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Wed, 18 Jun 2003 10:27:50 -0400

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John,

I admire your persistence, but fear that it might be a symptom of S.H.I.T.
(Syndrome of Hero Insecurity in Trauma--a regrettable and unshakable
assumption that the purpose of prehospital EMS in trauma is to do something,
and when that fails, to do something more).  The disease is especially
intractable among higher-level rationalizers, manifested as the ominous
condition of "S.H.I.T. for Brains."  

It's okay, you're not alone; the first step is admitting you have a problem:
"Hi, I'm Pret, and I have S.H.I.T. for Brains."

Especially among your target population (urban patients and providers), the
treatment for a pulseless patient with a knife in his chest is thoracotomy
by skilled hands.  If your energies cannot be completely devoted to a
realistic attempt at getting this fellow to a surgeon within the warm
ischemia time of his brain, then pronounce him dead.  Sorry, John, but
Christ, the guy's got no pulse and a knife in his chest.  Fate can be hasty.

Going all the way back to your original question, note how you characterized
the problem: "...retained knives in the anterior chest wall/epigastrium in
patients that require CPR."  The central issue is--listen
carefully--patients with knives in their chests do not benefit from, much
less require, CPR.  Once you start to envision or invent reasons to do CPR
in order to justify the removal of the knife, you're layering hypothesis
upon apocrypha, and useful dialogue evaporates.

Regards,

Pret

 -----Original Message-----
From: Black, John [mailto:John.Black@orh.nhs.uk]
Sent: Wednesday, June 18, 2003 9:16 AM
To: 'trauma-list@trauma.org'
Subject: Remove the knife???

Thanks Rick/Ken/Pret/Barry - I will try and clarify and apologies for not
being more explicit for the reasons for exploring this issue in the first
instance - I was hoping to obtain a broad feel for the general issues
(through discussion) before focusing in on the specifics - as well as taking
the risk of being controversial!

Our local ambulance services are currently reviewing operational protocols
delivered by field paramedics/technicians and ambulance control room staff
for penetrating chest trauma for this relatively rare scenario - although
sadly an increasing problem in our inner cities in the UK. I am also acutely
aware of a lack of robust evidence for virtually all pre-hospital clinical
interventions (and indeed much of hospital based clinical practice!). I am
very much aware of the enormous challenge (and in my view the almost
impossible task) of obtaining irrefutable class 1 evidence (or indeed any
level of evidence) for much of prehospital clinical care because of the size
of the studies required to demonstrate any significant effect because of so
many confounding variables - we will always be dependent on lower levels of
evidence for certain types of injury patterns in specific contexts. Lack of
evidence demonstrating an effect is in itself is not a reason for not
questioning current clinical practice and reviewing clinical
guidelines..........

When I referred to a 'lifeless patient' in the original post I meant to
refer specifically to the 'apparently clinically lifeless' patient with
recent loss of vital signs, organized cardiac electrical activity and a
retained weapon in the chest, who may or may not have an underlying
survivable penetrating cardiac/pulmonary injury pattern.

The surgical principle of "not removing the knife" in patients with vital
signs until you are set up to do this under direct vision is a principle
that I do not question in the operating theatre or indeed the Emergency
Department. I am questioning its validity when applied to the pre-hospital
phase of the patient's care in this particular context, when because of
circumstances the patient cannot access resuscitation/operating room
interventional skills in an acceptable time frame.

Cardiac tamponade, and possibly tension pneumothorax, are the only potential
salvageable injuries that could potentially be partially relieved by knife
removal followed by CPR (only a relatively small amount of blood/clot would
need to be evacuated from the pericardium to potentially restore a perfusing
rhythm) and thoracocentesis on the side of injury. Catastrophic haemorrhage
does not always complicate penetrating cardiac wounds or knife removal. If
hypovolaemia is the underlying cause of the arrest, the situation is clearly
not salvageable but cannot be made worse. Survival will ultimately depend
whether such patients can be 'bridged' to timely definitive care. 

