We read the article by Brookes et al. with great interest. [1] The work was well
conducted and the authors should be appreciated for the study. The need
for continuous, non-invasive and reliable respiratory rate monitoring has
long been recognised. The continuous respiratory monitoring of the
spontaneously as well as compromised breathing patients in the emergency
and inpatient hospital practi...
We read the article by Brookes et al. with great interest. [1] The work was well
conducted and the authors should be appreciated for the study. The need
for continuous, non-invasive and reliable respiratory rate monitoring has
long been recognised. The continuous respiratory monitoring of the
spontaneously as well as compromised breathing patients in the emergency
and inpatient hospital practice would be considerably improved with
regular use of such monitors.
There are few points in the published article, which need further
elaboration. It is commented in the discussion about this study as a pilot
study, validating the PEP as an accurate measure of the respiratory rate.1
There are several studies published prior to the current one on PEP and
related respiratory monitors in order to develop a non-invasive
respiratory monitoring device.[2-8]
It can be argued that the sample size of 12 volunteers is enough to
validate such study and to conclude regarding the correlation and the
agreement among different techniques of respiratory rate monitoring.
Furthermore, capnography, although a gold standard respiratory rate
monitoring device is mainly used in intubated patients. In the current
study, the PEP monitor was primarily compared against capnography. The two
systems can not be compared to prove one better as there are remarkable
differences in their applicability and clinical usage.
It is well described in the literature that routine recording of the
respiratory rate is inconsistent and inaccurate.[9] In such event, a world
wide need in the medical profession to have a safe, non-invasive and cheap
method for respiratory rate measurement can be well appreciated and PEP
monitor can be a milestone in the coming future. Not only in compromised
patients who present to emergency departments, but PEP monitor can also be
used in the wards and recovery rooms as to detect the alteration in
physiology at an early stage. Further large multi-specialty clinical
trials are required to establish a standard for the measurement of the
respiratory rate in both awake and sedated patients as well as acutely and
chronically compromised patients of varying age.
References
(1) Brookes CN, Whittaker JD, Moulton C, Dodds D. The PEP respiratory
monitor: a validation study. Emerg Med J 2003;20(4):326-8.
(2) Rapoport I, Cousin AJ. A pilot clinical PEP monitor. IEEE Trans
Biomed Eng 1979;26(6):345-9.
(3) Folke M, Granstedt F, Hok B, Scheer H. Comparative provocation
test of respiratory
monitoring methods. J Clin Monit Comput 2002; 17(2):97-103.
(4) Doyle DJ, Volgyesi GA Design and evaluation of a new respiratory
monitor. Anaesthesia 1990;45(6):492-3.
(5) Kulkarni V, Cyna A, Hutchison JM, Tunstall ME, Mallard JR. AURA: a
new respiratory monitor. Biomed Sci Instrum 1990; 26:111-20.
(6) Hok B, Wiklund L, Henneberg S A new respiratory rate monitor:
development and initial clinical experience. Int J Clin Monit Comput 1993;10(2):101-7.
(7) Arnson LA, Rau JL Jr, Dixon RJ. Evaluation of two electronic
respiratory rate monitoring systems. Respir Care 1981;26(3):221-7.
(8) Dodds D, Purdy J, Moulton C. The PEP transducer: a new way of
measuring respiratory rate in the non-intubated patient. J Accid Emerg
Med 1999;16(1):26-8.
(9) Kory RC. Routine measurement of the respiratory rate: an expensive
tribute to tradition. JAMA 1957;165:448–50.
I was interested to read Dr de Andrade Nishioka’s letter. He wonders
which interventions we should focus on to decrease the mortality from
meningococcal disease. In a review of deaths from meningococcal disease,
the most frequent and lengthy delays were parents not recognising that
their child was seriously ill and doctors failing to make the diagnosis
[1]. We therefore need to improve both of these.
Early...
I was interested to read Dr de Andrade Nishioka’s letter. He wonders
which interventions we should focus on to decrease the mortality from
meningococcal disease. In a review of deaths from meningococcal disease,
the most frequent and lengthy delays were parents not recognising that
their child was seriously ill and doctors failing to make the diagnosis
[1]. We therefore need to improve both of these.
