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Thu Oct 2 01:23:42 BST 2003

Just because many surgeons are doing this thing wrong doesn't mean it is the standard everywhere.  CT evaluation is a tool, like labs or history.  It should help to complete the picture of what is wrong with the patient.  A CT scan without history or physical exam will lead you down the wrong path.  

Example:  4 yo s/p MVC presents hypotensive after being thrown from a car (mother was wearing her seat belt but not the child).  Child intubated and sedated in the ER.  chest tubes are placed for bilateral pneumothorax.  Foley placed.  Frank blood returned.  Cystogram revealed intraperitoneal extravasation.  Patient given crystalloid and colloid.  Multiple ventilator maneuvers made in order to get the child to oxygenate.  Patient now relatively stable.  To CT.  CT of head - minor intraparenchymal contusion.  CT of ABD/Pelvis - renal lac., splenic lac, contrast seen in the left chest.  I take the patient to the OR.  Radiologist stops me in the hall.  He has seen the CT's and thinks that we need to do an aortogram to see if there is an aortic tear.  He is very worried about the contrast in the left chest.  

Now, I have examined this child.  I have read the literature.  I have been with this child and personally ordered every test.  If I listen to the radiologist, I would have wasted valuable time getting an aortogram on a 4 yo.  Instead, I thanked him for his concern and explained that I believed that the child had a ruptured diaphragm and the contrast was from her cytogram.  I promised that if the diaphragm was normal that I would evaluate the aorta in the OR.  In the OR, I found a ruptured diaphragm.  The patient has several other surgical problems which I address.  A temporary abdominal closure was placed.  The patient's coagulopathy was corrected in the ICU just in time for Children's hospital to come and take the child for more definitive care (pelvic fracture and proximal femur fracture needed to be addressed).  the child ended up doing fine.

We all must remember CT scan is only one tool in the arsenal. 

(For Dr. Mattox - this child never developed respiratory failure in spite of having a terrible pulmonary contusion.  She was never overhydrated!! FYI.)

E

Errington C. Thompson, MD, FACS
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx.
ecthompson at msn.com

Don't think you are
Know you are

                           - Morpheus (The Matrix)
  ----- Original Message ----- 
  From: Nick Nudell 
  To: Trauma & Critical Care mailing list 
  Sent: Wednesday, October 01, 2003 5:18 PM
  Subject: Re: Normotension, Fluids, CT Scans & Chest Tubes

  Where I work everyone gets CT unless they are bleeding out, as in OUT.

  I had to laugh the other day... the surgeon told the transporter to just tell the CT techs to CT the patient, they already know what to do.

  It does help those of us who watch the CTs to see the anatomy and note the problems and issues and correlate them with signs/symptoms. I have seen a lot of interesting things.

  Nick

  ____________________________________________
  Nick Nudell, NREMT-P, CCEMT-P
  California
  nudell at prehospitalperspective.net

  "Perception is reality" - Wise Old Paramedic

    ----- Original Message ----- 
    From: Bruce Way 
    To: Trauma & Critical Care mailing list 
    Sent: Wednesday, October 01, 2003 3:08 PM
    Subject: RE: Normotension, Fluids, CT Scans & Chest Tubes

    How worlds differ. In my world, the love affair is between the surgeons and the CT scanner. It has largely replaced physical examination, probably because it removes the need to interact with a conscious patient. The emergency physician just wants a decision. More tests just means a longer stay in our department.
    Bruce Way
    Emergency Physician
    Sydney Australia

    Email way-----Original Message-----
    From: KMATTOX at aol.com [mailto:KMATTOX at aol.com]
    Sent: Tuesday, 30 September 2003 22:55
    To: trauma-list at trauma.org
    Subject: Re: Normotension, Fluids, CT Scans & Chest Tubes

      In this case, as in the majority of thoracic trauma cases, especially penetrating thoracic trauma, and most especially as this patient presented, there is absolutely NO additional information that is gained from thoracic CT, especially enhanced spiral CT.   As a matter of fact, the enhanced spiral CT causes more confusion, as it did in this case, and is probably contraindicated.   I still do not understand the love affair between some physicians that work in emergency rooms and the CT scanner; especially as it relates to appendicitis and to thoracic trauma.     

      k

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