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Consider this Case Study

Terry Dinerman trauma-list@trauma.org
Wed, 5 Jun 2002 14:29:07 -0700


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Doc-

Perhaps you miss my point -

Could management of a warm limb distal to a serious angulated, closed =
fracture with no pulse - With signs of collateral circulation (strong =
Doppler tones) benefit from ER splinting and x-ray prior to transfer to =
more definitive surgical care, or should I put every pulse-less limb on =
an aircraft?

I decided that since the limb appeared to be perfused to some degree, =
that I would transport to the local ER first.  Plaster splint, x-rays =
and more analgesia accompanied this patient to a specialty orthopedic =
hospital since my suspicion of severe potential vascular compromise was =
confirmed by the ER Doc, and a team would be waiting for the Pt at the =
other end by the time the patient arrived, ready to start the reduction.

NO- Doppler is not a panacea.  But it has a place in the decision making =
tree even for us po' boys at the street level. After a good old =
fashioned physical exam.  The pain, MOI, lack of mobility, tingling at =
the fingertips, lack of pulse and slowed cap refill where more than =
enough to convince me this guy had problems.  Not to mention that extra =
elbow.

I do however welcome your offer of data, pro or con.  Teach me, for once =
having been admonished, I wish to learn from you.

Since the Pt was transferred to definitive care, and the fracture =
successfully reduced with circulation restored, I feel the man was =
properly treated.  But if what you say is true, could I be held =
criminally or civilly liable for the use of a non-invasive tertiary =
examination instrument, even if the treatment works to the favor of the =
Patient?  I decided that the local ER was ill equipped for open =
reductions and vascular surgery, and the ER Doc was in agreement. =20

How else would you attack the treatment of this patient, were you in a =
court-room? =20

Contact me off-list if you like at:  dinerman@computron.net=20

Regards-

Terry Dinerman EMTP
=20

ps - My MAST made nice water wings --------

----- Original Message -----=20
  From: DocRickFry@aol.com=20
  To: trauma-list@trauma.org=20
  Sent: Wednesday, June 05, 2002 12:54 PM
  Subject: Re: Consider this Case Study



  Terry Dinerman--
  Shades of MAST trousers and spinal steroids!
  Whoa just one minute.
  You should become at least passing acquainted with the literature on =
Dopplers in assessing for extrremity vascular injury--you have a serious =
misunderstanding of its proven value and role!  Please let me know if =
you would like any of the volumes of refs on this?
  It may interest you to know that Doppler flow does not at all exclude =
a vascular injury in an injured extremity--apparently you are under the =
misapprehension that it does.  Did you realize that Doppler flow can be =
present distal to a completely transected or occluded vessel?  =
Collaterals will be picked up by Doppler--but an absent pulse is a known =
hard sign of vascular injury that is well established as highly =
accurate--its absence in itself mandates immediate evaluation--following =
blunt trauma by arteriogram, follwoing penetrating trauma by direct =
operation.  This is again old and well established data.  The fact you =
appear to have gotten away with it in this presented case should NOT =
positively reinforce you--the simple phys exam is superior to any =
noninvasive testing for this purpose--and noninvasives have never yet =
been shown to have any benefit over and above the phys presence or =
absence of hard signs (absent pulse being only one of the five hard =
signs).  Don;t waste your money on these devices--and please, don't =
endanger your license by using it with your present level of =
understanding of its validity.  As an expert witness, I would do you =
in....
  ERF


  --
  trauma-list : TRAUMA.ORG
  To change your settings or unsubscribe visit:
  http://www.trauma.org/traumalist.html