Early antibiotic treatment decreases the risk of dying from meningococcal
disease [2]. Strategies to improve this are thus worthwhile. However in a
single centre these cannot be expected to show a decrease in mortality.
Dr de Andrade Nishioka’s suggests "first manifestation to first
examination time" might be a useful prognostic indicator. However children
with severe meningococcal disease become unwell rapidly and present to
hospital sooner. In a previously reported cohort of children with
meningococcal disease [3], median "first manifestation to first
examination time" was significantly shorter in those who died compared to
survivors (12 Vs 17 hours; P=0.012). The usefulness of this time is thus
confounded by disease severity. However early recognition of meningococcal
disease by parents can lead to better outcomes [4].
I agree that parents require accurate and appropriate information about
meningococcal disease, but improvements are also required in the early
recognition and treatment of children with this potentially life-
threatening disease [5].
References.
(1) Slack J. Deaths from meningococcal infection in England and Wales
in 1978. J Roy Col Phys London 1982;16:40-44.
(2) Cartwright K, Strang J, Gossain S, Begg N. Early treatment of
meningococcal disease. BMJ 1992;305:774
(3) Riordan FAI, Thomson APJ, Sills JA, Hart CA. Who spots the spots?
The diagnosis and treatment of early meningococcal disease in children.
BMJ 1996;313:1255-1256
(4) Riordan FAI, Thomson APJ. Early presentation of meningococcal disease
after media publicity. Arch Dis Child 1993;69:711
(5) Nadel S, Britto J, Booy R, Maconochie I, Habibi P, Levin M.
Avoidable deficiencies in the delivery of health care to children with
meningococcal disease. J Accid Emerg Med 1998;15:298-303
We read this article with interest. The authors have described the
mode of trauma with different vehicles hitting the patient in opposite
directions leading to asymmetric dislocations. This means
the dislcotions occurred at different times. We have seen this in indian
drivers who don't wear seat belts or any other protective wear. Due
to overcrowding, they are sitting with one knee hanging out of the win...
We read this article with interest. The authors have described the
mode of trauma with different vehicles hitting the patient in opposite
directions leading to asymmetric dislocations. This means
the dislcotions occurred at different times. We have seen this in indian
drivers who don't wear seat belts or any other protective wear. Due
to overcrowding, they are sitting with one knee hanging out of the window
and the foot on the accelerator this limb is externally rotated and other
on the clutch which is internally rotated. In head on collisions they sustain both asymmetrical dislocation simultaneously.
Usually the right side (foot on the accelerator; limb externally rotated) it is
anterior dislocation and left side (foot on the clutch; limb internally
rotated) it is the posterior dislocation.
We note with interest the letter by Bush and his final sentence " If
an agent without cocaine was shown to have similar efficacy to TAC
(Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of
topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC.
The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline
and Tetracaine) [2,3], E...
We note with interest the letter by Bush and his final sentence " If
an agent without cocaine was shown to have similar efficacy to TAC
(Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of
topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC.
The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline
and Tetracaine) [2,3], EMLA [4], Bupivanor [5], Tetraphen and
Tetralidophen [6,7].
We would like to share the formulation for a topical anaesthetic
which has been shown to be safe and effective. One of us (MGJ) has used
this regularly while working as Paediatric Emergency Medicine Fellow in
British Columbia's Children's Hospital Emergency Department.
We advise that the local hospital pharmacy services take
responsibility for quality assurance. Sourcing some of the ingredients may
prove difficult.
Procedure:
Dissolve lidocaine and tetracaine in 10ml bacteriostatic saline.
Transfer solution into a graduated cylinder.
Draw up epinephrine in 30ml syringe and add to the graduated cylinder Q.S.
to 50ml with bacteriostatic normal saline.
Weigh 1.5g of methylcellulose powder and place in mortar.
Slowly add small amounts of LAT solution to the methylcellulose, mixing
well before adding more liquid.
