Medical direction and control of emergency

CLINICAL AND COMMUNITY STUDIES
0
ETUDES CLINIQUES ET COMMUNAUTAIRES
Medical direction and control of emergency
medical services in Canada
James M. Thompson, MD, CCFP (EM); D. Gilchrist Curry, MD, FACEP, FRCPC
Objective: To determine the level of physician involvement in prehospital emergency
medical services (EMS) in Canada, as compared with published principles of medical
control and direction.
Design: Mail and telephone survey by means of a questionnaire from March to
November 1991.
Setting: All Canadian provinces and territories.
Participants: Fifty-six key prehospital EMS physicians, senior government administrators and senior representatives of the agencies responsible for licensing physicians in
each province or territory.
Main outcome measures: Responses to questions regarding the legislation, organization,
administration, practice and regulation of medical direction and control by physicians
in each province or territory.
Results: EMS legislation describing medical direction and control was completely
lacking in five provinces and both territories and was incomplete in the remainder.
Provincial guidelines written by physicians for prehospital patient care were present in
only four provinces. Formal organization of medical directors varied from none to
partially remunerated networks. Regional medical-director systems were present in three
provinces, and local medical directors were required for all communities in three. Most
rural ambulance services were found to engage physicians only when there was local
interest.
Conclusions: The level of physician involvement in the medical direction and control of
EMS appears to be inconsistent across Canada and insufficient in most jurisdictions, as
compared with accepted principles.
Objectif: Determiner le niveau de participation des medecins aux services medicaux
d'urgence (SMU) prehospitaliers au Canada par comparaison avec les principes publies
sur la direction et le contr6le medicaux.
Conception: Sondage postal et telephonique au moyen d'un questionnaire de mars A
novembre 1991.
Contexte: Toutes les provinces et les territoires canadiens.
Participants: Cinquante-six medecins cles prodiguant des SMU prehospitaliers, cadres
superieures du gouvernement et representants principaux des ordres des medecins de
chaque province et territoire.
Principales mesures des resultats: Reponses aux questions sur les lois, l'organisation,
l'administration, l'exercice et la reglementation de la direction et du contr6le medicaux
par les medecins dans chaque province ou territoire.
Resultats: Les lois sur les SMU decrivant la direction et le contr6le medicaux faisaient
Dr. Thompson is a rural physician in Sundre, Alta., an assistant clinical professor in the Faculty of Medicine, University of Calgary,
Calgary, Alta., and past president and secretary-treasurer ofthe Alberta Association ofEmergency Medical Services Physicians (AAEMSP).
Dr. Curry is a clinical lecturer in the Faculty ofMedicine, University of Calgary, founding president ofthe AAEMSP, chairman ofthe
Urban Medical Control Committee, AAEMSP, former medical director, City ofCalgary Emergency Medical Services, and a former
member of the CMA Conjoint Committee for the Accreditation ofEducational Programs in Emergency Medical Technology.
Reprint requests to: Dr. James M. Thompson, PO Box 930, Sundre, AB TOM IXO
-
For prescribing information see page 2048
CAN MED ASSOC J 1993; 148 (1 1)
1945
completement defaut dans cinq provinces et les deux territoires, et elles etaient
incompletes dans les autres provinces. Des lignes directrices provinciales redigees par
des medecins sur les soins prehospitaliers aux patients n'etaient presentes que dans
quatre provinces. L'organisation officielle des directeurs medicaux variait de nulle a des
reseaux partiellement remuneres. Des reseaux regionaux de directeurs medicaux etaient
presents dans trois provinces, et trois d'entre elles exigent des directeurs medicaux
locaux pour toutes les collectivites. La plupart des services ambulanciers ruraux, a-t-on
constate, n'engagent des medecins que lorsqu'un interet local se manifeste a cet egard.
Conclusions: Le niveau de participation des medecins a la direction et au contr6le
medicaux des SMU semble variable a travers le Canada et insuffilsant dans la plupart
des provinces et des territoires par comparaison avec les principes reconnus.
F ew areas of medicine in Canada are experiencing a more explosive evolution at present than
prehospital emergency medicine. The process
involves extraordinary technologic and legislative
changes. Because of the many interest groups involved it has created a unique kind of social turmoil
as these groups attempt to define their roles. Physicians with a special interest in emergency medical
services (EMS) are concerned that the best interests
of patient care be served during this evolutionary
period.
