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Sun May 15 14:41:17 BST 2005

Dr. Gross,

Please don't be offended; I didn't mention Drs. Mattox and/or Frykberg to
imply some special credentials.  They're just more empirically (and audibly)
averse to fruitless and unindicated diagnostics.  Nobody else comes close.

Thanks for your kind words of agreement.

Pret

----- Original Message -----
From: "Ronald Gross" <Rgross at harthosp.org>
To: <trauma-list at trauma.org>
Sent: Sunday, May 15, 2005 3:54 PM
Subject: Re: Case

Easy does it Pret - or else we are gonna take you to the OR for that
hypertensive bleed you are workin' on....
Well, I know Ken Mattox, and I am no Ken Mattox (haven't I heard that phrase
before), but I am with you all the way on this one;  a sterling model
citizen with a lovable personality, no focal neurologic findingsfindings, no
real reason to assume ICB, and NO indication to intubate just so you can do
a probable negative CT, tie up an ICU bed, stress out the nurses and RT's -
'cause he is not going to be extubated based on our usual criteria - and
spend a whole lot of time getting this all done.
Put him in a room where he can be watched - not in the back of the ED, outta
sight and outta mind - and pretend to be a real doctor.  In other words,
repeat your clinical physical exam frequently and scan him IF AND WHEN he
has any evidence of a focal finding.  I repeat that often missed term -
physical exam, 'cause it seems to have been replaced by knee-jerk legally
based paralysis and CT fairly often these days......
Motrin anyone?
Ron

>>> p.bjorn at netzero.net 5/15/2005 5:14:18 AM >>>
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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