Package in 50g ointment jars, which should be labelled.
This will produce 50ml of LAT, with an expiry time of 150 days.
Sample label: " LAT Topical Gel Lidocaine 4% Adrenaline 1:2000
Tetracaine 0.5% EXP 5months. Keep refrigerated. Protect from light."
We were surprised to note the use of Ametop® by 26% of respondents in
open wound repair in children.
Ametop® is unlicensed for use in such a way. This preparation has a
5% sodium chloride base: this will cause marked pain when applied to an
open wound [8]. We wonder if the respondents, when answering the
questionnaire mistook the question as relating to venepuncture.
The ideal topical anaesthetic should be safe, effective, have rapid
onset with rasonable duration of action, while not causing discomfort.
(1) Bush S. Topical anaesthesia use in the management of children's
lacerations, a postal survey. J Accid Emerg Med 2000;17:310-311.
(2) Ernest A A, Marvez E, Nick T G, et al. Lidocaine adrenaline and
tetracaine gel versus tetracaine adrenaline and cocaine gel for topical
anaesthesia in linear scalp and facial lacerations in children aged 5 to
17 years. Paediatrics 1995;95:255-258.
(3) Schilling C G, Bank D E, Borchert B A, et al. Tetracaine, epinephrine
(adrenaline) and cocaine (TAC) versus lidocaine, epinephrine and
tetracaine (LET) for anaesthesia of lacerations in children. Ann Emerg Med
1995;25:203-208.
(4) Zempsky W T, Karasic R B. EMLA versus TAC for topical anaesthesia of
extremity wounds in children. Ann Emerg Med 1997;30:163-166.
(5) Smith G A, Straubaugh S D, Harbech-Weber C, et al. Comparison of
topical anaesthetics without cocaine to tetracaine-adrenaline-cocaine and
lidocaine infiltration during repair of lacerations:bupivicaine-
norepinephrine is an effective new topical anaesthetic agent. Paediatrics
1996;97:301-307.
(6) Smith G A, Strausbaugh S D, Harbech-Weber C et al. New non-cocaine
containing topical anaesthetics compared with tetracaine-adrenaline-
cocaine during repair of lacerations. Paediatrics 1997;100:825-830.
(7) Smith GA, Strausbaugh SD, Harbech-Weber C et al. Prilocaine-
phenylephrine and bupivacaine-phenylephrine topical anaesthetics compared
with tetracaine-adrenaline-cocaine during repair of lacerations. Am J
Emerg Med 1998;16:121-124.
(8) Professor Wolfson, The Queen's University of Belfast, Inventor of
Ametop ®, personal correspondence.
We read the article by Lam et al. with interest.[1]
The authors have described the mode of trauma with different vehicles hitting the patient in opposite directions leading to
asymmetric dislocations. This means the
dislocotions occurred at different times. We have seen such cases with Indian drivers who don't wear seat belts or any
other protective apparatus. Due to overcrowding, they sit wi...
We read the article by Lam et al. with interest.[1]
The authors have described the mode of trauma with different vehicles hitting the patient in opposite directions leading to
asymmetric dislocations. This means the
dislocotions occurred at different times. We have seen such cases with Indian drivers who don't wear seat belts or any
other protective apparatus. Due to overcrowding, they sit with one knee hanging out of the window
and one foot on the accelerator. This limb is
externally rotated and other on the clutch which is
internally rotated. In head-on collisions they sustain both asymmetrical dislocation
simultaneously. Usually the right side (foot on
accelerator; limb externally rotated) it is anterior
dislocation and left side (foot on clutch; limb
internally rotated) it is the posterior dislocation.
Reference
(1) Lam F, Walczak J, A Franklin. Traumatic asymmetrical bilateral hip dislocation in an adult. Emerg Med J 2001;18:506-507.
I thank Drs McIlwee and Jenkins both for their interest in this topic
and for their detailed LAT recipe. The sharing of such information and
experience is the key to enhancing UK knowledge of this technique's
effectiveness. I note that their practical experience with LAT was first
gained in North America.
