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Consider this Case Study

stephanie staford trauma-list@trauma.org
Tue, 11 Jun 2002 05:38:43 -0700 (PDT)


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 we often used AAi's or ABI's (as they are also called) in the ED.  used doppler to get numbers for ratios to compare perfusion of limbs.  
this along with other clinical signs and symptoms of hypoperfusion of lower lilmbs put together seemed to give complete picture.  
stephanie stafford, DO
  Terry Dinerman <dinerman@computron.net> wrote: 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.   How else would you attack the treatment of this patient, were you in a court-room?   Contact me off-list if you like at:  dinerman@computron.net  Regards- Terry Dinerman EMTP  ps - My MAST made nice water wings -------- ----- Original Message ----- From: DocRickFry@aol.com To: trauma-list@trauma.org Sent: Wednesday, June 05, 2002 12:54 PMSubject: 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


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<P> we often used AAi's or ABI's (as they are also called) in the ED.&nbsp; used doppler to get numbers for ratios to compare perfusion of limbs.&nbsp; 
<P>this along with other clinical signs and symptoms of hypoperfusion of lower lilmbs put together seemed to give complete picture.&nbsp; 
<P>stephanie stafford, DO
<P>&nbsp; <B><I>Terry Dinerman &lt;dinerman@computron.net&gt;</I></B> wrote: 
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<DIV><FONT face="Comic Sans MS">Doc-</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Perhaps you miss my point -</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Could management of&nbsp;a warm limb distal to a serious angulated, closed fracture with no pulse - With signs of collateral circulation (strong Doppler tones)&nbsp;benefit from ER splinting and x-ray prior to transfer to more definitive surgical care, </FONT><FONT face="Comic Sans MS">or should I put every pulse-less limb on an aircraft?</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">I decided that since the limb appeared to be perfused to some degree, that I would transport to the local ER first.&nbsp; 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.</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">NO- Doppler is not a panacea.&nbsp; But it has a place in the decision making tree even for us po' boys at the street level.&nbsp;<U>After</U> a good old fashioned physical exam.&nbsp; 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.&nbsp; Not to mention that extra elbow.</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">I do however welcome&nbsp;your offer of data, pro or con.&nbsp; <U>Teach me,</U> for once having been admonished, I wish to&nbsp;learn from you.</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Since the Pt was transferred to definitive&nbsp;care, and the fracture successfully reduced with circulation restored, I feel the man was properly treated.&nbsp; 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&nbsp;treatment&nbsp;works to the favor of the Patient?&nbsp; I decided that the local ER was ill equipped for open reductions and vascular surgery, and the ER Doc was in agreement.&nbsp; </FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">How else would you attack the treatment of this patient, were you in a court-room?&nbsp; </FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Contact&nbsp;me off-list&nbsp;if you&nbsp;like at:&nbsp; <A href="mailto:dinerman@computron.net">dinerman@computron.net</A> </FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Regards-</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">Terry Dinerman EMTP</FONT></DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face="Comic Sans MS">ps - My MAST made nice water wings --------</FONT></DIV>
<DIV><FONT face="Times New Roman"></FONT>&nbsp;</DIV>
<DIV><FONT face="Times New Roman">----- Original Message ----- </FONT></DIV>
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<DIV style="BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: black"><B>From:</B> <A title=DocRickFry@aol.com href="mailto:DocRickFry@aol.com">DocRickFry@aol.com</A> </DIV>
<DIV style="FONT: 10pt arial"><B>To:</B> <A title=trauma-list@trauma.org href="mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> </DIV>
<DIV style="FONT: 10pt arial"><B>Sent:</B> Wednesday, June 05, 2002 12:54 PM</DIV>
<DIV style="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 steroids!<BR>Whoa just one minute.<BR>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!&nbsp; Please let me know if you would like any of the volumes of refs on this?<BR>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.&nbsp; Did you realize that Doppler flow can be present distal to a completely transected or occluded vessel?&nbsp; 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.&nbsp; This is again old and well established data.&nbsp; 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).&nbsp; 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.&nbsp; As an expert witness, I would do you in....<BR>ERF<BR><BR><BR>--<BR>trauma-list : TRAUMA.ORG<BR>To change your settings or unsubscribe visit:<BR><A href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/"http://www.trauma.org/traumalist.html">http://www.trauma.org/traumalist.html</A><BR><BR></BLOCKQUOTE></BLOCKQUOTE><p><br><hr size=1><b>Do You Yahoo!?</b><br>
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