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Mon, 25 Feb 2002 08:30:51 -0500

Dr. Namir,

Be assured that I share your prayers.

The case as you relate it is complex, but I think you're specifically
interested in the 18-year-old abdominal wound in respiratory arrest.  Yes?
And I also believe that your scenario involves a rather simple EMS decision:
they can wait for a physician to jog to their distant ambulance to assist
with the patient care; or simply bag and drive.  

If that's the case, then it all boils down to what a Family Practitioner is
able to offer a critically-injured teenager with a patent airway and
palpable pulses, which is--regrettably--nothing.  Indeed, running fluids on
this kid is probably a mistake.  Airway, Breathing, and Rapid Sequence
Hospitalization.  The kid doesn't need you, and moreover, it sounds as if
you have your hands full.  If this were a heart attack or a stroke or
somebody septic, then your skills and experience become more valuable; but
in trauma, there's rarely much to offer besides assisted respiration and
competent driving.

I can't imagine that you'd be in any medicolegal trouble.  At the very
least, if I've interpreted your scenario accurately, you could probably call
Ken Mattox as a witness in your defense.  I hear he can work a crowd.

Any issues with the remaining triage?  

All best to you, and all sympathy for your horrid circumstances.  If you're
able, I'm sure we're all interested in hearing what became of these tragic
cases.

Pret Bjorn, RN
Bangor, ME USA.

-----Original Message-----
From: San namir [mailto:sody@gotomy.com]
Sent: Monday, February 25, 2002 7:44 AM
To: trauma-list@trauma.org
Subject: What would you do?

wgh

Dear Colleagues, 
   You receive a call that there's been shooting rounds heard on the main
road you normally take home to reach year village. The only vital route for
commuting from your village to the rest of the country. You jump into your
car and are informed that an arab terrorist has attacked a number of
vehicles on the road and the wounded are lying there. You speed to where all
the action is flying and are faced with the body of a 30 year old mother of
two (your regular family practice patient) in a puddle of blood with two
penetrating bullet wounds of the right chest, not breathing and pulseless
being bagged by a volunteer. In front is a one arm amputee who sustained
bullet wounds to the palm of his only hand and a short range wound of his
leg in stable condition. You are radioed that further down this road , on an
ambulance lies a wounded 18 year old with a penetrating wound of the right
lower abdomen, without spontaneous breathing but maintaining a radial pulse.

  Next to you, you find the body of what must be that of the assailant and
another two of his victims while at least two hand grenades were visible
lying on the ground , security won't let any vehicle further down the road
until sappers approve. |I figure at this point it better (to save from any
further delay)to send the ambulance carrying the shocky patient with staff
qualified to do nothing more than bag and infuse on their way, unescorted by
a physician.  This alternative preferable than waiting a further 5 minutes
till running  all the way up  the road..

Some ambulance drivers will argue they don't want to take the responsibility
of evacuating such an unstable case to a medical centre 25 minutes away. I
feel this the only way to give the guy a fighting chance. 
   Not a hypothetical case, but what we  have to tolerate here,fresh from
this week.
    What would you do? Do you think such a stance is medicolegally
defensible? Unfortunately we recognize that in many situations the best for
the patient may be outlawed especially with a rigid judicial system/ 

    |In prayer for better times and anticipating your opinions...

> "Cotton, Chris (SAAS)" <cotton.chris@saambulance.com.au>
"'trauma-list@trauma.org'" <trauma-list@trauma.org> Re: low volume
resusReply-To: trauma-list@trauma.org
>Date: Sun, 24 Feb 2002 23:47:36 +1030
>
>"K" wrote ... 
>
>First the IVs.   It is now widely accepted from both clinical and 
>experimental models of large animal hemorrhage, that the "urban legend" of 
>two large bore IVs wide open and the 3cc crystalloid replacement to the 1cc

>estimated blood loss, is now considered to be a dangerous strategy.   One 
>"pops the clot" at about 80/- to 85/- and the more crystalloid one gives
the
>
>greater the dilution of coagulation factors and the greater the logrithmic 
>turn on of cytokines.   
>
>Second:  There is not a single controlled study which demonstrates the 
>benefit of field decompression of hemothorax.  I can point out individual 
>cases where the death was caused from an iatrogenic puncture of the heart,
a
>
>lung, or a major vessel, including intercostal vessels.   Without question,