I agree that there are several non-cocaine containing agents which
have been reported wit...
I thank Drs McIlwee and Jenkins both for their interest in this topic
and for their detailed LAT recipe. The sharing of such information and
experience is the key to enhancing UK knowledge of this technique's
effectiveness. I note that their practical experience with LAT was first
gained in North America.
I agree that there are several non-cocaine containing agents which
have been reported with similar effectiveness to TAC. There is little
doubt that LAT or LET (adrenaline vs. epinephrine) have similar
anaesthetic profiles to 1% lignocaine infiltration [1] or TAC [2-5].
Bupivanor [6] and Tetraphen [7] are also promising agents. However, wounds
treated with Tetralidophen had significantly greater pain scores than
those with TAC [7] or 1% lignocaine [8]. EMLA has also been shown to be
effective in extremity wounds in children [9] but it is not licensed for
this indication and also requires a prolonged application time. These
factors may have prevented its more widespread use. Ametop is similarly
unlicensed. If its application was associated with significant pain, this
may have contributed to the low satisfaction rate reported in the survey.
The subject of the questionnaire was wound management in children and the
questions were clearly worded. Confusion with venepuncture was unlikely to
occur.
Anyone who has had to restrain a struggling child during lignocaine
infiltration would agree that painless anaesthesia is better. Furthermore,
a child who has not been hurt may be calm, allowing more intricate
suturing under local anesthesia and so reduce the need for a general
anaesthetic.
Drs McIlwee and Jenkins feel that the LAT formula used in their
A&E department is safe and effective. If they were to publish their
results, along with the details of their application method and sterility
precautions, more UK A&E departments may be encouraged to adopt
topical anaesthesia for suturing lacerations in children.
I read with interest the short report by Dr F O’Leary. The idea of
this interesting study is very relevant in the current scenario of rapid
information technology.
Computers and specifically the internet has provided the medical
fraternity a innovative tool in the context of the swiftness of
distribution of published manuscripts in a plethora of available journals.
This is further substanti...
I read with interest the short report by Dr F O’Leary. The idea of
this interesting study is very relevant in the current scenario of rapid
information technology.
Computers and specifically the internet has provided the medical
fraternity a innovative tool in the context of the swiftness of
distribution of published manuscripts in a plethora of available journals.
This is further substantiated by the rapid response electronic letters
facilities. The best example of this can be visualized when one sees the
number of rapid responces published on the BMJ website in a single day.
Not even a couple of years back, this all was possible. And not a
fraction of all this amount of correspondence was being done. I think most
authors find it easier to respond through email rather than by postal
'snail' mail which not only increases cost and time, but also wastes a lot
of paper. In a nutshell, I personally feel that all journals should switch
over to the additional electronic versions (apart from paper)and all
manuscript submissions (most, if not all)and responses should utilize the
email as a cost effective, faster and environmentally safer means of
knowledge distribution and acquisition.
Brown and Warwick [1] have published an interesting descriptive study of
'blue calls' made to a single inner city hospital over a 3 month period in
1998. They state that their aim was to determine whether the current
system results in inappropriate deployment of hospital staff. However,
the results in the published paper do not show whether any of the patients
who arrived with a pre-hospital warning ha...
Brown and Warwick [1] have published an interesting descriptive study of
'blue calls' made to a single inner city hospital over a 3 month period in
1998. They state that their aim was to determine whether the current
system results in inappropriate deployment of hospital staff. However,
the results in the published paper do not show whether any of the patients
who arrived with a pre-hospital warning had staff inappropriately deployed
to their care. In addition, the authors state that the preparation of
specific drugs or equipment might be useful with warning calls, but no
exploration of whether this was done or not is contained within the paper.
The comparison group chosen (''clinically critical'') was based on
subsequent outcome, (though from Figure 1 at least on patient was
discharged and thus fails to meet the criteria for inclusion), and thus is
poorly matched with the study group recruited in the pre-hospital phase.
