acute myocar- dial infarction: an effective, safe, simple and inexpensive intervention. Circulation. 1993; 87:2043-6. Guidelines for cardiopulmonary resuscitation and emergency cardiac care: recommendations of the 1992 conference. JAMA. 1992; 268: 2171-302.

Reflections

I IN APPROPRIATE CONSULTATION

I Inappropriate consultations have become an increasing problem over the last two decades. Although this pervasive and insidious disorder is common, there has been little discussion of it. Therefore, little is known and less has been published. I hope that this essay will stimulate discussion and dkpel myths.

Epidemiology and Pathophysiology Because this disorder has a seasonal incidence, occur-

ring predominately in the late summer with a sharp peak in July, i t has been postulated that an infectious agent may be the cause. Despite an intensive search for various organ- isms, no evidence for an infectious link has been found. In particular. there is no evidence of a link to retroviruses. Nevertheless, inappropriate consultation does seem to oc- cur in small epidemics among housestaff and fellows on various subspecialty services. There is no explanation for the fact that there is a significant negative correlation between the prevalence of inappropriate consultation and the incomes of both the consulter and the consultant.

Attention has recently shifted away from the realm of infectious diseases toward an endocrine cause. There are

several reasons for this. First, there is a definite circadian variation in the incidence of inappropriate consultation, which occurs mainly at night, especially after 10 PM.

Clearly the pituitary-adrenal axis is involved in some way. In addition, it has been noted that there is a strong correla- tion between inappropriate consultation and both the heart rate and the blood pressure of the consultant at the time of initial consultation. Therefore, abnormalities of the sym- pathetic nervous system have been postulated. It is impor- tant to note that there is no evidence to date that this is another presentation of pheochromocytoma. Others have suggested thyroid abnormalities or excessive interleukins as a cause of the syndrome, but no study of these hormones has been reported.

A genetic link has been postulated. This may be one of the few Y-linked chromosomal disorders. Some investiga- tors have noted excessively large Y-chromosomes in af- flicted male consultants. The disorder is uncommon but not unheard of in women. Whether or not abnormal adrenal steroid metabolism is involved is not known.

There is a positive correlation between the number of consultations with a particular patient and the prevalence

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468 ACADEMIC EMERGENCY MEDICINE SEP/OCT 1994 VOL 1 /NO 5

of inappropriate consultation. Furthermore, the last con- sultant to see a particular patient is much more likely to be affected than the first consultant. One theory proposed to account for this phenomenon is kindling. TWO specialties are therefore particularly plagued by this disorder, psychi- atry and neurology. Other specialties, particularly those whose trainees work the longest hours, are also prone to the disorder. Although there are regional variations, inap- propriate consults seem to occur mainly in teaching hospi- tals.

Psychoanalysts have long been interested in the disor- der and postulate ego-superego imbalance as a possible cause. Interruptions of REM sleep have been universally noted, as have dream disturbances. Some behavioral theor- ists feel that it represents a personality disorder, but this diagnosis is not found in the Diagnostic and Statistical Manual-IIIR classification scheme.

Diagnosis It is often difficult to predict the onset of the syndrome

or to make the diagnosis. In the earliest reports i t was noted that the probability of inappropriate consultation rose exponentially with the volume of the consultant’s voice. Having to pull the phone away from your ear is an early and useful clue.

Because consultants rarely allow you to take their vital signs, it is important to carefully examine their skin, especially around the face. The redder the skin, the more likely the consult is to be inappropriate. The differential for this syndrome includes various erythrodermas, including sunburn and allergic reactions, as well as the carcinoid syndrome and systemic mastocytosis.

Bulging neck veins are often seen, but this sign is neither sensitive nor specific. Congestive heart failure, pericardial tamponade, the superior vena cava syndrome, or tying one’s tie too tightly are all in the differential.

If possible, an attempt to measure rectal tone, either directly or indirectly, can be helpful. Though rectal tone is often difficult to measure, if it is increased, it is likely that inappropriate consultation is occurring. Inappropriately elevated rectal tone can be found even between consulta- tions in an afflicted consultant.

Smiles and jokes virtually rule this disorder out. How- ever, if palpable or visible sarcasm is noted, inappropriate consultation is still possible.

One very specific sign is tousled hair, especially if

unilateral. In fact, unilateral tousled hair, puffy eyes, and bedroom slippers constitute the classic triad of inappropri- ate consultation. It is important to remember, however, that the triad is often completely absent.

The laboratory may be useful at times. If the technician has been yelled at by a consultant or if laboratory reports are found crumpled up, the syndrome should be strongly suspected.

Natural History and Treatment The natural history of the disorder is that once afflicted

a consultant will have recurrent attacks, but the frequency will decline over time. A particularly precipitous decline should occur after housestaff training is complete. If this does not occur, another diagnosis should be considered. Although some of the consultants report long-term feelings of loneliness, no other serious sequelae have been noted. Therefore, the prognosis is generally quite good.

Treatment is basically supportive. Phone calls to a consultant’s superior can shorten the duration of the prob- lem and make recurrences less likely, unless the superior is also afflicted. In this situation, the problem can become chronic, and no effective remedies exist. Trials of beta- blocking agents are under way. Support groups are avail- able in certain cities. It is important to remember that the possibility of an infectious link has not been totally ruled out and universal precautions are always in order when dealing with an affected consultant. Latex gloves are, however, not sufficient; you must use “kid” gloves, which are often in short supply.

Conclusion Inappropriate consultation is an increasing problem.

Although difficult to diagnose early, the syndrome almost always becomes evident late in its course. The prognosis is generally good. Treatment is supportive at present. Further research needs to be done on the neurohumoral processes involved in the disorder so that other preventive and treatment molalities can be generated. There is hope on the horizon; an animal model has been developed - moronic oxen.

KEITH WRENN, MD Vanderbilt University Medical Center Department of Emergency Medicine Nashville, TN