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Sun May 15 15:20:25 BST 2005

But that's exactly the point, Pret.  I'm not scanning
him to make myself feel better or so I can sleep with
a clear conscious.  I'm doing it because there isn't a
person practicing in medicine today who can reliably
exclude closed head injury or even neurologic decline
in a drunk with even MARGINAL (which I have wonder
about given that many of the people witnessing this
incident was as or more inebriated than himself)
mechanism.

What sort of physical signs are you expecting him to
manifest if he starts going south?  Slurred speech? 
Disorientation?  Uncooperativeness?  Motor weakness? 
Decreased level of consciousness?  Decreased
respirations? What clinical manifestation OTHER than
head injury do these symptoms mimic?  If, among the
many answers you may choose you say alcohol
intoxication, then maybe you'll start seeing my point.
 Even if you're not the one who was drinking, the
alcohol CLOUDS your judgment.  

By the time a sternal rub won't wake him, he's a GONER
and you've lost EVERYTHING.  Suddenly the
inconvenience of RSI pales to the morbidity posed by
the decompressive craniectomy and ventriculostomy he
may have just bought; a maneuver necessary now that
his brain has been insidiously subjected to the
crushing physics of the Monro-Kellie doctrine during
the hours spent "conservatively managing" his problem.
 Which ultimately is just waiting for him to sleep it
off, no?  

Oh yeah, let's not forget to mention his bright future
as a vegetable or an organ donor; a fate which might
well have been avoided if his injury had been detected
earlier.

Risk versus benefit, folks.

Ben Reynolds, PA-C
Pittsburgh, PA

--- "p.bjorn" <p.bjorn at netzero.net> wrote:
> Before this is over, I'll need a CT for pounding my
> head against the wall,
> and intubation for going blue in the face. 
> Nonetheless, I'm gonna try this
> one more time...
> 
> Your justification for paralyzing and intubating
> this guy is that he
> *desperately* needs a CT; but the fact that you NEED
> to paralyze and
> intubate him is completely due to his undeniably
> decent neuro function.  A
> guy can get vertigo just thinking about it.
> 
> So: you're intubating based on a) mechanism of
> injury--which is close to
> nil--and b) the paranoid belief that there's
> something in his head to
> operate on, which his clinical findings conclusively
> prove that there isn't,
> at least yet.  No matter how this plays out, you're
> going to need ANOTHER
> scan before you take him to the OR, 'cause nobody's
> cutting on him just
> because his brain injury has turned him into an
> asshole: his condition will
> have to objectively worsen, and change in neuro
> function (if you can pick it
> up over the sedation and paralysis) will force
> repeat CT before anyone will
> commit to surgery.  Your ICU nurses are gonna just
> LOVE this scenario.
> 
> Where the hell are Frykberg and Mattox on this?!?
> 
> > So Gina....how do you tell when the "sleeping it
> off" has changed to a GCS
> of
> > <5  Guess what?    YOU CAN"T!!!  Maybe if you work
> ER with 10 visits per
> > night,but if avg 250 to 320 a day.......
> 
> Well, cripes, Statman, do neuro checks q15 to 30,
> and the minute he snores
> through a sternal rub, slide him through the
> scanner.  You've lost NOTHING,
> you haven't endangered the patient, and you haven't
> set a precedent for
> turning ornery old men into critical care cases. 
> RSI and CT aren't going to
> change his plan of care (other than to complicate
> it); and they certainly
> aren't going to protect his survival probability.
> 
> I just want to hear ONE of you admit that you want
> the scan so that YOU can
> feel better.  That's what this is all about, isn't
> it?
> 
> Pret
> 
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