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<BODY bgColor=3D#ffffff>
<DIV><FONT face=3D"Comic Sans MS">Doc-</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Perhaps you miss my point =
-</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Could management of&nbsp;a warm limb =
distal to a=20
serious angulated, closed fracture with no pulse - With signs of =
collateral=20
circulation (strong Doppler tones)&nbsp;benefit from ER splinting and =
x-ray=20
prior to transfer to more definitive surgical care, </FONT><FONT=20
face=3D"Comic Sans MS">or should I put every pulse-less limb on an=20
aircraft?</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">I decided that since the limb appeared =
to be=20
perfused to some degree, that I would transport to the local ER =
first.&nbsp;=20
Plaster splint, x-rays and more analgesia accompanied this patient to a=20
specialty orthopedic hospital since my suspicion of severe potential =
vascular=20
compromise was confirmed by the ER Doc, and a team would be waiting for =
the Pt=20
at the other end by the time the patient arrived, ready to start the=20
reduction.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">NO- Doppler is not a panacea.&nbsp; =
But it has a=20
place in the decision making tree even for us po' boys at the street=20
level.&nbsp;<U>After</U> a good old fashioned physical exam.&nbsp; The =
pain,=20
MOI, lack of mobility, tingling at the fingertips, lack of pulse and =
slowed cap=20
refill where more than enough to convince me this guy had =
problems.&nbsp; Not to=20
mention that extra elbow.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">I do however welcome&nbsp;your offer =
of data,=20
pro or con.&nbsp; <U>Teach me,</U> for once having been admonished, I =
wish=20
to&nbsp;learn from you.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Since the Pt was transferred to=20
definitive&nbsp;care, and the fracture successfully reduced with =
circulation=20
restored, I feel the man was properly treated.&nbsp; But if what you say =
is=20
true, could I be held criminally or civilly liable for the use of a =
non-invasive=20
tertiary examination instrument, even if the&nbsp;treatment&nbsp;works =
to the=20
favor of the Patient?&nbsp; I decided that the local ER was ill equipped =
for=20
open reductions and vascular surgery, and the ER Doc was in =
agreement.&nbsp;=20
</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">How else would you attack the =
treatment of this=20
patient, were you in a court-room?&nbsp; </FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Contact&nbsp;me off-list&nbsp;if =
you&nbsp;like=20
at:&nbsp; <A =
href=3D"mailto:dinerman@computron.net">dinerman@computron.net</A>=20
</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Regards-</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Terry Dinerman EMTP</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS">&nbsp;</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">ps - My MAST made nice water wings=20
--------</FONT></DIV>
<DIV><FONT face=3D"Times New Roman"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Times New Roman">----- Original Message ----- =
</FONT></DIV>
<BLOCKQUOTE=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3DDocRickFry@aol.com=20
  href=3D"mailto:DocRickFry@aol.com">DocRickFry@aol.com</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, June 05, 2002 =
12:54=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: Consider this Case =

  Study</DIV>
  <DIV><BR></DIV><BR>Terry Dinerman--<BR>Shades of MAST trousers and =
spinal=20
  steroids!<BR>Whoa just one minute.<BR>You should become at least =
passing=20
  acquainted with the literature on Dopplers in assessing for extrremity =

  vascular injury--you have a serious misunderstanding of its proven =
value and=20
  role!&nbsp; Please let me know if you would like any of the volumes of =
refs on=20
  this?<BR>It may interest you to know that Doppler flow does not at all =
exclude=20
  a vascular injury in an injured extremity--apparently you are under =
the=20
  misapprehension that it does.&nbsp; Did you realize that Doppler flow =
can be=20
  present distal to a completely transected or occluded vessel?&nbsp;=20
  Collaterals will be picked up by Doppler--but an absent pulse is a =
known hard=20
  sign of vascular injury that is well established as highly =
accurate--its=20
  absence in itself mandates immediate evaluation--following blunt =
trauma by=20
  arteriogram, follwoing penetrating trauma by direct operation.&nbsp; =
This is=20
  again old and well established data.&nbsp; The fact you appear to have =
gotten=20
  away with it in this presented case should NOT positively reinforce =
you--the=20
  simple phys exam is superior to any noninvasive testing for this =
purpose--and=20
  noninvasives have never yet been shown to have any benefit over and =
above the=20
  phys presence or absence of hard signs (absent pulse being only one of =
the=20
  five hard signs).&nbsp; Don;t waste your money on these devices--and =
please,=20
  don't endanger your license by using it with your present level of=20
  understanding of its validity.&nbsp; As an expert witness, I would do =
you=20
  in....<BR>ERF<BR><BR><BR>--<BR>trauma-list : TRAUMA.ORG<BR>To change =
your=20
  settings or unsubscribe visit:<BR><A=20
  =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/3D"http://www.trauma.org/traumalist.html">http://www.trauma.org/trau=
malist.html</A><BR><BR></BLOCKQUOTE></BODY></HTML>

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