Re: "Manager's Guide to Surgical Supplies" (October supplement). I am a board-certified plastic surgeon and I read each edition of your magazine. I'm writing to alert you to some disturbing photographs in your recent supplement.

• The cover shows broken-open boxes on the bottom shelf of the cupboards. These boxes should be 12 inches from the floor to maintain sterility.
• On the top shelf are boxes in cartons that weren't unloaded from the boxes they came in (the mailing labels are still on the boxes!).
• The nurse on the cover is carrying sterile items under her arm. This is poor form. She should have placed these items in a cart and wheeled them into the OR.
• Photos on pages 14 and 16 show OR personnel wearing garments beneath their scrubs - again, poor form and poor sterile technique.

These are not acceptable behaviors, but presenting them in the magazine makes it seem as though they are.

Francis J. Collini, MD, FACS
Shavertown, Pa.
writeMail("fcollini@collini.com")

Generation Gap
Re: "When Generations Collide in the OR" (November, page 18). I enjoyed your article on the generations working together. Half of my OR staff is over 50 and half is under 50. They clash at times, but for the most part try to tolerate each other's ideas, with the patient being at the top of the list.

Joyce Danels, RN
Director of Surgery
Twin Rivers Regional Medical Center
Kennett, Mo.
writeMail("joyce.danels@kennett.hma-corp.com")

Way With Words
Re: "Trick or Treat" (October, page 112). Great article! Paula Watkins puts in to words what we all think at one time or another.

Brenda Smith, BSN, RN, CNOR
Clinical Director
Tulsa Outpatient Surgery Center
Tulsa, Okla.
writeMail("bsmith@unitedsurgical.com")

Is It Possible to Pre-empt Pain?
Re: "Beyond Opioids: Understanding Surgical Pain" (October, page 60). I looked askance at Dr. Brennan's assertion that "you can't pre-empt pain." A recent meta-analysis of Level I studies failed to demonstrate pre-emptive analgesia with injection of local anesthesia before injection under general anesthesia. This paper wasn't able to consider the paradigm of dissociative technique because there are no Level I studies. Under conditions of dissociative anesthesia, the injection of local analgesia doesn't send noxious signals to the brain. In this manner, dissociative anesthesia is like a "mid-brain" spinal anesthetic for the 10 minutes to 20 minutes the effect of the 50mg ketamine dose typically lasts. It is axiomatic that the brain can't respond to information it doesn't receive.

Pre-emptive analgesia does exist under specific and clearly defined, reproducible conditions. The dissociative effect is regularly observed when the NMDA receptors are saturated. The dissociative effect sets the stage for reproducible pre-emptive analgesia. There are a finite number of NMDA receptors in adults in the spinal cord and mid-brain. This number doesn't appear to vary with body weight in adults. A 50mg IV ketamine bolus will effectively saturate the fixed number of NMDA receptors in the brains of 98 percent of adult patients. Com-pletely blocking incoming noxious signals to the cortex using the dissociative effect (the so-called mid-brain spinal) is most likely responsible for the observed preemptive analgesia. Hypnosis (propofol to BIS <75) first, then dissociation (50mg ketamine) eliminates the historically reported, undesirable side effects of ketamine.

Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
Corona del Mar, Calif.
writeMail("drfriedberg@doctorfriedberg.com")

Tim Brennan, MD, PhD, (writeMail("tim-brennan@uiowa.edu")) replies: Dr. Friedberg notes that "pre-emptive analgesia does exist under specific and clearly defined, reproducible conditions" and that analyses have not yet been able to demonstrate a consistent positive effect. We agree and await the evidence for these specific, clearly defined and reproducible conditions.