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Tue May 24 16:47:53 BST 2005

There is a bit of a misconception in this post, Bill--FAST is not meant to find organ or vascualr injury.  It is only meant to screen for fluid in the abdomen, and in some hands look for PTX--attributing capabilities to it that were never meant to be is flawed.  You can't criticize a diagtnositic modlaity for something it is not meant or capable of doing.  Splenic pseudoaneurysm in fact is not something that you can reasonalby expect to find on the level of screening that is currently standard of care--you would have to CT everybody, including a lot of asympotomatic people for this to have shown up, and this is far from being any kind of accepted standard.  some injuries are so raree and undetectable they will just be missed--of course your lawyers would love to propagate the myth that everything shyould be found with 200% success rate, but this is not true--in their profession as well.  This CANNOT be blamed on inadequacies of FAST--only on the inadequacy of those misapplying or misinterpreting it.  In fact, you may recall that Grace Rozycki made this very observation in her discussion of the paper on this issue from Mike Pasquale at Allentown at the AAST in 2002, titled Not So--FAST 
 ERF

-----Original Message-----
From: William Bromberg <brombwi1 at memorialhealth.com>
To: trauma-list at trauma.org
Sent: Tue, 24 May 2005 11:01:03 -0400
Subject: RE: pre hospital fast reply to K and ERF

Tim,

Thanks for your reply. In my training program (Lehigh Valley Hospital, Allentown 
PA) we were trying to cut down on the negative CT rate by using serial FAST 
exams but had a similar single patient experience. Post trauma day 2 
suddenshock--> hypotension --> OR where we found a ruptured splenic artery 
aneurysm (P3G3 34 year old). Sadly she had significant anoxic injury and died. 
The lawsuit is ongoing and the argument is of course "If you'd used CT you 
would've found it." Based on this single case if you are standing near someone 
who was in an accident you get a CT if you show up in the ED. Sadly It just 
doesn't seem worth the legal risk in this resource rich, lawyer rich (?) 
environment. 

Yes, before VOMIT syndrome is mentioned I do know there are risks to over CT'ing 
(false positives, ? future risk of lymphoma). It's just that AFAIK you usually 
don't get sued for sins of commission.

Regards,
Bill

>>> tch at sun.ac.za 05/24/05 09:38AM >>>
Bill

Can't give you numbers, but it is low in our center's experience, those who have 
a negative FAST are followed clinically for signs of bowel injury - the only 
thing FAST may "miss" (due to minimal intial fluid) that CT may also miss. We 
increase the sensitivity with repeat FAST on all initially normals at 6 - 12 
hours post admit. I can only think of one case in the last 6 months (unit sees 
some 900 trauma laparotomies per year) where we had a rebleed from a splenic 
injury on day 7, where the initial sonars were normal, and patient's haematocrit 
fell suddenly after being stable from admission to day 6; therefore probably a 
"clot-lysis" bleed. He probably did not have a major bleed initially, therefore 
FAST negative, was stable despite injury till rebleed some 6 days later. This 
would have been avoided if there was a CT - but we have to be selective given 
our scant resources.

Tim

-----Original Message-----
From: William Bromberg [mailto:brombwi1 at memorialhealth.com] 
Sent: Monday, May 23, 2005 3:00 PM
To: trauma-list at trauma.org 
Subject: RE: pre hospital fast reply to K and ERF

Tim,

Just a quick question. Have you guys looked at the"clinical"  false negative 
rate for FAST alone? By that I mean the number of people that need an abdominal 
operation even though they have a negative FAST. I haven't seen that published.

Bill Bromberg

William J. Bromberg
Savannah Surgical Group
912 350-7412

>>> tch at sun.ac.za 05/23/05 01:16AM >>>
Rick

Here again is a perspective from the other side of the world - i.e. not the U.S. 
environment. WE will Ultrasound all neurologically impaired trauma patients - 
stable or not, as a determinator for the need for CT abdom, since we don't have 
ready access to it like you guys. We have both lack of CT numbers and vast 
distances so a negative FAST would enable the patient to remain under the care 
of the generalists if the CT head (in our scenario easier to obtain / quicker 
and uncontrasted - thus done by a tech not a radiologist, therefore available in 
some of the regional smaller hospitals after hours) is normal and only shows 
non-surgical pathology.

Again this is OUR environment and should not be generalised to the entire world.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
General Surgeon (Trauma and ICU)
ATLS and DSTC instructor
Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (U.S.)
Operational Head: Diana Princess of Wales Trauma Unit
Department of Surgery Room 4064
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa

2 Lorient Close
Vredekloof, Brackenfell
7560, Western Cape,
South Africa
e-mail: tch at sun.ac.za 
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302
Home: +27219813098

-----Original Message-----
From: docrickfry at aol.com [mailto:docrickfry at aol.com] 
Sent: Friday, May 20, 2005 4:16 PM
To: trauma-list at trauma.org 
Subject: Re: pre hospital fast reply to K and ERF

Ahhhh....your last sentence says it all--thank you.  Thus, the US has made no 
difference in your care of the patient.  You never answered 2 questions tho--
Why would you FAST a stable patient, and how in the world would THAT be of 
benefit preshospital?
What is the design of your study to show its use prehospital has BENEFIT, rather 
than that it can be done?
ERF 

-----Original Message-----
From: Ronald Gross <Rgross at harthosp.org>
To: trauma-list at trauma.org 
Sent: Fri, 20 May 2005 07:16:40 -0400
Subject: Re: pre hospital fast reply to K and ERF

Oh come on Ken.....if the radiologist tells you that the CT shows a gangrenous 
gall bladder in a septic patient, are you going to repeat the CT yourself before 

you operate?  Au contraire - the surgeon will do the physical exam, correlate 
the patient's condition with that exam and the other ancilarry tests done (BY 
OTHERS) and make the decision to operate with all of that information in hand.  
If I have an unstable patient in flight, and a WELL-TRAINED ultrasonographer has 

told me that I have a belly full of blood, I am going to book that OR.  Whether 
I go directly to OR will depend on the patient'c condition on arrival to the ED.
Ron

>>> KMATTOX at aol.com 5/19/2005 10:31:43 PM >>>

In a message dated 5/19/2005 6:38:59 P.M. Central Standard Time,  
kenh at careflight.org writes:

One  of  the spin offs of this is that we are also taking a  simple
ultrasound  machine with us and 2 of the trauma services at  least say they
will call in  the surgeon if we tell them the fast is  positive on the way
into the  hospital. This WILL save time to the  operating  theatre.

I seriously doubt it.     Surgeons are NOT like a lab  tech that you just 
order to do an operation based on your tests.   The  surgeon is a cognative 
being 
that makes her/his own evaluations and decisions,  and then becomes a 
technician

k
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pre hospital fast reply to K and ERF