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Thu, 24 Apr 2003 20:04:11 -0700

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Please, do not abuse of my good manners.

Taken out of contest,the line you pasted and unrespectfuly answered has =
a changed meaning. Obviously you need to reed or, may be understand de =
whole message.
I know the medicine of 20 years ago, because of the simple fact that I =
have been there.
Do not read to me the text book, nor talk about costs out of the context =
of an economy model. For such matter you need to know more than what you =
 have systematically heard and repeated.

It will be good for you to realize that when you take care of patients =
the comitment is to attempt to solve 100% of the cases, and not most of =
them.
As, now I do not know if you know, there are some cases in which all the =
items in the chapter you have memorized in adition to the thinking =
proccess, which for your surprise is a skill that millions other =
physicians share with you, do not lead to diagnosis.

Now that the so called EB medicine is in fashion, it is moment to =
address that  conclusions, as you used to support general rules an =
evidence, are based in averages and calculations creating a reality that =
do not apply for the 100% of the patients. Even in the group of the =
99.99, are individual patients that, may be, would have done better with =
a care particularly pointed to the especific case.

On the other hand, it is not going to be the first occassion  that EB =
conclussions were found to be not the right truth.

Protocols and standar of care are square, some times patients are round: =
they do not fit. Do not push them, they can be hurt.

By the way I am not blid nor deaf, do not raise the VOICE WITH CAPITAL =
LETTERS. I know that the keyboard and the distance of a monitor =
encourage people to be tough and unrespectful. Humbleness is needed =
paticularly in medicine.

Now, in your experience, have you made 100% of the acute abdomen =
etiologic diagnosis with the tools you have memorized? Is there, in =
particular cases a use for other diagnostic techniques?
I am just asking, not making a statement.

My respects
JLAM

  ----- Original Message -----=20
  From: DocRickFry@aol.com=20
  To: trauma-list@trauma.org=20
  Sent: Thursday, April 24, 2003 5:02 PM
  Subject: Re: Appendicitis & CT

  In a message dated 4/23/2003 11:49:16 PM Eastern Daylight Time, =
pandanas@OregonFAST.net writes:

    Now, my question is, as a non surgeon, in a acute abdomen of non =
clear
    etiology, what do you do? to CT or not CT?

  You examine the patient (pretty novel, huh?), order a minimum of =
simple tests (maybe WBC, lipase, CXR, KUB), and then--use some clinical =
acumen.  And guess what?  In the great majority of these cases, nothing =
more is necessary!  Surprised?  If so, you need a lot more experience =
with the acute abdomen and surgical diseases--and ordering more =
expensive and exotic tests does not substitute for some thinking, =
reading, studying and clinical experience.  It is done because the =
former is much easier, and usually only by those who have no =
responsibility for the ultimate care and welfare of the patient.  You =
must remember--before about 20 years ago there was no CT---and guess =
what?  The diagnosis of the acute abdomen was no different!  The use of =
CT has done NOTHING to improve diagnosis, reduce hospital stay, reduce =
morbidity, --it CERTAINLY increases costs--from diseases presenting with =
acute abdominal pain, over a large population.  IF you assert otherwise, =
please refer us all to the citation demonstrating such?  I will be happy =
to refer you to the data (for about the fourth time in the last 2 weeks) =
showing it has made no difference in a statewide population
  ERF=20

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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML><HEAD>
<META content=3D"text/html; charset=3Diso-8859-1" =
http-equiv=3DContent-Type>
<META content=3D"MSHTML 5.00.2722.2800" name=3DGENERATOR>
<STYLE></STYLE>
</HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3DArial size=3D2>Please, do not abuse of my good=20
manners.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Taken out of contest,the line you =
pasted and=20
unrespectfuly answered has a changed meaning. Obviously you need to reed =
or, may=20
be understand de whole message.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>I know the medicine of 20 years ago, =
because of the=20
simple fact that I have been there.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Do not read to me the text book, nor =
talk about=20
costs out of the context of an economy model. For such matter you need =
to know=20
more than what you  have systematically heard and repeated.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>It will be good for you to realize that =
when you=20
take care of patients the comitment is to attempt to solve 100% of the =
cases,=20
and not most of them.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>As, now I do not know if you know, =
there are some=20
cases&nbsp;in which all the items in the chapter you have memorized in =
adition=20
to the thinking proccess,&nbsp;which for your surprise is a skill that =
millions=20
other physicians share with you, do not lead to diagnosis.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Now that the so called EB medicine is =
in fashion,=20
it is moment to address that&nbsp; conclusions, as you used to support =
general=20
rules an evidence, are based in averages and calculations creating a =
reality=20
that do not apply for the 100%</FONT>&nbsp;<FONT face=3DArial =
size=3D2>of the=20
patients. Even in the group of the 99.99, are individual patients that, =
may be,=20
would have done better with a care particularly pointed to the especific =

