Emergency Coma Scale as an alternati”>EMS activation that may have impacted the drug’s effects or any potential vertiginous causes of the symptoms.

The limitations encountered during this study will need to guide future projects on this subject. Future projects might include comparison with 1 or several antiemetics, a blinded control, or placebo.

1. Patanwala AE, Amini R, Hays DP, Rosen P. Antiemetic therapy for nausea and vomiting in the emergency department. J Emer Med 2009. doi:10.1016/j.jemermed.2009.08.060.
2. Ananthanarayan C, Blight K. Dystonic reaction after anesthesia. Can J Anesth 2001;48(1):101.

John P. Benner NREMT-P Madison County Department of Emergency Medical Services Madison, VA 22727, USA

Jeffrey D. Ferguson MD, NREMT-P Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

Madison County Department of Emergency Medical Services Madison, VA 22727, USA Department of Emergency Medicine Brody School of Medicine

Eastern Carolina University Greenville, NC 27834, USA

Anthony E. Judkins NREMT-I Madison County Department of Emergency Medical Services Madison, VA 22727, USA

Robert E. O’Connor MD, MPH Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

William J. Brady MD Department of Emergency Medicine University of Virginia School of Medicine Charlottesville, VA 22908, USA

Madison County Department of Emergency Medical Services Madison, VA 22727, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2011.03.022

References

1. Braude D, Crandall C. Ondansetron versus promethazine to treat acute undifferentiated nausea in the emergency department: a randomized, double-blind, noninferiority trial. Acad Emerg Med 2008;15(3):209-15.
2. Barrett TW, DIPersio DM, Jenkins CA, Jack M, McCoin NS, Storrow AB, et al. A randomized, placebo-controlled trial of ondansetron, metoclopramide, and promethazine in adults. Am J Emerg Med 2009. doi:10.1016/j.ajem.2009.09.028.

The Emergency Coma Scale as an alternative to the Glasgow Coma Scale^?,??

To the Editor,

We read, with great interest, the article published by Takahashi et al [1] that suggested the Emergency Coma Scale as an alternate triage tool for the assessment of patients with neurologic impairment.

Although the ECS presented had certain merits in the form of less Interobserver variability as compared with the Glasgow Coma Scale (GCS) and an easily applicable format, we have noted certain areas that deem attention. The ECS has been seen to be a definite improvement on the preexisting Japan Coma Scale, as it is easier to implement, and has fewer parameters and a less complicated pattern of assessment and scoring [2,3].

One of the limitations we have observed in the use of the ECS in the emergency department is the classification of patients with nontraumatic neurologic impairment in more severe categories. This is possibly due to the ECS being designed primarily with Trauma victims and patients with head injury in mind as opposed to cerebrovascular incidents and intoxications, a shortcoming also noted in the Glasgow Coma Scale [4,5].

In addition, the ECS, like the GCS, has no provision to assess the neurologic condition of intubated patients and does not include assessment of eye movements and pursuit movements. This prevents the accurate assessment of patients with neuromuscular abnormalities but normal higher mental functions. In addition, patients with minimally conscious states and vegetative states (as may be seen in a variety of medical conditions) may be inadvertently misclassified, resulting in major clinical, therapeutic, and ethical consequences [6].

Other scores have been assessed with respect to these particular shortcomings of the GCS and ECS. These include the Full Outline of Unresponsiveness score that takes both eye movements and brainstem reflexes into account [7,8].

In our opinion, the ECS is more oriented to the triage and assessment of trauma patients in various stages of con- sciousness as opposed to patients with medical complaints or intoxication. It is also more useful in assessing patients with milder neurologic impairment as compared with patients who are severely obtunded. Scoring systems may need modification when dealing with patients with metabolic and

1. Warden CR, Moreno R, Daya M. Prospective evaluation of ondansetron

for undifferentiated nausea and vomiting in the prehospital setting. Prehosp Emerg Care 2008;12(1):87-91.

^? Conflict of Interest: None

^?? Funding: None

toxic encephalopathies as opposed to traumatic brain injury and other polytrauma patients.