Does this simple approach have any merit at all or should the towel be
thrown in and admit defeat admitted in the field on every occasion? We
already know what the outcome is for this subset of patients when delivered
to hospital under existing protocols.

Regarding ambulance control room operational protocols, the decision (to
remove the knife) on the basis of telephone information from bystanders is
clearly fraught with difficulty and I suspect existing advice (leave knife
in situ) should stand. 

John Black

-----Original Message-----
From: DocRickFry@aol.com [mailto:DocRickFry@aol.com] 
Sent: 17 June 2003 18:18
To: trauma-list@trauma.org
Subject: Re: Remove the knife!

In a message dated 6/17/2003 10:22:15 AM Eastern Daylight Time,
John.Black@orh.nhs.uk writes:

Could someone try and explain to me (again) how a lifeless patient benefits
from current advice of leaving the knife in situ and not performing CPR if
they are more than a say 5-10 minutes from hospital? 

John--
I'm not sure of the point of your question given you answered it in spades
yourself in the first part of your post--I must be missing something.  First
off, a lifeless patient by definition is dead--does this really need
explaining?  A lifeless patient at the scene should be pronounced dead--all
experts, texts, etc agree on this.  Especially if "more than 5-10 minutes "
from a hospital. 
If there are signs of life (which is not what you are asking) then of course
there could be no indication anyway for CPR (because there ARE signs of
life), CPR is useless anyway as it cannot at all help the underlying
problem, and cannot at all do anything to perfuse the body in this setting.
The only thing that can be done of any value if resuscitation is deemed to
not be futile is to rapidly transport to a definitive care center for rapid
thoracotomy.  Removing an impaled object can only worsen, cannot improve,
the problem.  Like you say, there is the explanation--again!
ERF

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<BODY lang=3DEN-US link=3Dblue style=3D"tab-interval: 36.0pt" =
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<DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN=20
class=3D200182713-18062003>John,</SPAN></FONT></DIV>
<DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN=20
class=3D200182713-18062003></SPAN></FONT>&nbsp;</DIV>
<DIV><FONT color=3D#800000 face=3DArial size=3D2><SPAN =
class=3D200182713-18062003>I=20
admire your persistence, but fear that it might be a symptom of =
S.H.I.T.=20
(Syndrome of Hero Insecurity in Trauma--a regrettable and unshakable =
assumption=20
that the purpose of prehospital EMS in trauma is to <EM>do =
something</EM>, and=20
when that fails, to <EM>do something more</EM>).&nbsp; The disease is =
especially=20
intractable among higher-level rationalizers, manifested as the ominous =