case.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>On the other hand, it is not going to =
be the=20
first&nbsp;occassion  that EB conclussions were found to be not the =
right=20
truth.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Protocols and standar of care are =
square, some=20
times patients are round: they do not fit. Do not push them, they can be =

hurt.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>By the way I am not blid nor deaf, do =
not raise the=20
VOICE WITH CAPITAL LETTERS. I know that the keyboard and the distance of =
a=20
monitor encourage people to be tough and unrespectful. Humbleness is =
needed=20
paticularly in medicine.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>Now, in your experience, have you made =
100% of the=20
acute abdomen etiologic diagnosis with the tools you have memorized? Is =
there,=20
in particular cases a use for other diagnostic techniques?</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>I am just asking, not making a=20
statement.</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV><FONT face=3DArial size=3D2>My respects</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>JLAM</FONT></DIV>
<DIV>&nbsp;</DIV>
<DIV>&nbsp;</DIV>
<BLOCKQUOTE=20
style=3D"BORDER-LEFT: #000000 2px solid; MARGIN-LEFT: 5px; MARGIN-RIGHT: =
0px; PADDING-LEFT: 5px; PADDING-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A href=3D"mailto:DocRickFry@aol.com"=20
  title=3DDocRickFry@aol.com>DocRickFry@aol.com</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A=20
  href=3D"mailto:trauma-list@trauma.org"=20
  title=3Dtrauma-list@trauma.org>trauma-list@trauma.org</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Thursday, April 24, 2003 =
5:02=20
  PM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: Appendicitis &amp; =
CT</DIV>
  <DIV><BR></DIV><FONT face=3Darial,helvetica><FONT face=3DArial =
lang=3D0 size=3D2=20
  FAMILY=3D"SANSSERIF">In a message dated 4/23/2003 11:49:16 PM Eastern =
Daylight=20
  Time, <A =
href=3D"mailto:pandanas@OregonFAST.net">pandanas@OregonFAST.net</A>=20
  writes:<BR><BR>
  <BLOCKQUOTE=20
  style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT: 5px; =
MARGIN-RIGHT: 0px; PADDING-LEFT: 5px"=20
  TYPE=3D"CITE">Now, my question is, as a non surgeon, in a acute =
abdomen of non=20
    clear<BR>etiology, what do you do? to CT or not=20
  CT?<BR></BLOCKQUOTE><BR><BR>You examine the patient (pretty novel, =
huh?),=20
  order a minimum of simple tests (maybe WBC, lipase, CXR, KUB), and =
then--use=20
  some clinical acumen.&nbsp; And guess what?&nbsp; In the great =
majority of=20
  these cases, nothing more is necessary!&nbsp; Surprised?&nbsp; If so, =
you need=20
  a lot more experience with the acute abdomen and surgical =
diseases--and=20
  ordering more expensive and exotic tests does not substitute for some=20
  thinking, reading, studying and clinical experience.&nbsp; It is done =
because=20
  the former is much easier, and usually only by those who have no=20
  responsibility for the ultimate care and welfare of the patient.&nbsp; =
You=20
  must remember--before about 20 years ago there was no CT---and guess=20
  what?&nbsp; The diagnosis of the acute abdomen was no different!&nbsp; =
The use=20
  of CT has done NOTHING to improve diagnosis, reduce hospital stay, =
reduce=20
  morbidity, --it CERTAINLY increases costs--from diseases presenting =
with acute=20
  abdominal pain, over a large population.&nbsp; IF you assert =
otherwise, please=20
  refer us all to the citation demonstrating such?&nbsp; I will be happy =
to=20
  refer you to the data (for about the fourth time in the last 2 weeks) =
showing=20
  it has made no difference in a statewide population<BR>ERF</FONT>=20
</FONT></BLOCKQUOTE></BODY></HTML>

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