It would thus be expected that these patients form a significantly
different population from the study group population and comparisons
between the two should be made cautiously. With the difficulties in
studying this population a case-control study, matching non cardiac arrest
blue calls with controls based on pre-hospital physiological criteria may
have proved more useful. This would then enable an analysis of subsequent
outcome, as well as departmental process, in patients for whom blue calls
were or weren't made. The evaluation of significant confounding variables
(e.g. pre-hospital transport time, on scene time, patient age,etc) could
be made in a regression model.
In any study where separate individuals assess 'appropriateness' of
an intervention or adequacy of an assessment it is useful to know not just
the final (93% in this case) agreed level, but the degree of discrepancy
between the two observers. A measurement of agreement such as Cohen's
kappa would have been useful to determine the inter-observer variability
between an emergency physician and a paramedic in deciding appropriateness
of 'blue calls'.
King's College Hospital may one of the few emergency departments in
the UK where 'blue calls' made by civilian controllers in the ambulance
control centre are given to non-medically trained reception staff rather
than nursing or medical personnel. The authors conclude that no critical
changes were made in this further relay of the message, yet in the results
section they illustrate nine cases of the receptionist making errors in
recording the messages.
The most important message that can be drawn from this paper is that
prior to the introduction of the London Ambulance Service (LAS) 'acute
coronary syndrome' protocol, based on the national service framework for
coronary heart disease [2], some patients with myocardial infarction
arrived at King's College Hospital without a prior warning from the
control room. It may be that the subsequent outcome of these patients
differed during the study period from those that were 'blue-lighted' in.
However, the study design does not allow us to determine whether this
warning call and rapid transport was beneficial or detrimental to their
subsequent outcome. The impact of the change in LAS protocols should be
assessed with a more rigorous analysis of impact on not only adherence to
the 60 minute standard (in the case of patients with myocardial
infarction), but also on overall patient outcome.
Dr Peter Leman
Consultant in Emergency Medicine
St Thomas' Hospital
London SE1 7EH
References
(1) Brown R, Warwick J Blue calls—time for a change? Emerg Med J
2001; 18: 289-292
(2) Department of Health. National Service Framework for Coronary
Heart Disease. , London: March 2000
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom...
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom departments varies so widely. For example, some accident and emergency consultants have greater experience in the management of patients with minor musculoskeletal injury - a major component of our workload - than in the resuscitation of critically ill medical patients. In addition a significant number of consultants draw private income from medicolegal reports, specialising in 'accidents', which at such a stage cannot be considered 'emergencies'. Such arguments have been put forward by our colleagues in support of retaining the word 'accident' in our title.
That terms such as 'Casualty' or 'Accident and Emergency' are derogatory is a matter of opinion. Of greater relevance is that disagreement continues not only over our name, but also regarding our specialty's key direction and consultants' future working patterns in a climate of increasing public demand, limited staffing and resources, and uncertainty over the future structure of emergency health care in the National Health Service. That is what makes emergency medicine such a fascinating specialty to be in, and the formation of a College of Emergency Medicine such a critical step in defining a unified direction for the specialty, whatever we in the United Kingdom finally agree to call it.
References
(1) Reid C, Chan L. Emergency Medicine Terminology in the United Kingdom - time to follow the trend? Emerg Med J 2001;18:79-80
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergenc...
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergency Medicine defined the appropriate terminology as 'Emergency Medicine'. The United Kingdom was a founding member and agreed to this definition!
Following this, the Australasian College for Emergency Medicine (ACEM) produced a position paper on standard terminology. This paper states that older terms such as 'casualty' and 'accident and emergency' should be actively discouraged. [2]
At the same time, the then president of ACEM wrote a paper titled: 'Why "Emergency Department" - not "Casualty" or "Accident and Emergency" which was published in Emergency Medicine. [3] I recommend this paper to all readers. In summary , older terms such as "Casualty" or "A&E" are derogatory as the underlying thrust is that the standard of care in the emergency department is "not up to scratch." "Casualty" implies "casual treatment by casual doctors for casual patients." The term "Accident & Emergency" is an absurd tautology.