In a landmark 1986 paper Holroyd, Knopp and
Kallsen' provided a fundamental definition of medical control of prehospital care: a "system of physician-directed quality assurance that provides professional and public accountability for medical care in
the prehospital setting."
The Alberta Association of Emergency Medical
Level
EMT-1
EMT-lI
Services Physicians (AAEMSP) has been committed
to this definition,2 because it views prehospital care
as physician-directed care practised outside the hospital in a unique and difficult environment. Pre-
hospital patients cover the entire spectrum with
regard to age and the type and acuity of clinical
problems; these patients can be some of the sickest
and most desperate in the health care system. Although prehospital-care providers are recognized
experts in the safe extrication, transport and initial
treatment of patients, the level of medical training
and experience of even the best-trained emergency
medical technician is considerably less than that of a
physician (Table 1).
The definitions and principles accepted by the
AAEMSP for the terms "medical direction," "medical control" and "medical advice" are shown in
Table 2. The principles of these new physician roles
Description of
accredited program
180 to 260 h of instruction, 24 to
72 h of hosppil experience, 25 to
30 calls of.r*otlcum
Basic lfe su wtils: s l
patient ass mt, erication
and sinp tipt m.
including ba-valve-mas ventilation
200 to 208 h of iruction, 36 to
92 h of hospital experience,
20 to 60 h of am a practicum
EMTi- soope of prctice, with some
advancd lb urt ills (e.g.,
Provinces with
accredited program
British Columbia
Alberta
Saskathwan
MeMba
-Prince Edwuard sland
Newfoundiand
British Columbia
Manitoba
* _t $
F wlf:oytng
mitkvy t1tlhekIoser,
admin roig ni
xide and
EMT-I1I
1Qto3Swkpfi
su
ion, 7to
British Columbia
Albet
andrdtr mdns
by various routles
1946
CAN MED ASSOC J 1993; 148 ( 1)
19
LE ler JUIN 1993
have evolved over the past two decades.6-'0 Although
nonphysicians can and should be involved in medical control, it has been argued by EMS physicians
and others that physicians must be involved intimately and authoritatively for medical control to be
effective.6-22
The medical direction and control of EMS by
Canadian physicians has been encouraged in position papers by the Canadian Association of Emergency Physicians,23 the AAEMSP2,24 and the Department of National Health and Welfare." The medical
direction of educational programs in emergency
medical technology is -mandatory according to the
guidelines for accreditation issued by the CMA,3 and
it is encouraged widely.'2
The AAEMSP believes that an EMS system in
which physicians provide medical direction to ambulance services and medical control of all levels of
prehospital care should be present in every Canadian
community.
Despite these calls for physician involvement we
suspected that problems exist in the organization of
medical direction and control across Canada. We
conducted a survey to determine the current level of
physician involvement in EMS relative to the principles outlined.
identified as senior EMS consultants to the government in their province or territory or if they were
known to be active leaders in EMS development. We
did not attempt to trace all active EMS physicians,
assuming that a few key representatives could describe the situation adequately.
Each participant was asked a series of questions:
Does existing legislation mention medical direction
and control? How are medical direction and control
practised in urban and rural areas? Do ambulance
services engage physicians to act as medical directors? Is there an organization of medical directors?
Are there provincial protocols for prehospital patient
care and are physicians involved in their development? Does the provincial government engage physicians to sit on an advisory committee or act as
provincial medical directors? Does the agency responsible for licensing physicians play a role in
EMS? We interviewed the 56 participants by telephone if the written response was incomplete or
missing, achieving a response rate of 100%. The
answers to the questions were compared with the
ideal definitions already described.
Methods
From March to November 1991 we wrote and
telephoned 56 key physicians, senior administrators
of the government agencies responsible for ambulance services and senior representatives of the
agencies responsible for licensing physicians in each
province and territory.
