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Sun, 6 Jul 2003 07:55:36 -0500

Ben-

Well put.   A minor process to me may not be so minor after
all...........but in all my many moon's, and all the traumatised airways I
have attended, I have yet to have to resort to puncturing a trach in ANY
fashion.

Don't be so nervous........I espouse mastery of basic skills rather than
reliance on bells, whistles, kits or scalpels........

If, at some time in the future, I am presented with an airway that cannot be
accessed by ANY other means besides puncturing it, I want the largest, most
secure hole I can get.  The surgical cric fills that need and is the
procedure my medical director and I have chosen to qualify on and practice.
Neither of us would employ such a methodology in a cavalier fashion, I
assure you.

But, in my humvble opinion, when taken in context of what is being cut and
the potential for misadventures, a surgical cric is still a minor invasive
procedure.........

TD

----- Original Message -----
From: "Ben Reynolds" <aneurysm_42@yahoo.com>
To: <trauma-list@trauma.org>
Sent: Wednesday, July 02, 2003 11:07 PM
Subject: Re: Please Wash Your Hands Before You Cut My Throat

>
> --- "T.A. Dinerman" <dinerman@computron.net> wrote:
> > Ben-
> >
> > I am deeply sorry that you are so uncomfortable with
> > the concept of minor
> > surgical procedures being placed in the hands of us
> > dirty ol'
> > Paramedics...........
>
> Actually it's more about skill than sanitation, and
> less about paramedics than experience.  Sorry to
> disappoint you Terry ol' paramedic for however long
> you have been one, but it's not personal.  I'm just
> uncomfortable about those who consider surgical
> procedures 'minor' and then believe that they possess
> the credibility to perform them sight-unseen.
> 'Uncomfortable' indeed...
>
> > If the occassion arose and my own airway was in such
> > a sad state of repair
> > that I  coudl not be intubated, I would welcome the
> > attention of  Dr. Crow.
> > His broad experience with mamaillian physiology and
> > experience with a knife
> > gives him a decided edge over those of us who
> > specialize solely in hominids,
> > and run into a truly mangled airway only
> > infrequently.
>
> What Dr. Crowe doesn't seem to get, or you for that
> matter is that any situation where there is a need for
> the scalpel to be placed to the skin of a patient for
> WHATEVER reason, by WHOMEVER MUST undergo a thorough
> examination of the benefits or consequences of
> allowing such a thing to be done.  In this instance,
> is there a preponderance of data showing chest tube
> insertion or thoracotomy by paramedics is safe, as is
> asserted by Dr. Crowe?  Don't waste your time on
> Pubmed, there is none.
>
> But the literature is peppered with reports of
> iatrogenic injury from simple NEEDLE decompression,
> OVERdiagnosis of pneumothorax, SOFT indications for
> treatment among a plethora of other complications by
> physicians and paramedics alike.  Which begs the
> question we should all be asking: Who do you think you
> are helping?
>
> Norman McSwain wrote in a critique of one study
> looking at PHYSICIAN performed field chest tube
> placement:
> "...the reader must not be confused to believe that an
> emergency medical technician-paramedic (skilled as
> they are in many prehospital techniques) will have the
> expertise and training to carry out the same chest
> tube thoracostomy as a third-year surgery resident. I
> would expect that the surgery resident has performed
> several hundred of these inside the hospital while
> being supervised by professors. The technique is not
> difficult to learn, but it does require practice and
> skilled supervision. To believe that an emergency
> medical technician-paramedic can learn to accomplish
> this skill with the same rate of expertise by
> practicing it once or twice in the dog lab is not
> realistic..."*  I don't think I can expand on that.
>
> Even the data on paramedic performed crics point to a
> potential problem with overuse and questionable 'soft'
> indications.  Scott Frame, in writing his chapter on
> prehospital care in Mattox et al used words like
> 'technical imperative'*  to describe one
> overperforming a procedure simply because one can.  In
> the case of the field cric the potential for harm
> occurs because it is done unilaterally and without
> direct oversight. Therein the problem lies.  It is
> unethical and immoral to take the same liberties with
> humans that Dr. Crowe apparently takes so eagerly with
> his animals.
>
> > Please endevour to avoid injury in Brazoria County
> > Texas, as well  as Carson
> > City, for me and my ilk lie in wait for such as
> > ye.......
> >
> > Regards-
> >
> > Terry Dinerman EMTP
>
