CORRESPONDENCE

problem. A written record in the ED of individuals who make frequent prescription requests may help to identify potential abusers. We must, of course, avoid unjustly stigmatiz- ing such patients. While it is unfortu- nate that the ED staff must be in- volved in policing activities, the pre- vent ion of prescription fraud will u l t ima te ly benefi t all leg i t imate users of the health care system.

Richard M Rosenberg, MD Barton H Lerner, MD Emergency Services Columbia-Presbyterian

Medical Center N e w York

I. Wilford BB: Abuse of prescription drugs. West J Med 1990;152:609-612.

2. Taibbi M, Phil l ips AS: Prescription for danger. WCBS-TV News, April 25-26, 1991.

3. Cushman P: Clonidine and alcohol withdrawal. Adv Alcohol Subst Abuse 1987;7:17~28.

4. Caballeria J, Baraona E, Rodamilans M, et ah Effects of cimetidine on gastric alcohol dehydrogenase activity and blood e thanol levels. Gastroenterology 1989; 96:388-392.

5. Somogyi A, Muirhead M: Pharmacokinetic interac tions of cimetidine 1987. CJin Pharmacokinet 1987;12: 321-366.

6. Webster LK, Jones DB, 8mallwood RA: Influence of cimetidine and ranitidine on ethanol pharmacokinetics. Aust NZ J Med 1985j5:359-360.

Flumazenil & Coma

To the Editor: We noted with interest the excel-

lent review "Flumazenih A New Benzodiazepine Antagonist" [Febru- ary 1991;20:181-188], by Votey et al. Although it appears very promising, f lumazenil ' s potential side effects must be further elucidated before it can be used in coma of unknown eti- ology.

The authors point out the poten- tial for complications in ingestions involving chloral hydrate and possi- bly even tricyclic antidepressants. However, they did not discuss the ef- fects of flumazenil on cerebral blood flow and intracranial pressure. Al- though Forster et al ~ found flu- mazenil to have no effect on these parameters when it was given to seven healthy volunteers, Fleischer et al 2 described a significant increase in intracranial pressure in nine dogs

given flumazenil to reverse the seda- tive effects of midazolam. Chiolero et al 3 also found significant increases in intracranial pressure following flu- mazenil administration to patients with severe head injury.

Space-occupying lesions are a com- mon cause of coma; before flu- mazenil can be administered safely to all comatose patients, its effects on intracranial pressure must be clar- ified.

Francois R LaFleche, MD, FRCPC Department of Emergency Medicine Vancouver General Hospital Vancouver, British Columbia,

Canada

David P MiJzman, MD Department of Emergency Medicine Georgetown University Hospital Washington, DC 1. Forster A, Juge O, Louis M, et al: Effects of a specific benzodiazepine antagonist (Ro15 1788] on cerebral blood flow. Anaesth Analg 1987;66:309-313.

2. Fleischer IE, Milde [H, Moyer TP, et ah Cerebral ef- fects of high-dose midazolam and subsequent reversal with Rot5d788 in dogs. Anaesthesiology 1988;68: 234 242.

3. Chiolero RL, Ravussin P, Anderes IP, et a[: Mid- azolam reversal with Ro15 1788 in patients with severe head injury. AnaesthesioJogy 1986;65:No.3A:A358.

The CDC's Role in Emergency Preparedness and Response

To the Editor. Dr Mickel is to be commended for

addressing an issue of critical impor- tance to the future of emergency medicine in his editorial "Critical Need for a Na t iona l Ins t i tu te of Emergency Medicine" [November 1990;19:1340-1341]. The fu r the r growth and development of the spe- cialty will depend on high-quality re- search being conducted in important areas such as resuscitation, toxicol- ogy, prehospital emergency medical services, and the public health as- pects of emergency medical care.