Physicians were chosen if they were formally
Results
The organization of medical direction and control varied tremendously across Canada, from a
highly organized system in British Columbia (where
a network of partially remunerated regional and
local medical directors is fostered by the provincial
government) to virtually no formal medical control
in some regions (Table 3). Ambulance services in
most small communities in Canada were not expected to engage local physicians to act as medical
directors, except in British Columbia, Alberta and
Degree of
Term
Medical diretiion
r;
Medical contr( D1
Prospective
-*
Immediate patient care in
person.or by voice
Retrospecti yve
Chart review, quality
assurance, risk
*Adap~sd
authority
Variable
Considerable
design
Direct
Medical advice
JUNE 1, 1993
Definition*
-Advice or directives given
oto an ambu4ance or
dispatch service
..Orders given to ambulance
attendants:
Protocols, standing orders,
training and system
-tlecommunication
management
Advice- given to an organization
other than an armibulance or
dispatch service
Little
rom Rein.6
CAN MED ASSOC J 1993; 148 (1 1)
1947
directors except in Alberta, where prospective and
retrospective medical control is required. (By sufficient we mean that the legislation specifically requires at least some of the three types of medical
control defined in Table 2.)
Direct medical control was well developed in
many but not all major urban communities. It was
found that basic life support services throughout
Manitoba. Systems of regional medical direction
found in Saskatchewan and Ontario.
EMS legislation was not present in five jurisdictions, although it is planned in four of these (Table
4). In the remaining seven, medical control was
reportedly legislated in only two provinces, and
medical directors were required in only four. None
of the legislation gave sufficient authority to medical
were
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CAN MED ASSOC J 1993; 148 ( 1)
19
LE 1 er JUIN 1993
Canada tend to operate without direct medical
control, so that physician-directed care usually does
not begin until the patient reaches the hospital.
Prospective medical control was present to some
extent in all the provinces. Protocols are developed
by physicians at a provincial level in only three
provinces (Table 3). In others protocols are developed locally for some advanced life support skills. In
several provinces physician involvement in protocol
Provinc or
territory
British
Columbia
Alberta
Saskatchewan
Manitoba
Ontario
QQuebec
New Brunswick
development has been very limited. Retrospective
medical control was required in a few jurisdictions
but was not universally applied or enforced in any
province.
The CMA recommended that the agencies responsible for licensing physicians be responsible for
identifying medical acts that may be delegated to
ambulance attendants.4 These agencies were found
to have variable and often limited involvement with
Medical diretcion
*or control features.
AlIows. attendant to perform emergency
procedures until a vihyecian is
available. Establishes.guidelines
for local medical diectors, termed
"local. medical coordinators."
Health Disciplines -Ac
Defines prospective and retrospective
medical control and EMT scopes of
pract!e.i9. EMT can praotis only.
while uidet'medical control.
Proposed amendment adds direct
mediCal control.
Ambulance Servicas Act
Might require that each ground
ambulance service engage a medical
. (pending)
director and each ground ambulance
-boarden
a medical adviser.
Defines prospective and direct
Ambulance Act
medical oontrol.
Ambulance Servicas.Act
Specifies that each ambulance service
must name a medical adviser or
medcal director.
Ambulance At (piIanned, - Allo.ws physicians to determine the
* receiving hospital. Defines base
hospitals and base-hospital
. physicansbut.only.defines
relationship to ambulance
attenda.nts in general terms.
*Health S.ervices AI,cit
Medical control legislation planned.
The Qorporation d'urgences-santb de
Ia.r6gion de Montrhal M6tropolitain
s. required to appoint a .member
from the emergency department
*
coordinators of Montreal hospitals.25
Ambulance Servicaes Act
No reference to medical direction
or. control. Proposewd leislaton
states that an attendant will not
EMS legislation
Health Eme. rgen4y Actu
Nova Scotia
Prince Edward
Island
Planned
Public Health Act
Newfoundland
Motor Carrier Act
Northwest
Territories
Yukon Territory
None
practise outside scope of ractice
(basic life support) without
deiegation from a-physician. Major
changes to the existing legislation
are planned.
Requires services using defibrillation
to have a medical adviser. Under
the planned "EMS act" the government
proposes to require a medical
director for each service.
No reference.to medical direction or.
control.
JUjNE 1, 1993
Planned.
CAN MED ASSOC J 1993; 148 (1 1)
1949
v. , r R
control
of
a
physician, most services tend to
identify~~~~~
EMS (Table 5). They tended to approve, in prin- control of a physician, most services tend to identify
ciple, the delegation of specific medical acts to a "medical director"; this role is poorly defined.
ambulance attendants but were not involved in
developing protocols for use of these skills in pre- Saskatchewan
hospital care.
