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Thu Apr 7 11:05:37 BST 2005

Mo--
You keep talking as if yours is "the real world" when in fact you are the one losing perspective--because your "real world" is really only within your own imagination--it seems like you are not willing to see this--your word for "afraid of standing up for what is right", or "confidence in my knowledge and ability" is "pressure"
ERF 

-----Original Message-----
From: Mohamed al Malik <traumawon at yahoo.com>
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Sent: Wed, 6 Apr 2005 15:30:15 -0700 (PDT)
Subject: We need help, not speeches - Please ACS

I am very embarrased to have caused so much discussion.    I only wanted help.   
Now I have caused the ACS, the nursing support for trauma services, and some of 
my heros to be upset with me for bringing this to the attention of the group.    
I apologize and will go back to my being quiet.   I only wanted to let each of 
you know what it is like in the real world.   I wanted you to know the impact of 
your writings and your courses.    I find that the ACS ATLS course and the ACS 
sponsored Trauma & Critical Care course are as different as day and night.   
Will someone with influence please help us here in private hospitals just 
practice good medicine.  

Mo

Phil,
Glad you asked! The recommendation of our state trauma system, backed up by
the surveyors that surveyed this facility (Trauma Program Manager at a large
Level 1 Center and Chief of Trauma Surgery at large University operated
Level 1 center), is that every trauma patient receive a minimum of UA, Tox
screen, Etoh, CBC, and C-spine, Chest and Pelvis plain films. Our policy is
that any level II activation (which this patient was) have a CBC, Chem 12,
Etoh and UA and a chest xray with any other exam or injury specific
diagnostics added. This policy was formulated at the request of the Trauma
Medical Director and his associates, because they were getting activated by
the ED physicians and the diagnostics they wanted were not completed when
they arrived. One of the trauma surgeons has stated "a trauma surgeon should
never ever be called for blunt trauma without a chest film being done". The
ED doc felt that he was saving the patient money by not ordering these
tests. While I agree that these may be unnecessary all the time at this
point our system is to do them. It's much easier to defend an action that
followed protocol than to defend one that didn't. 
I am also not sure that everytime a new study is released that we should
believe it's gospel and start zealously following it. How many times have we
discontinued a practice based on study results only to have another study a
few years later that says oops, we were wrong first study was flawed.
REM

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of P. Hoffman
Sent: Wednesday, April 06, 2005 3:53 PM
To: Trauma & Critical Care mailing list
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

Rick,

Maybe I am getting too specific for this list, but can you help us to
understand why your protocol required the lab tests and the x-rays, yet the
physician did not feel that they were warranted.

Is this a CYA mentality on the part of the SYSTEM under which you operate?
Are there sound medical reasons for each of these tests for every trauma
patient? Did the physician (ER Doc) have a brain-fart and he/she should
have requested these tests? Does the hospital generate additional revenue
by having unnecessary tests performed, thus increasing health care costs for
the rest of us...

I'm not attacking you personally. Just curious about the SYSTEM.

Phil Hoffman
EMTP

-----Original Message-----
From: Moore Rick [mailto:Rick.Moore at TriadHospitals.com]
Sent: Wednesday, April 06, 2005 4:28 PM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

Thanks for the replies. Let me clarify a couple of points then I'll move on.
No, nurses don't get sued a lot for what doctors do, but I have been close
to 3 law suits over the years that occurred even though the involved
physicians and facilities were using "sound evidence based practice" Two of
them were settled out of court at the insistence of the physician's and in
one case the hospital's insurance carrier. One of the cases involved 2
doctors, the hospital and the county ems. The insurance provider for the
hospital and the EMS (both county owned) insisted on and did settle out of
court. 1 week later a District Court Judge dismissed the lawsuit against the
physicians and commented that it was a shame that the hospital and EMS
settled because the suit did not have any merit.
As far as telling surgeons what to do, no I don't. I did however draft and
put into operation protocols dealing with Trauma Patients. These protocols
had to comply with State guidelines and in many cases mirror the ACS COT.
All of these were approved by a very supportive TMD, Medical Executive
Committee and Board of Trustees. But that still doesn't stop physicians from
trying to get around them. I had to insist just today that the ED doc,
follow protocol and order a set of lab and x-ray on a trauma patient. I
might add that this is the ED Medical Director who also signed off on the
trauma protocols. When we are surveyed for designation the surveyors spend
less than two hours with the TMD and the rest of the day with me. During the
time with me they review charts and point out what the PI process didn't
handle to their liking (even though all the reviews we had conducted were
according to our policy). My point, our State Health Department and ACS
dictate or suggest the protocols we follow. I have never developed a policy
or protocol that didn't directly correlate to a state or ACS guideline.
My ultimate point here is this: We shouldn't berate, degrade, humiliate or
diminish the views of those who are only trying to operate within the system
that they have in their area of practice.
I practice in Texas and wouldn't dream of telling someone in Maine that
following their local standard of practice was inappropriate.
Thanks,
REM