The basic premise of his editorial was that responsibility for research relevant to emergency medicine is f ragmented among many federal agencies, with some important areas not addressed by any agency at all. One research area that Dr Mickel identified as critical concerns medi-

cal conditions associated with disas- ters. Regarding the latter, he states that "... no federal agency is respon- sible for inves t iga t ions into the causes and t r ea tmen t of medical problems related to disasters." This is not the case. The Centers for Dis- ease C o n t r o l (CDC), an agency within the US Public Health Service (PHS), has long been responsible for conducting investigations into the health effects and medical conse- quences of natural and technological disasters. Another PHS agency, the National Institute on Mental Health, funds research on psychosocial re- sponses to disasters and supports di- saster preparedness to cope with the psychological stress associated with e n v i r o n m e n t a l cr ises and cata- strophic events.

Within the PHS, the CDC has been designated as the lead agency for re- sponding to technological hazards and natural disasters. As the primary US government health agency in di- saster situations, the CDC is respon- sible for coordinating and managing the overall PHS response; alerting other appropriate federal agencies; helping to assess the health impact of an event; consulting with state and local health agencies on the med- ical resources required and helping to locate those needed resources; advis- ing federal, state, and local officials on emergency response and worker protection issues; and establishing public health surveillance systems.

For the past 20 years, no other in- stitution in the world has been able to match the CDC's rich and diver- sified experience in responding to natural and man-made disasters, both domest ical ly and internationally. Through the involvement of CDC medical staff in the massive interna- tional relief operation mounted dur- ing the civil war in Nigeria in the late 1960s, techniques were devel- oped for rapidly assessing nutritional status and for conducting surveys to identify populations in need. In the 1970s and 1980s, the CDC conducted investigations following earthquakes in Peru, Nicaragua, and Guatemala, 1 a cyclone in the Bay of Bengal, z a chemical release in Bhopal, India, 3 floods in Bangladesh, and the volca-

160/1397 Annals of Emergency Medicine 20:12 December 1991

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nic eruptions of Nevada del Ruiz in Columbia and Mt St Helens in Wash- ington State. 4

CDC scient is ts have also exam- ined patterns of morbidity and mor- tality in refugee camps in Ethiopia, the Sudan, and Southeast Asia. Most recently, the CDC conducted health investigations following earthquakes in California 5 and the Philippines, 6 Hurricane Hugo in South Carol ina and Puerto Rico, 7 and a tornado in northern Illinois. s

Other CDC responsibilities in the area of emergency preparedness and response include 1) provision of tech- nical and epidemiologic assistance to state and local governments after di- sasters; 21 documentat ion and quan- tification of the public health conse- quences of different types of natural and technological disasters; 9 3) iden- t i f i ca t ion of p o t e n t i a l s t r a t eg ie s through risk factor analysis that may p reven t or m i t i g a t e these conse- quences; 4) development of preven- t i o n p r o g r a m s and c o n t i n g e n c y plans; 5) development and mainte- nance of national systems for acute env i ronmenta l hazard survei l lance (eg, CDC has established a surveil- lance system with the American Red Cross for tracking all deaths and se- rious injuries related to natural disas- ters in the United States); 6) rapid as- sessment of health care needs in the immediate postdisaster period; 7) as- sessment of health risk; and 8) provi- sion of epidemiologic and scientific support services to other agencies in- volved in disaster planning and re- sponse, such as the Federal Emer- gency, Management Agency, the Of- fice of US Foreign Disaster Assis- tance, and the American Red Cross. As a r e c e n t l y d e s i g n a t e d Wor ld Heal th Organiza t ion Col labora t ing Center in Disaster Preparedness and Response, the CDC also can provide similar assistance to foreign govern- ments and intergovernrnental organi- za t ions such as the Office of the United Nations Disaster Relief Coor- dinator and the League of Red Cross and Crescent Societies.