The provincial government has a policy stating
that each advanced life support service must have a
British Columbia
medical director who doubles as a regional medical
Ambulance services are owned and operated by adviser. The regional advisers form a committee
the province, and medical control is exerted at all chaired by a provincial medical director, who is
levels by a network of physicians. The senior phys- appointed by the provincial government. Protocol
ician gives advice at meetings of the government's changes are submitted through the Saskatchewan
multidisciplinary Pre-hospital Care Committee and Medical Association and the College of Physicians
is a voting member of that committee. Recommen- and Surgeons of Saskatchewan for approval by the
dations for changes to protocols flow up from local general medical community. There is no requiremedical directors through regional directors, and ment for basic life support services to have a medical
changes are made at a provincial level.
director.
Alberta
Manitoba
A regulation of the Ambulance Services Act
Planned regulations of new legislation (Ambulance Services Act) are expected to define the role of specifies that each ambulance service must have a
physicians in EMS. Since registered emergency med- "physician adviser." This regulation is not enforced
ical technicians must practise under the medical strictly because of the difficulty in recruiting phys-
Province or
territory
Britsh Columbia
Alberta
Invodvement
None
'Er o),W.kilnameonlyAH
thdtegIohof "medical acts
Nn&ifunswick'
N*b
pS protocols.
Apov
of a medical act but then is not
ApprovEs
irvolted with prtcol ddeveomnt.
Appro.s.
of awdlmcaat but then is not
Has pubUshed
i iWmR
nW
i protocol de Hped.
gu5_Wines regarding the delbgation of medical acts and
s regarding ptehospita care programs.
Wilt
ne involved wit issu resated to delegation of a
medicalact when
attendiants begin to
funcon at a klevl hOgr than that of first aid.
None
Plans to se up a committee to ou d ted medical
Prince Edward
None
Saskatchewan'
ManitOa'
Ontario*
Quebect
acts.
a
9|t'SD stlpe
iJju'
Dpar o
CM.
1950
CAN MED ASSOC J 1993; 148 (1 1)
of _osn
oiis
'd~ ~ ~ ~Ite
a
c
an
l"rb Aff*.
.
LE 1 er JUIN 1993
icians in rural areas. The provincial government tion and control are not required. There is a tentastrongly encourages physician involvement with tive plan to organize EMS into regions around
EMS. The Provincial Medical Advisory Committee central hospitals. Local physicians hope to see medapproves protocols for use by local ambulance ser- ical directors required for these regional centres.
vices.
Prince Edward Island
Ontario
Each of the 19 designated base hospitals and 5
associate base hospitals in the province engages a
physician to act as a medical director for EMS in the
region served by the hospital. These physicians sit on
a multidisciplinary committee called the Base Hospital Advisory Group, which reports to the provincial
government. Base-hospital physicians influence ambulance services within their catchment area. Ministry of Health policy states that base hospitals "provide leadership and medical direction in the provision of prehospital and interhospital emergency
health services within a specified geographic area in
order to ensure that services provided are medically
sound and well coordinated." The government's
5-year goal is to provide medical control to all
ambulance services.
Quebec
Local physicians have been instrumental in
assisting a community college to become accredited
to train ambulance attendants. A few services have
developed informal relationships with local physician advisers. The government has organized a
multidisciplinary committee to recommend features
of a planned "EMS act."
Newfoundland
The provincial government retains a part-time
physician consultant for EMS issues. There are no
specific plans for medical direction or control in
planned EMS legislation. The request from interested physicians to delegate the medical acts of intravenous access and semiautomatic defibrillation to ambulance attendants was recently approved for one
service after years of lobbying.
Northwest Territories
Although medical direction and control by physIn the western Northwest Territories a multidisicians has not been well developed in Quebec in the
committee is attempting to set minimum
ciplinary
past, there is a strong movement by the provincial
for EMS operations, but it has little
standards
government and concerned physicians to change
The committee has produced limsupport.
financial
this. There are plans to develop provincial protocols
written by physicians and to introduce new legis- ited prehospital-care guidelines. The region tends to
lation that will encourage medical control and direc- rely heavily on charter aircraft for EMS transportation organized by St. John Ambulance and crewed
tion at all levels of EMS.
by trained nurses. A physician assists St. John
Ambulance in organizing this service.