condition of "S.H.I.T. for Brains."&nbsp; </DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV>It's=20
okay, you're not alone; the first step is admitting you have a =
problem:&nbsp;=20
"Hi, I'm Pret, and I have S.H.I.T. for Brains."</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>Especially among your target population =
(urban patients=20
and providers), the treatment for a pulseless patient with a knife in =
his chest=20
is thoracotomy by skilled hands.&nbsp; If your energies cannot be=20
completely&nbsp;devoted to a realistic attempt at getting this fellow =
to a=20
surgeon within the warm ischemia time of his brain, then pronounce him=20
dead.&nbsp; <SPAN=20
class=3D200182713-18062003>Sorry, John, but Christ, the guy's got no =
pulse and a=20
knife in his chest.&nbsp; Fate can be hasty.</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV>Going=20
all the way back to your original question, note how you characterized =
the=20
problem: "...retained knives in the anterior chest wall/epigastrium in =
patients=20
that require CPR."&nbsp; The central&nbsp;issue is--listen=20
carefully--patients with knives in their chests do not benefit from, =
much=20
less require, CPR.&nbsp; Once you start to envision or =
invent=20
reasons to do CPR in order to justify the removal of the knife, you're =
layering=20
hypothesis upon apocrypha, and useful dialogue =
evaporates.</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>Regards,</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>Pret</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;</DIV>
<DIV><SPAN=20
class=3D200182713-18062003>&nbsp;-----Original =
Message----- From:=20
Black, John [mailto:John.Black@orh.nhs.uk] Sent: Wednesday, =
June 18,=20
2003 9:16 AM To: 'trauma-list@trauma.org' Subject: =
Remove=20
the knife??? </DIV>
<BLOCKQUOTE style=3D"MARGIN-RIGHT: 0px">
 <DIV class=3DSection1>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">Thanks=20
 Rick/Ken/Pret<FONT=20
 color=3Dnavy face=3DArial size=3D2><SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">/Barry - I =
will try=20
 and clarify and apologies for not being more explicit for the reasons =
for=20
 exploring this issue in the first instance - I was hoping to obtain a =
broad=20
 feel for the general issues (through discussion) before focusing in =
on the=20
 specifics - as well as taking the risk of being=20
 controversial!<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">Our local =
ambulance=20
 services are currently reviewing operational protocols delivered by =
field=20
 paramedics/technicians and ambulance control room staff for =
penetrating chest=20
 trauma for this relatively rare scenario - although sadly an =
increasing=20
 problem in our inner cities in the=20
 <st1:country-region><st1:place><SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt">UK</st1:place></st1:country-region><FONT=20
 color=3Dnavy face=3DArial size=3D2><SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">. I am =
also acutely=20
 aware of a lack of robust evidence for virtually all pre-hospital =
clinical=20
 interventions (and indeed much of hospital based clinical practice!). =
<SPAN=20
 class=3DGramE>I am very much aware of the enormous challenge (and in =
my view the=20
 almost impossible task) of obtaining irrefutable class 1 evidence (or =
indeed=20
 any level of evidence) for much of prehospital clinical care because =
of the=20
 size of the studies required to demonstrate any significant effect =
because of=20
 so many confounding variables - we will always be dependent on lower =
levels of=20
 evidence for certain types of injury patterns in specific =
contexts.=20
 Lack of evidence demonstrating an effect is in itself is not a reason =
for not=20
 questioning current clinical practice and reviewing clinical =
guidelines<SPAN=20
 class=3DGramE>..........<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">When I =
referred to a=20
 'lifeless patient' in the original post I meant to refer specifically =
to the=20
 'apparently clinically lifeless' patient with recent loss of vital =
signs,=20
 organized cardiac electrical activity and a retained weapon in the =
chest, who=20
 may or may not have an underlying survivable penetrating =
cardiac/pulmonary=20
 injury pattern.<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">The =
surgical=20
 principle of "not removing the knife" in patients with vital signs =
until you=20
 are set up to do this under direct vision is a principle that I do =
not=20
 question in the operating theatre=20
 or =
<FONT=20
 color=3Dnavy face=3DArial size=3D2><SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">indeed the =
Emergency=20
 Department. I am questioning its validity when applied to the =
pre-hospital=20
 phase of the patient's care in this particular context, when because =
of=20
 circumstances the patient cannot access resuscitation/operating room=20
 interventional skills in an acceptable time=20
 frame.<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">Cardiac =
tamponade,=20
 and possibly tension pneumothorax, are the only potential salvageable =
injuries=20
 that could potentially be partially relieved by knife removal =
followed by CPR=20
 (only a relatively small amount of blood/clot would need to <SPAN=20
 class=3DGramE>be evacuated from the pericardium to potentially =
restore a=20
 perfusing rhythm) and thoracocentesis on the side of injury. =
Catastrophic=20
 haemorrhage does not always complicate penetrating cardiac wounds or =
knife=20
 removal. If hypovolaemia is the underlying =
cause of=20
 the arrest, the situation is clearly not salvageable but cannot be =
made worse.=20
 Survival will ultimately depend whether such patients can be =
'bridged' to=20
 timely definitive care. <o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">Does this =
simple=20
 approach have any merit at all or should =
the towel be=20
 thrown in and admit defeat admitted in the field on every occasion? =
We already=20
 know what the outcome is for this subset of patients when delivered =
to=20
 hospital under existing protocols.<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">Regarding =
ambulance=20
 control room operational protocols, the decision (to remove the =
knife) <SPAN=20
 class=3DGramE>on the basis of telephone information from =
bystanders is=20
 clearly fraught with difficulty and I suspect existing advice (leave =
knife in=20
 situ) should stand. <o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt">John=20
 Black<o:p></o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: =
10pt"><o:p>&nbsp;</o:p>
 <SPAN=20
 style=3D"COLOR: navy; FONT-FAMILY: Arial; FONT-SIZE: 10pt"><SPAN=20
 style=3D"mso-spacerun: =
yes">&nbsp;<o:p></o:p>
 <SPAN=20
 style=3D"FONT-FAMILY: Tahoma; FONT-SIZE: 10pt">-----Original=20
 Message----- From: =

