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Thu Oct 21 14:58:44 BST 2004

This is a very reasonable approach for me here, too, Tim.
cheers,
claudia
 '>'-- Mensagem Original --
 '>'Date: Thu, 21 Oct 2004 07:22:42 +0200
 '>'From: "Hardcastle Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
 '>'To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
 '>'Subject: RE: trauma-list Digest, Vol 16, Issue 25
 '>'Reply-To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
 '>'
 '>'
 '>'Rainer
 '>'
 '>'>From the "3rd" World perspective:
 '>'If a patient is in a persistant vegatative state (as you describe here),
 '>'we would do a tracheostomy, wean to "trachy-mask O2", not initiate any
new
 '>'anti-biotic therapy and offer "TLC". She would not qualify for renewed
ventilation
 '>'or CPR if asystole occurs. We would not withhold enteral feeding via
a tube,
 '>'but would not intitiate TPN. Basic nursing care / physiotherapy and
family
 '>'support are standard care issues. We would watch for clinical improvement
 '>'and not do any new diagnositic studies.
 '>'
 '>'These patients can unfortunately survive fairly long periods of time
with
 '>'this conservative support. Less than 1% in our experience, however,
survive
 '>'beyond 1 year.
 '>'
 '>'In the first world environment, where often facilities and potential
law-suits
 '>'exceed logic this would probably be frowned upon; but it works for our
situation
 '>'
 '>'Regards
 '>'Tim
 '>'Dr TC Hardcastle
 '>'M.B.Ch.B(Stell); ATLS(I), DSTC(I); M.Med(Surg)(Stell); FCS(SA)
 '>'General Surgeon (Sections Trauma / ICU)
 '>'Dept. General Surgery
 '>'University of Stellenbosch / Tygerberg Hospital
 '>'PO Box 19063, 7505
 '>'Operational Head: Diana, Princess of Wales Trauma Centre
 '>'Program Coordinator: Emergency Medicine
 '>'Intern Rotation Coordinator: Surgery
 '>' 
 '>'tch at sun.ac.za <mailto:tch at sun.ac.za> 
 '>'2 Lorient Close
 '>'Vredekloof
 '>'Brackenfell
 '>'7560, W. Cape
 '>'South Africa
 '>'Cell: +27824681615
 '>'Home: +27219813098
 '>'Work: +27219384911 pager 0302
 '>'
 '>'
 '>'-----Original Message-----
 '>'yes, we are all of one mind here -  but when can we be certain enough

 '>'about this to withhold for example pneumonia treatment?
 '>'
 '>'what would you think about withholding other treatment modalities?
 '>'nutrition, ventilation ?????
 '>'
 '>'we put here on low dose propofol again -  even if most of us strongly
feel
 '>'
 '>'that she is not awake at all.
 '>'
 '>'we are aiming for another EEG and an NMR next week.
 '>'
 '>'
 '>'i shall be pleased to receive further opinions and advice!
 '>'
 '>'
 '>'greetings from a darkening Sweden, with grey skies ...  it will 
 '>'brighten again, when it really gets cold.
 '>'
 '>'Rainer
 '>'
 '>'
 '>'> 
 '>'> E
 '>'> 
 '>'> Errington C. Thompson, MD
 '>'> Author - A Letter to America
 '>'> www.erringtonthompsonmd.com
 '>'> ecthompson at msn.com
 '>'> 
 '>'> Everyone deserves to make an informed decision
 '>'>                                               - Errington C. Thompson,
 '>'MD
 '>'> 
 '>'> 
 '>'> 
 '>'> -----Original Message-----
 '>'> From: trauma-list-bounces at trauma.org
 '>'> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Rainer Gatz
 '>'> Sent: Tuesday, October 19, 2004 2:22 PM
 '>'> To: trauma-list at trauma.org
 '>'> Subject: another trauma cpr scenario
 '>'> 
 '>'> 
 '>'> 
 '>'> hi all,
 '>'> 
 '>'> a few times already the subject of cpr for trauma victims and its
futility
 '>'> 
 '>'> has been discussed on this forum, once about 18months ago a case posted
 '>'by
 '>'> 
 '>'> me (little lad overrun by a car .... ).
 '>'> 
 '>'> now we are taking care of a patient with a type of scenario that was
not
 '>'> discussed on the previous occasions -  and at least as sad.
 '>'> 
 '>'> 
 '>'> our patient is a fourteen years old girl that a few weeks ago was
struck
 '>'> by a car and flung high up through the air, while trying to cross
the
 '>'> road,
 '>'> emerging in front of the school bus she had just left, in front of
her
 '>'> waiting father's eyes. the bloke who ran her over was driving at about
 '>'> 100km/h.
 '>'> 
 '>'> 
 '>'> she is described as being without respiration or circulation at the
scene
 '>'> - i don't know how far the attending persons were medically qualified
-
 '>'> and somebody started CPR on her.
 '>'> 
 '>'> she was taken to a tertiary center (not our place), in stable
 '>'> cardiopulmonary conditions. diagnoses:
 '>'> - suspected occipital condylar fracture with suspected medullary
 '>'> transsection, about 12 days later confirmed by NMR
 '>'> - C6/C7 displacement
 '>'> - thalamic bleeding, left side
 '>'> - contusions in liver and spleen, stable pelvic fracture
 '>'> - the NMR in additon showed diffuse axonal injury
 '>'> 
 '>'> she went through a period of high and volatile intracranial pressure.
 '>'> 
 '>'> after this resolved, she was transferred to our care.
 '>'> 
 '>'> there is minimal neurologic function: small eye movements on the left
side
 '>'> 
 '>'> -  the eyeball always points medially and caudally, but seems to be
 '>'> drifting around a bit, no corneal reflex, but positive eye lash reflex.
 '>'> these seems to augment a bit when stimulating her. no reactions at
all
 '>'on
 '>'> the right side, the right pupil does not react to light and is mildly
 '>'> dilated, the eyeball pointing straight ahead.
 '>'> 
 '>'> 
 '>'> now, she has been sedated up till today, we plan an EEG tomorrow.
 '>'> 
 '>'> 
 '>'> 
 '>'> comments?
 '>'> 
 '>'> 
 '>'> Rainer
 '>'> 
 '>'> 
 '>'> 
 '>'
 '>'--
 '>'
 '>'"there is enough for everybody's need, but not for everybody's greed."
Mahatma
 '>'Gandhi
 '>'happily using linux and pine !
 '>'Rainer Gatz * anaesthesiologist * Skaraborg Sjukhus - KärnSjukhuset
i Skövde
 '>'(KSS)   Sweden
 '>'e-mail:  m.und.r.gatz at t-online.de    
 '>'
 '>'--
 '>'trauma-list : TRAUMA.ORG
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