Arjun Dutt Law MD Ashish Bhalla MD Vikas Suri MD

Department of Internal Medicine Post Graduate Institute of Medical Education and Research

Chandigarh, India E-mail address: [email protected]

doi:10.1016/j.ajem.2011.03.024

References

1. Takahashi C, Okudera H, Origasa H, et al. A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale. Am J Emerg Med 2011;29:196-202.
2. Ohta T. Transition of judgment on depth of Consciousness disturbance and its perspectives-from the Japan Coma Scale to the Emergency Coma Scale. J Jpn Congr Neurol Emerg 2003;16:1-4.
3. Takahashi C, Okudera H, Wakasugi M, et al. What is an excellent coma scale? Comparative study among JCS and ECS-first report. Neurosurg Emerg 2007;12:129-35.
4. Jennet B, Snoek J, Bond M, et al. Disability after severe head injury: observations on use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiatry 1981;44(4):285-93.
5. Teasdale GM, Murray L. Revisiting the Glasgow Coma Scale and Coma Score. Intensive Care Med 2000;26:157-61.
6. Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002;58:349-53.
7. Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: the FOUR score. Ann Neurol 2005;58:585-93.
8. Murthy TVSP. A new score to validate coma in emergency department

-FOUR score. Indian J Neurotrauma (IJNT) 2009;6(1):59-62.

Is America ALSO missing out? The effect of an obstetric resuscitation course on the developing world

To the Editor,

The mastery of resuscitation is the heart of emergency medicine (EM). It is preached from day 1 of residency. It is reinforced every time we march through the mantra of A to B then C. Whether it be traumatic or medical, adult or pediatric, our role in resuscitation remains paramount. In reality, this responsibility is the very essence of our profession and alone justifies our existence. Come what may, we will be ready. This was my thought process as I traveled to San Miguel de Allende, Mexico, in June 2010 for a medical Spanish immersion program called El Programa de Actualizacion Continua en Emergencias (PACE) led by Dr Haywood Hall. While there, I was exposed to the multiple public health initiatives aimed to improve the standard of care in a modern yet still developing country. Most notable was the extensive effort to train health care providers nationwide in a course called Advanced Life Support in Obstetrics . I found this shocking-a resuscitative course that I had never heard of! Yet it soon

became clear that ALSO is there to stay, and with its emergence brings a slew of questions. What is it? Where is it being used and why? Is it helpful? Should all EM residents receive this training? Is there a promising future to this program? This article will attempt to answer these questions. Advanced Life Support in Obstetrics as well as Basic Life Support in Obstetrics was created in 1991 by family physicians from the University of Wisconsin and purchased by the American College of Family Physicians in 1993 as a training supplement for health care providers. It is still used in multiple Family Medicine residencies throughout the country. However, per a random sampling of nationwide accredited allopathic EM residencies, it has not been integrated into the EM curriculum. This is also not a required course for obstetric and gynecologic residents or midlevel

providers in the United States.

Although the ALSO course has never reached the level of integration into American medical education as has other resuscitative courses such as Basic Life Support (BLS), Advanced cardiac life support , Pediatric Ad- vanced Life Support (PALS), or Advanced Trauma Life Support (ATLS), it has experienced a remarkable reemer- gence internationally. Starting in the 1990s, dozens of countries have started and expanded ALSO programs that are successful, sustainable, and with favorable results. There is an annual ALSO international conference. This year, it was held in Cancun and featured over 50 countries with ALSO programs. Central and South America, in particular, have robust national ALSO programs. Advanced Life Support in Obstetrics and Basic Life Support in Obstetrics training courses in these Developing countries are aimed not only at obstetrics and gynecology physicians but also to midwives, nurses, and Prehospital providers. The teaching model uses hands-on learning, with patient models to educate the provider on the key aspects of obstetric emergencies such as postpartum hemorrhage, ecclampsia, obstructed labor, and neonatal resuscitation.

In Mexico, ALSO has grown exponentially under the initiative of Dr Hall and PACEMD. Although Mexico, as a nation, has a more advanced health care system than many other countries in Latin America, it still boasted a 0.002% Maternal mortality in 2009 (roughly 3 times than that of the United States) [1]. There are areas that have almost 8 times than that of the United States, including the capital, Mexico City, with a population of roughly 22 million people. According to the Mexican Health Department, nearly 90% of these cases are preventable, including nearly 45% from hemorrhage, infection, and ecclampsia [1].

PACEMD has responded with increasing their number of ALSO trainees, and the pace has been impressive. The total number trained is more than 2000 in the last 4 years since its inception and 1000 within the last year [1]. It has been embraced both regionally and nationally. The state of Oaxaca, one of the nation’s largest and poorest states, has adopted it as their official maternal health strategy and dedicated large amounts of state funding and resources to