New Brunswick
In the eastern region nurses at the hospital in
A multidisciplinary committee sponsored by the Iqaluit are trained for air ambulance escort, and
provincial government is investigating alternatives under protocols evaluated by the medical staff at the
for EMS regulation. The committee includes at least hospital they serve a wide area. Emergency medical
one physician. Physicians are formally involved with technicians in the Iqaluit ground ambulance service
EMS systems in larger, urban communities. A few work under direct medical control and are trained in
small, rural services work with physicians informally part by local physicians. Neither the air nor the
to develop protocols. Direct medical control is avail- ground ambulance system has a formal medical
able in a few regional hospitals, which are linked in director.
networks with primary care hospitals.
Yukon Territory
Nova Scotia
Physicians are involved in writing EMS protocols for very few services. A multidisciplinary committee organized in 1990 by the Department of
Health has completed a report recommending extensive changes. The department has agreements with
individual ambulance services, in which minimum
standards for the service are listed. Medical direcJUNE 1, 1993
Owing to the heavy reliance on air ambulance
services, the government seeks advice from specialists such as obstetricians and pediatricians outside
the Yukon Territory regarding some aspects of
patient management; it also looks to the BC ambulance service for many suggestions. The government
is contemplating major changes in the EMS legislation and plans to involve local physicians more
CAN MED ASSOC J 1993; 148 (1 1)
1951
not necessary. We have found that considerable skill,
knowledge and commitment is required to negotiate
the grey areas between administrative functions and
medical direction that can lead to conflict.26
Experienced EMS physicians clearly feel that
Discussion
medical direction and control can substantially imWe found that the legislation as well as the prove patient care;116-'9'22 however, published reorganization and practice of medical direction and search into this issue is scarce, and more should be
control of EMS are at an early stage of development undertaken.
in Canada. The ideal situation would be one in
Until there is substantial evidence to the conwhich physicians participate in all three forms of trary, we believe that to achieve optimum medical
medical control and provide medical direction to care for prehospital patients physicians must retain
both regional governments and individual services the ultimate authority for patient care. As EMS
in all communities. Given the strong calls for med- systems develop across the country politicians, hosical direction and control of EMS by physicians pitals, fire departments, owners of ambulance comwith experience in prehospital emergency medical panies, unions of prehospital care providers and
care,6-101316-822 this finding suggests that a con- professional associations are all struggling for control
certed effort to improve physician involvement of prehospital care. Knowledgeable, committed EMS
is required.
physicians are needed to provide leadership in this
In many jurisdictions prehospital-care providers rapidly evolving area of medicine and to ensure the
are evolving toward independent practice. They may appropriate use of increasingly complex and expenhave limited contact with other health care providers sive technology. Provincial legislation should be
and can develop more allegiance to public service developed to formalize the need for appropriate
agencies, such as the police and fire services. The physicians to have a major role in the design,
AAEMSP believes that collaboration between emer- delivery and ongoing evaluation of all medical asgency medical technicians and knowledgeable, com- pects of EMS, including ambulance services, dismitted physicians providing medical control is essen- patch services and educational programs.
tial for the provision of high-quality care based on
sound, current scientific knowledge. Our belief, and We thank the government agents and the representatives
that of others,62022 is that abdication of or exclusion of the physician-licensing institutions in each province and
from this role increases the risk of inappropriate, territory who assisted us. We also thank the following
for descriptions of medical direction and concost-ineffective and potentially dangerous prehospi- physicians
in
trol
their
regions: Drs. Charles Sun (British Columbia);
tal medical care.
Robert Johnston, Maurie Simpson, Ivars Argals, Chris
Our study raises many questions for further Westover, Daryl Stewart, David Shragge, Terry Sosnowski,
research. Our choice of survey questions and method James Davidson, Dennis Nesdoly, Peter Lindsay, Keith
of identifying survey participants could have caused Spackman and Peter Gant (Alberta); James Cross and
us to overlook some important findings. By exclud- James O'Carroll (Saskatchewan); Urbain Ip and Neil
ing emergency medical technicians and EMS manag- Donen (Manitoba); Marion Lyver and Christopher Rubes
ers we could not document their opinions or their (Ontario); Pierre Frechette, Marcel Boucher and Ted
experience with physicians acting as medical direc- Leibovici (Quebec); Bertrand Laporte, Jane Findlater and
tors. Since our survey did not include many phys- Robert Beveridge (New Brunswick); Edward Cain (Nova
icians working in rural EMS systems or physician Scotia); David MacKenzie and Arthur Losier (Prince
Edward Island); Vinod Patel (Newfoundland); Robert
educators we might have missed some key phys- Williams
and Paul Stubbing (Northwest Territories); and
icians or administrators with special knowledge. Bruce Beaton
(Yukon Territory).