DocRickFry@aol.com [mailto:DocRickFry@aol.com] =
 <SPAN=20
 style=3D"FONT-WEIGHT: bold">Sent<SPAN=20
 style=3D"FONT-WEIGHT: bold">: <st1:date =
Year=3D"2003"=20
 Day=3D"17" Month=3D"6"><SPAN=20
 style=3D"FONT-FAMILY: Tahoma; FONT-SIZE: 10pt">17 June=20
 2003</st1:date><SPAN=20
 style=3D"FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"> =
<st1:time=20
 Minute=3D"18" Hour=3D"18"><SPAN=20
 style=3D"FONT-FAMILY: Tahoma; FONT-SIZE: =
10pt">18:18</st1:time><FONT=20
 face=3DTahoma size=3D2><SPAN=20
 style=3D"FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"> <SPAN=20
 style=3D"FONT-WEIGHT: bold">To: =
trauma-list@trauma.org <SPAN=20
 style=3D"FONT-WEIGHT: bold">Subject: Re: Remove the=20
 knife!
 <o:p>&nbsp;</o:p>
 In a message dated 6/17/2003 =
10:22:15 AM=20
 Eastern Daylight Time, John.Black@orh.nhs.uk writes: <BR=20
 style=3D"mso-special-character: line-break"><![if =
!supportLineBreakNewLine]><BR=20
 style=3D"mso-special-character: =
line-break"><![endif]><o:p></o:p>
 <FONT=20
 color=3Dnavy face=3DArial size=3D2><SPAN=20
 style=3D"BACKGROUND: white; COLOR: navy; FONT-FAMILY: Arial; =
FONT-SIZE: 10pt">Could=20
 someone try and explain to me (again) how a lifeless patient benefits =
from=20
 current advice of leaving the knife in situ and not performing CPR if =
they are=20
 more than a say 5-10 minutes from hospital? <SPAN=20
 style=3D"BACKGROUND: white; COLOR: black; FONT-FAMILY: =
Arial"><o:p></o:p>
 <SPAN=20
 style=3D"BACKGROUND: white; COLOR: black; FONT-FAMILY: Arial; =
FONT-SIZE: 12pt"> <FONT=20
 color=3Dblack> John-- I'm=20
 not sure of the point of your question given you answered it in =
spades=20
 yourself in the first part of your post--I must be missing =
something.&nbsp;=20
 First off, a lifeless patient by definition is dead--does this really =
need=20
 explaining?&nbsp; A lifeless patient at the scene should be =
pronounced=20
 dead--all experts, texts, etc agree on this.&nbsp; Especially if =
"more than=20
 5-10 minutes " from a hospital. If there are signs of life (which =
is not=20
 what you are asking) then of course there could be no indication =
anyway for=20
 CPR (because there ARE signs of life), CPR is useless anyway as it =
cannot at=20
 all help the underlying problem, and cannot at all do anything to =
perfuse the=20
 body in this setting.&nbsp; The only thing that can be done of any =
value if=20
 resuscitation is deemed to not be futile is to rapidly transport to a =

  definitive care center for rapid thoracotomy.&nbsp; Removing an =
impaled object=20
  can only worsen, cannot improve, the problem.&nbsp; Like you say, =
there is the=20
  =
explanation--again!<BR>ERF</SPAN></FONT><o:p></o:p></P></DIV></BLOCKQUOT=
E></BODY></HTML>

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