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Wed May 18 16:23:21 BST 2005

In fact, not one of the settings mentioned so far was there any validity in the assertion of possible benefit--seeing blood in an unstable patient is NOT of any use in prehospital--it is the instability that determines decision, NOT the blood or no blood in the abdomen--same vice versa for a stable patient--if I missed some circumstance you think is valid, please explain to us how in the world there is benefit?  
ERF 

-----Original Message-----
From: Lorick Fox, PA-C <Lorick at Lorick.org>
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Sent: Wed, 18 May 2005 17:56:15 +0300
Subject: RE: prehospital FAST

Whoa, folks...

No one that I've read here said pre-hospital FAST was a GOOD idea....or a better idea than 100 other cheaper gadgets.  I saw the (mil spec) FAST units that are in Iraq, and when they told me the price, I about fell over, remembering the comments about pre-hospital units thinking about them.

Several folks on this list, however, asked, "What possible use can they be?".  Several of us have answered that question. It COULD be useful in a (very) few settings, but none of the folks posting have even implied that anyone should go out and buy one for their ambulance.
Let's separate an academic exercise "What good could it be?" from the underlying question "Do you think pre-hospital providers should all have FAST?"
Nobody NEEDS it, a few units might provide better patient care with it, and even fewer can afford it.

Lorick

At 10:40 AM 5/18/2005 -0400, you wrote:

-----Original Message-----
From: paul.middleton [ mailto:paul.middleton at usa.net] 
Sent: Wednesday, May 18, 2005 8:59 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: prehospital FAST

"I have to agree with Tim here, and despite the potential need to urine test
me for saying this, I think that to totally deny any prehospital value in a
portable, relatively lightweight, relatively simple diagnostic device is to
display this list's USA-centric tone at its worst."

Portable and lightweight (you forgot stylish) are no match for fragile and
expensive, which are more relevant concerns when purchasing a sexy new
technology with no proven (or predictably significant) benefit.  In case you
haven't got a catalog handy, the cost of a single PROBE can buy a nice used
car here in the States.  

And "simple?"  Relative to WHAT?  MRI?  Ultrasound isn't something you can
pick up and use a couple of times a year.  Without continuous training and
practice, the sensitivity and specificity of prehospital ultrasound will
rapidly approach that of a Ouija Board.  Diagnostic ultrasound in trauma,
inappropriately applied, executed, or interpreted, will completely screw
your triage process.  Bet on it.

BTW, if I'm the one you think is USA-centric, you must be new to the List,
or anesthetized.  I'm about three emails away from a late-night flight to
Guantanamo Bay.

"Despite what I am sure are a profusion of impeccable academic pedigrees, I
would ask the list members to consider the simple truism that current lack
of evidence does not mean there is no evidence to be found. The systems in
place in much of the world do not include trauma centres, or even hospitals
containing experienced trauma surgeons waiting poised at the door of the ED.
The possible value of pre-hospital FAST to triage patients to the
appropriate facility, with someone waiting who has at least seen a trauma
patient before, should not be so glibly dismissed out of hand by list
members who are often conspicuous by their intelligent and incisive
comments, or even by those who may be conspicuous for the opposite."

Glib, schmib.  

Think about what you're asserting here: that your rural community medical
resources are too inexperienced or incompetent to manage the ABC's of
trauma, so the solution is to comprehensively train and equip a diffuse and
exponentially larger array of scene responders in sophisticated medical
imaging to compensate.  Furthermore, you're conveniently assuming that
sophisticated medical imaging--even perfectly applied--is likely to
significantly improve on more mundane triage criteria.  Expect
disappointment.   

"New South Wales (in Australia for those who don't know) is not the Third
World. It boasts an enviable network of tertiary referral hospitals with all
conceivable medical and surgical specialities, one of the largest (the
largest?) ambulance service in the world, and helicopter and fixed-wing
retrieval services to bring patients in from a largely deserted land mass
approximately the size of North America. Yet even in a tertiary referral
hospital not too far from home for me, the surgical response to a trauma
call is a registrar (general surgical trainee of varying experience) who
although often full of self-importance is far less often full of knowledge
or experience. To think one could persuade a consultant (attending) surgeon
to actually be regularly present in the hospital out of hours, let alone
respond to a trauma call, really is displaying the need to be tested for
hallucinatory drugs. (As a quick example, in case the list thinks I am
exaggerating, a relatively recent trauma call resulted in a general surgical
registrar arriving to an intubated and paralysed patient with severe head
injury, unilateral haemopneumothorax, and marked abdominal bruising, pushing
his way through the trauma team (largely ED and anaesthetics), resting his
hand briefly on the abdomen and grandly declaiming that he "wasn't worried
because the patient wasn't tender!"."

This is classic: why bother with individual performance and responsibility
when we can BUY STUFF?  One surgical registrar is reliably and regrettably
inferior; but we can expect twenty rural medics to be conscientious and
proficient at an ever expanding array of complex and rarely-utilized skills?
Please.

"Although this might seem like a late night rant (and probably is to a large
extent), is it not possible that in a country as vast as Australia, without
the immediate resources of the US, techniques such as pre-hospital FAST
scanning to discover free fluid in the abdomen might result in the transport
of a patient to an institution with a competent trauma surgeon (and with
less idiots)? I think so. Have I any proof at this time - no. Might I get
some in the future - possibly. Should we dismiss it out of hand at the
moment - well I don't think so, and I would ask the list member to be a
little more inclusive in their thinking, and not quite so dismissive."

I'm NOT dismissive; I'm EMPHATICALLY SELECTIVE.  A country as vast as
Australia will spend an obscene amount of money implementing prehospital
ultrasound.  Surely there are myriad more profitable places to devote your
resources.

Pret
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Lorick

Lorick Fox, PA-C
SEAVIN/GSC
USAF Peace Vector IV
Gianaclis Egyptian Air Force Base
Gianaclis, Egypt
+(20)3-448-2335 or FAX +(20)3-448-2339
www.lorick.org

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