Finally, EMS systems are evolving in Canada so
This study was funded by the Alberta Association of
rapidly that our information for some jurisdictions Emergency Medical Services Physicians and the Governcould soon be out of date.
ment of Alberta.
It is not clear from our study why medical
direction and control are not developed to the ideal References
level we defined. Although we did not specifically
ask about obstacles to physicians delivering medical
1. Holroyd BR, Knopp R, Kallsen G: Medical control:
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1027-1031
ing inadequate physician training, psychologic resistance by emergency medical technicians who are 2. Alberta Association of Emergency Medical Services Physicians: Medical Control of Emergency Medical Services (posiattempting to establish their role, poor remuneration
tion paper), AAEMSP, Edmonton, 1987
for physicians providing these services and a percep- 3. Conjoint Committees for the Accreditation of Educational
Programs in Allied Medical Disciplines: Section H: Emergention by administrators that physician involvement is
formally. One physician currently acts as a liaison
between the territorial government and the Yukon
Medical Association on EMS matters.
1952
CAN MED ASSOCJ 1993; 148 (11)
LE lerJUIN 1993
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Aug. 31-Sept. 3, 1993: 5th International Congress on
Ethics in Medicine
London, England
Castle House Conferences, 28-30 Church Rd., Tunbridge
Wells, Kent, England TNl lJP; tel 011-44-892539606, fax 011-44-892-517005
a
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JUNE 1, 1993
Sept. 5-9, 1993: European Atherosclerosis Society
62nd Congress
Jerusalem, Israel
Gil-Kenes, 946-1617 J.F.K. Blvd., Philadelphia, PA
19103, tel (800) 223-3855, fax (215) 568-0696; or
Secretariat, 62nd European Atherosclerosis Society
Congress, PO Box 50006, Tel Aviv 61500, Israel,
tel 011-972-3-517-4571, fax 011-972-3-660-325
Sept. 9-11, 1993: 2nd International Congress on Peer
Review in Biomedical Publication (sponsored by the
American Medical Association)
Chicago
Annette Flanagin, North American coordinator, Peer
Review Congress, JAMA, 515 N State St., Chicago, IL
60610, tel (312) 464-2432, fax (312) 464-5824; or Jane
Smith, European coordinator, Peer Review Congress,
BMJ, BMA House, Tavistock Square, London
WC1H 9JR, England, tel 011-44-1-71-387-4499,
fax 011-44-1-71-383-6418
Du 9 au 13 sept. 1993: Les soins specialises en crise? 62e Assemblee annuelle du College royal des medecins et
chirurgiens du Canada
Vancouver
Anna Lee Chabot, chef, section des reunions et
assemblees, Bureau des affaires des Associes, Colltge
royal des medecins et chirurgiens du Canada, 774,
prom. Echo, Ottawa, ON KIS 5N8; tel (613) 730-6233
ou (613) 730-8177; fax (613)730-8830
Sept. 9-13, 1993: Specialty Care in Crisis? - 62nd Annual
Meeting of the Royal College of Physicians and
Surgeons of Canada
Vancouver
Anna Lee Chabot, chef, section des reunions et
assemblees, Bureau des affaires des Associes, College
royal des medecins et chirurgiens du Canada, 774,
prom. Echo, Ottawa, ON KIS 5N8; tel (613) 730-6233
ou (613) 730-8177; fax (613)730-8830
Oct. 10-15, 1993: 4th International Conference on
Noninvasive Cardiology
Limassol, Cyprus
Ambassador Chevy Chase Travel, 2 Wisconsin Circle,
Chevy Chase, MD 20815, tel (800) 424-8282,
fax (301) 907-4787; or Secretariat, 4th International
Conference on Noninvasive Cardiology, PO Box 50006,
Tel Aviv 61500, Israel, tel 011-972-3-517-4571,
fax 011-972-3-660-325
continued on page 1966
CAN MED ASSOC J 1993; 148 (1 1)
1953

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