>this practice can contribute to systemic air embolism, a much greater cause

>of death than most on this list would like to openly admit.   
>
>Should you have presented this case to our M&M, you as an OVERTREATING
field
>
>personnel, would have had an opportunity for considerable attitude 
>adjustment.   I would hope that you, in your own quality review, make a
real
>
>assessment as to just why you are doing some of the things you listed that 
>you did.    
>
>k 
>
>Well Ken,
>          this case is infact 18 months old, and the reason for the fluid
>regime at the time was to try and obtain no more than return of a radial
>pulse and then back off. This was never achieved, as he arrested well
before
>this point was ever obtained.
>
>The POINT of the post (as I presume is also the point of M&M's - sorry,
>never had the pleasure of attending one) was to bring up some issues that
>appear to have stalled somewhat in the management of these patients who are
>generally accepted as doomed to die as a result of their injuries with
>current technology available to first arriving medical teams. To quote your
>own words when sent recently to the ccm-l website ...
>
> To Paramedic Cotton: 
>(and any others on this list who are interested) 
>
>I want to commend you for your curiosity and your question.   With the old 
>and new knowledge about resuscitation, there is no question that the terms 
>"Pop a CLOT" and "iatrogenic resuscitative traumatic exansguination" will 
>increasingly be used.   Without question, in my assessment, many of our 
>protocols (especially the two large bore IVs and wide open IVs) create NEW 
>iatrogenic problems and CAUSE the exsanguanation.    More data is emerging 
>every day that what we have been doing for the last 40 years is harmful.
In
>
>my view, at least 80% of the ARDS ICU syndromes are iatrogenic and could
>have 
>been prevented by avoiding cyclic hyper resuscitation in the ambulance and 
>the emergency center.   
>
>We need to change our protocols and educational policies.  
>
>k    
>
>Yes, I agree with you that the IV fluid management in hindsight was not
>ideal, but was the best we were able to do given our situation at the time,
>and the fact that return of a radial pulse was a good point to aim for, as
>literature preceding the episode had indicated this should be a guide as to
>how much fluid to give. The fact that it was never able to be achieved begs
>questions as to exactly how much fluid we should be trying to give - if
any.
>Is it best to give nothing? The job for all of us, ESPECIALLY those with
>influence at a teaching level, is in my opinion not to criticise those who
>try and do the best with the knowledge and training they have, but to
>support them, listen to feedback when cases go to shit, and ask why was
this
>so? Have we failed in our attempts to adequately inform Medicine's first
>intervention "Force" of the importance of newer resuscitation techniques?
>How can we better get the message out? How can the latest, tried and tested
>research that Medicine has to offer be more effective in getting its
message
>accross to it's frontline representatives? Moreover...how can we better
>equippe them to provide the best patient care with our latest knowledge? 
>
>Ken, and others, this is the question I have asked myself ever since
>attending this job all that time ago - I apologise for making it sound so
>current. The lessons and implications from my patient's death are no
>different from any one else's on this web site. Yes, I have taken a good
>look at my attitude and rationale for what I did on that case ... and I am
>proud to say that. THAT, in my opinion is the hallmark of a true
>professional, or someone who is trying to become one. HELP is appreciated
>... cynacism is not. The challenge, in my opinion begs us all to strive to
>get the latest tried and tested research on to the frontline to make a
>difference, be that an approach that says to scoop and run and do nothing
>more than administer oxygen and control haemorrhage en route to
>medical/surgical intervention, or to stay and play when considered
necessary
>and appropriate. Ofcourse the ideal approach (once again, in my opinion) is
>for us to UNDERSTAND WHAT WE SEE so we can make those decisions correctly,
>and that means sharing knowledge - not hiding it ;o)
>
>Regards,
>Chris Cotton, 
>Intensive Care Paramedic,
>South Australian Ambulance Service.
>
>--
>trauma-list : TRAUMA.ORG
>To change your settings or unsubscribe visit:
>http://www.trauma.org/traumalist.html

Sody Naimer
Goosh Katif Emergency Ambulance Team 
Israel 79779
Fax. 972-8-6846329
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