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Iatrogenic coagulopathyCotton, Chris (SAAS) email@example.com
Wed, 27 Nov 2002 17:34:20 +1030
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Hi Ian, i think you have summed things up very well. This is an area that has had some conflicting opinion on this and other web sites. What i am starting to understand more now is: there appears to be no convincing evidence suggesting an approach other than what you have stated below. Those who continue to insist that one approach is best are probably doing a disservice to the industry, as the good science does not appear to be there to back up their claims. Good evidence works for me ... and we just haven't cracked it in some of those areas yet. Roll on good quality research that asks the right questions - and provides the answers! Chris Cotton Intensive Care Paramedic South Australia. -----Original Message----- From: Ian Seppelt To: firstname.lastname@example.org; email@example.com Sent: 27/11/02 12:07pm Subject: Re: Iatrogenic coagulopathy Chris Cotton: I know it is an individual thing with each patient and trade offs - but lets do the nitty gritty. What's best? Who's right, and most importantly - where does the most convincing evidence lie? Reply: The biggest prblem with evidence based medicine is its misuse. "Evidence creep" is one such example, where because something is proven in a specific population a, it gets applied to the much more general group A. There is NO CONTROVERSY that fluid is bad if you have penetrating truncal trauma in an urban environment with a well organised ambulance service. The opposite extreme is mixed multisytem blunt trauma including neurotrauma, in a remote environment with many hours to definitive care (I'm thinking about the Kimberley, for example, where there is a "Golden 24 hours" to definitive care). No good studies but I think we would all support maintenance of organ perfusion above 'popping the clot' in this extreme - anyone who is going to bleed to death will die anyway, and the ones we can save are the ones in whom we prevent the sequelae of multiple organ failure. Unfortunately there is a HUGE grey zone between these two extremes, there is no good level 1 science and we are left with the 'art' of medicine that some of us still have to practice. I teach residents that there are three distinct syndromes in trauma, being 'penetrating trauma', 'multisystem blunt trauma', and 'neurotrauma', which may however coexist. It is dangerous to extrapolate clean science from one group to another. Unfortunately the both with two or more of the trauma syndromes is just like the patient with both chronic severe congestive heart failure and sepsis, and a lot of art is needed to ride the middle ground between conflicting priorities Cheers, Ian Ian Seppelt FANZCA FJFICM Staff Specialist in Intensive Care Medicine The Nepean Hospital, Sydney.