Words are powerful implements because they shape our thoughts. [3] When someone uses the term "Emergency Department" (or "ED"), they are connoting a facility that provides a decent standard of care for every member of the community, from minor ailments through to life threatening conditions.
It is time for the standard terminology to be adopted and used in the United Kingdom To not use standard terminology is an anathema to our speciality. If the speciality cannot agree on this, then we will be the casualty and this will be no accident!
References
(1) Reid C, Chan L. Emergency Medicine terminology in the United Kingdom -time to follow the trend? Emerg Med J 2001; 18:79-80
(2) http://www .acem.org.au/open/documents/standard.htm
(3) Epstein J. Why Emergency Department" ~ not "Casualty" or " Accident and Emergency". Emergency Medicine 1991 ;3 :70- 73
Dear Editor
We read the article by Brookes et al. with great interest. [1] The work was well conducted and the authors should be appreciated for the study. The need for continuous, non-invasive and reliable respiratory rate monitoring has long been recognised. The continuous respiratory monitoring of the spontaneously as well as compromised breathing patients in the emergency and inpatient hospital practi...
I was interested to read Dr de Andrade Nishioka’s letter. He wonders which interventions we should focus on to decrease the mortality from meningococcal disease. In a review of deaths from meningococcal disease, the most frequent and lengthy delays were parents not recognising that their child was seriously ill and doctors failing to make the diagnosis [1]. We therefore need to improve both of these. Early...
Dear Editor
We read this article with interest. The authors have described the mode of trauma with different vehicles hitting the patient in opposite directions leading to asymmetric dislocations. This means the dislcotions occurred at different times. We have seen this in indian drivers who don't wear seat belts or any other protective wear. Due to overcrowding, they are sitting with one knee hanging out of the win...
We note with interest the letter by Bush and his final sentence " If an agent without cocaine was shown to have similar efficacy to TAC (Tetracaine, Adrenaline, and Cocaine), it may allow more widespread use of topical anaesthesia (TA) in the UK." [1]
There are several agents which are at least as efficacious as TAC. The following agents do not contain cocaine: LAT (Lidocaine, Adrenaline and Tetracaine) [2,3], E...
Dear Editor
We read the article by Lam et al. with interest.[1]
The authors have described the mode of trauma with different vehicles hitting the patient in opposite directions leading to asymmetric dislocations. This means the dislocotions occurred at different times. We have seen such cases with Indian drivers who don't wear seat belts or any other protective apparatus. Due to overcrowding, they sit wi...
Editor,
I thank Drs McIlwee and Jenkins both for their interest in this topic and for their detailed LAT recipe. The sharing of such information and experience is the key to enhancing UK knowledge of this technique's effectiveness. I note that their practical experience with LAT was first gained in North America.
I agree that there are several non-cocaine containing agents which have been reported wit...
Dear Editor
I read with interest the short report by Dr F O’Leary. The idea of this interesting study is very relevant in the current scenario of rapid information technology.
Computers and specifically the internet has provided the medical fraternity a innovative tool in the context of the swiftness of distribution of published manuscripts in a plethora of available journals. This is further substanti...
Dear Editor
Brown and Warwick [1] have published an interesting descriptive study of 'blue calls' made to a single inner city hospital over a 3 month period in 1998. They state that their aim was to determine whether the current system results in inappropriate deployment of hospital staff. However, the results in the published paper do not show whether any of the patients who arrived with a pre-hospital warning ha...
We are delighted that our paper [1] has stimulated a response from overseas colleagues, who have shared with us some Australasian opinions.
Whilst we agree that adopting the term 'emergency medicine' would bring us into line with international standard terminology, the fact remains that 'accident and emergency' appeals to many, and debate will continue as long as practice between and within United Kingdom...
The paper on Emergency Medicine terminology by Reid and Chan [1] has stimulated me to write this letter. As an Australian emergency physician who works in a Department of Emergency Medicine, I view the debate on the naming of our specialty in the United Kingdom with some bewilderment and concern. What should be clearcut has somehow been usurped.
In October 1991, the International Federation of Emergenc...
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