In summary, I cannot argue wi th the author 's contention that a critical need exis t s for bas ic r e sea rch in emergency medicine nor that current

basic research in areas of p r imary concern for emergency medicine are scattered among several government agencies, wi th several areas not ad- dressed at all. The health effects and medica l consequences of disasters, however, are being studied in a con- certed and sys temat ic way by the USPHS.

Eric K Noji, MD, MPH, FACEP Center for Environmental Health

and Injury Control Centers for Disease Control Atlanta, Georgia

1. Spencer HC, Campbell CC, Romero A, et ah Disease surveillance and decision making after the 1976 Gua- temala earthquake. Lancet 1977;2:181.

2. Sommer A, Mosley WH: East Bengal cyclone of No- vember, I970. Lancet 1972;1:1029-1036.

3. Parrish RG, Falk H, Melius JM: Industrial disasters: Classification, investigation and prevention. Recent Adv Occnpat Health 1987;3:155-168.

4. Bernstein RS, Baxter PJ, Falk H, et ah hnmediate public health concerns and actions in volcanic erup- tions: Lessons from the Mt St Helens eruptions, May 18-October 18, 1980. Arn J Public Health 1986;76 (suppl]:25-37.

5. CDC: Earthquake-associated deaths California. MMWR 1990;38:767-770.

6. CDC: Earthquake disaster Luzon, Philippines. MMWR 1990;39:573 577.

7. CDC: Medical examiner/coroner reports of deaths associated with Hurricane Hugo 8 Carolina. MMWR 1989;38:754-762.

8. Brenner SA, Noji EK: Tornado disaster: Northern Illi- nois, August 28, 1~90. Report of the CDC epidemiologic team. Atlanta, Centers for Disease Control, November 23, 1990.

9. Gregg MB {ed): The Public Health Consequences of Disasters. Atlanta, Centers for Disease Control, 1989, p 1-127.

In Reply: I thank Dr Noji for an interesting

discussion concerning the role that the CDC has had in conducting in- vestigations into the heal th effects and medical consequences of natural and technological disasters. His con- tribution is important to a review of federal agencies responsible for re- search relevant to emergency medi- cine. I regret and apologize for the omission of the CDC's contribution to disaster medicine research in my editorial.

There is some consolation that the federal government has focused at- t en t ion of these problems th rough the PHS and CDC. Dr Noji should be highly complimented for his role in this effort. However, the CDC is still

another federal agency responsible for investigation into problems that direct ly relate to emergency medi- cine.

The omiss ion of the role of the CDC in the editorial does not in any way negate the conclusion that a Na- tional Institute of Emergency Medi- cine is needed. Given the potential for terrorist actions on one hand and natural disasters on the other, it is most difficult for me to understand how those in responsible positions wi th in our gove rnmen t can fail to understand the critical nature of this need.

Hubert S Mickel, MD Emergency Department Barnes Hospital St Louis, Missouri

Literary Latin Lesson

To the Editor: "S t r iv ing to better , oft we ma r

what ' s well. ' ' l The editorial "Com- mon Sense" [March 1991;20:319-320] was pe rsuas ive un t i l the finale. I hope Dr Henry is not urging us to commit medicolegal suicide, though that is the act ion of which Hamlet speaks. After urging action over too much thought, I also wonder why he r e c o m m e n d s caput , r a t h e r t h a n carpe, deum.

Lisa Santer, MD University of Florida Health Science

Center Jacksonville 1. William Shakespeare: King Lear, I, iv, 353.

In Reply: Dr Santer has raised two interest-

ing points concerning my editorial. First, I am not urging medicolegal suicide, a l t h o u g h tO p roc ras t ina t e would be just that. Dr Santer is cor- rect in tha t the init ial ac t ion that Hamlet is contempla t ing is that of his own destruct ion, but his com- men t s about t hough t rul ing ac t ion are perfect ly val id no ma t t e r wha t the s i tua t ion m a y be, and I hoped that it would be viewed in this wider context.

Many years ago when I was an un-

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