> That's quite a dangerous phrase to end with.  I know a
> physician who was jailed for using just such a smart
> comment with a police officer who misconstrued it as a
> threat.  It would be wise to think before you speak or
> write.
>
> Ben
>
> *McSwain NE, Editorial Comment to:
>    Schmidt U, Stalp M, Gerich T, Blauth M, Maull KI,
> Tscherne H. Chest tube decompression of blunt chest
> injuries by physicians in the field: effectiveness and
> complications.  J Trauma. 1998 Jan;44(1):98-101.
>
> Frame SB.  "Prehospital Care" in 'Trauma' fourth
> edition 2000: Mattox, Feliciano, and Moore pp 103-127
>
>
> > ----- Original Message -----
> > From: "Ben Reynolds" <aneurysm_42@yahoo.com>
> > To: <trauma-list@trauma.org>
> > Sent: Tuesday, July 01, 2003 7:36 PM
> > Subject: Re: Video education
> >
> >
> > > You are a very scary man.
> > >
> > > >From reading your posts it is apparent to me why
> > you
> > > practice only on animals (with the exception of
> > your
> > > EMT practice).  If you are truly interested in
> > > performing surgical procedures on the species
> > sapiens,
> > > I humbly suggest medical school.
> > >
> > > Until then, do MANkind a favor by recognizing that
> > > even the best and brightest of paramedics MUST
> > have
> > > limitations on practice, not unlike all
> > professions
> > > INCLUDING surgery.  These limitations must include
> > any
> > > procedure where a knife is put to flesh,
> > ESPECIALLY if
> > > it is to be done in the back of an loud, bumpy,
> > dirty,
> > > poorly lit, poorly equipped ambulance by someone
> > who
> > > has been 'tested off' to do it after successfully
> > > completing the 'see one, do one, teach one'
> > symposium.
> > >  The variable phenotypy of trauma disease in
> > humans is
> > > not something which can lend itself to be field
> > > treated per say on the observation of someone who
> > > doesn't do it several times a day, INCLUDING those
> > who
> > > treat canine, bovine, porcine, and feline
> > patients.
> > >
> > > It's simply not the same animal.
> > >
> > > Note to self:  Don't get hurt in Carson City.
> > >
> > > Ben
> > > --- CROWEHOME@aol.com wrote:
> > > > Kate: I have some very good video on performing
> > > > surgical trachs and emergency
> > > > thoracotomies on the cadaver dog that I use to
> > teach
> > > > emergency vets,
> > > > residents, EMTs, paramedics, etc.  Let me know
> > if
> > > > you would want copies. This is my
> > > > concern however.. there seems to be a big
> > problem
> > > > with developing these tapes if
> > > > many of the trauma surgeons can't agree on the
> > roles
> > > > each part of the team
> > > > should play.  At least here in the USA.  As an
> > > > example we have some that say
> > > > "never should a surgical trach be done in the
> > field
> > > > by paramedics" while others
> > > > teach and expect their paramedics to be doing
> > such
> > > > procedures and then these
> > > > are done!  I believe you still need to train the
> > > > trainer including some that
> > > > think its only their way that is correct (as
> > > > exemplified by the last two weeks of
> > > > dialog on the list). My thoughts are that when
> > there
> > > > is no time for the
> > > > patient to make the trip to the hospital ER as
> > will
> > > > a blocked airway that cannot be
> > > > remedied with Magill Forceps and laryngoscope
> > that a
> > > > surgical CT or trach
> > > > should be done NOW as other wise the patient is
> > > > going to be a dead patient!  You
> > > > better train those that are going to be there so
> > > > they can save the patient's
> > > > life and not have complications from doing it;
> > > > whether it be flight physician,
> > > > EMT, paramedic, nurse or other rescue personnel.
> > You
> > > > don't have to be an MD or
> > > > DO to place a chest tube or do surgical
> > tracheotomy
> > > > (as is what has been
> > > > proven in many rural areas of the US where the
> > MD in
> > > > charge of the paramedic/EMT
> > > > training have been aggressive). You just have to
> > be
> > > > trained properly and
> > > > regularly and then tested off that you can do
> > the
> > > > procedures rapidly and safely.
> > > > Let me know.
> > > >
> > > > Dennis T. (Tim) Crowe, Jr., DVM, DACVS, DACVECC,
> > > > NREMT-II PI, FF
> > > > Veterinary Surgery and Emergency - Critical Care
> > > > Consulting
> > > > 2621 Simons Court, Carson City, Nevada 89703
> > > > phone and fax 775-841-6821  crowehome@aol.com
> > > > <><
> > > > Clinical Associate Professor, The Institute of
> > > > Critical Care Medicine
> > > > 1695 N Sunrise Way, Palm Springs, CA 92262
> > > > 760-788-4911
> > > >
> > >
> > >
> > > __________________________________
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>
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