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Green, Brian
Sent: Wednesday, April 06, 2005 1:16 PM
To: Trauma & Critical Care mailing list
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

Never been sued. Never seen it successfully happen when a doctor is using
sound evidence based practice either - but perhaps I am living in the land
of make-believe. (As a side note, we do not give steroids either.) The law
suit argument bewilders me. It's a definite shame that some practice solely
based upon the fact that some yahoo ambulance chasing lawyer scum-bag has
the potential to ram a BS law suit where the sun doesn't shine.

I thought that the essence of sound medical practice was utilizing evidence
based medicine to GUIDE what we do. Some choose to be current, others are
stuck in the sixties.

As for nurses dictating how a surgeon practices, I think this argument is a
bunch of horse pucky - as a TPM I do write protocols and see to it that
issues are brought forth as needed in conjunction with a very supportive
TMD, but I definitely do not dream things up out of my own craziness and
shove them done the throats of surgeons who have considerable more
responsibility and education that I. The statement made previously in this
regard quite frankly gives me chest pain.

Regards,

Brian J. Green RN, BSN, CEN
Trauma Program Manager
Trauma Surgery
St. John Hospital and Medical Center
313 343 7309

-----Original Message-----
From: Robert Smith [mailto:rfsmith at interaccess.com]
Sent: Wednesday, April 06, 2005 2:01 PM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

Rick,

I think you are making a good point. In your job as TNC, you are not in a
position to change this practice. You can speak up at every opportunity, try
to bring the science to people's attention etc. But if you are not getting
support in this from you Trauma Director, Director of Nuerosurgery, Director
of Orthopedics then you're stuck.

As an aside, I'm curious about the lawsuit thing because it seems nurses
often bring this up. Do nurses really get sued a lot for things doctors do
or write for?

Rob Smith, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Moore Rick
Sent: Wednesday, April 06, 2005 1:51 PM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

As a Trauma Nurse Coordinator, I am charged with writing the protocols that
lead our trauma care. I am charged by our state oversight agency and the
American College of Surgeons to have these protocols established and
followed. It is also my job to see that they are addressed in Trauma PI and
action taken when not followed. In my last designation survey one of the
listed weaknesses is that our PI program is not "hard enough" on the
surgeons that don't follow protocols. I don't agree with them all, but I
have to do my job. I don't know how many times when questioning a protocol
or directive from the state, I have been told, "look at the gold book" or
"It's ACS Standard". If Dr. Frykburg and Dr. Gross have so much time on
there hands that they can write these long messages that degrade and call to
task the Surgeons and nurses that follow protocol as directed, maybe they
can work with ACS or the state health departments and get things changed the
way they want them. I noted that when asked why if it was bad practice, did
ACS approve it, that Dr. Frykburg didn't answer that question. Then again, I
am guessing there is a reason that the rest of the trauma world isn't
practicing under those guidelines. Let's stop harassing each other for
practicing as close to "national standard" or "local standard" as possible.
Not everyone has the time or energy to "push back when pushed". Like it or
not, we are bound by this until a national change takes place. Push back or
not, ultimately our fate lies in the hands of 12 people who couldn't get out
of jury duty and that's if the malpractice carrier doesn't insist on
settling just to make it go away.
I am sure this post will receive many negative posts in return and I expect
that. I am not sure that when our colleagues ask for guidance or explain why
they operate the way they operate that "There is so much baloney in that
statement that I am chocking on it" is an appropriate and professional
response.
Rick Moore, RN

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Green, Brian
Sent: Wednesday, April 06, 2005 12:16 PM
To: Trauma & Critical Care mailing list
Subject: RE: Steroids Protocols, QA, Pressure, NEED ADVICE

Yikes.

Brian J. Green
Trauma Program Manager
Trauma Surgery
St. John Hospital and Medical Center
313 343 7309

-----Original Message-----
From: Andrew J Bowman [mailto:sumieb at compuserve.com]
Sent: Wednesday, April 06, 2005 1:09 PM
To: Trauma & Critical Care mailing list
Subject: Re: Steroids Protocols, QA, Pressure, NEED ADVICE

I am a nurse that chairs our trauma committee and I only write protocols
that affect nursing. I do not, and would not dream, of writing protocols
that affect physicians practice.

Andrew Bowman

The nurses on the trauma services basically write the "best practice"
practice guidelines after they return from their national meetings and we
must abide by the protocols or be called for violations by the trauma
committee, the hospital QA committee, and even sentinel event committee.

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We need help, not speeches - Please ACS