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Sat Apr 8 13:41:04 BST 2006

Ahhhh...this argument always manages to rear its ugly head at some point--
"Well, you know, evidence is fine, data-based medicine is fine, until, that is, that is fails to support something that I just want to do--then....MY own imagination and what I think sounds logical  prevails"
Remember just 250 years ago this same argument was used for bloodletting--perfectly logical to everybody, lets out the evil humors, plenty of anecdotal cases of how people suddenly felt better, etc--who needs data for such OBVIOUSLY beneficial intervention?  Then the data came out, and guess what--not only no benefit, but it KILLED!  Same with electro-shock Rx, frontal lobotomy--without a QA process applied, any interventio is DANGEROUS until PROVEN otherwisw--why?  Because THAT, not the opposite, is what is SAFEST for the patient.
And we think witch doctors were only a thing of the past.....
ERF 

-----Original Message-----
From: Mike MacKinnon <mmackinnon at cox.net>
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Sent: Fri, 7 Apr 2006 20:25:42 -0700
Subject: Re: Clamp the the chest tube?

Hey Dr. KM

No data to my knowledge. However, just because something hasn't been studied
doesn't mean it has no empirical benefit (i.e.: the classic parachute
example). 

The procedure is utilized in air med for the same reasons (more stringent I
would suggest) as in the trauma room. Patient in extremis with clear chest
tube indication and long transport times. I can tell you, no more than 1-2
of these are done a year at my service and everything done is reviewed by
our 4 med directors and the receiving trauma surgeon. While there is no data
 I would suggest that with those two groups in agreement that the patient
needed a chest tube and it was justified that there is oversight and control
in regards to such a high risk procedure. 

Really, are you suggesting you need a peer reviewed study to show indication
for a procedure that is a "no brainer" and clinically driven in the trauma
room? The indications for air med are few and far between for chest tubes
(much less than in the trauma room).    

In anycase, here are three studies which I found after a quick search.

Prehosp Emerg Care. 2005 Apr-Jun;9(2):191-7. 

The safety and efficacy of prehospital needle and tube thoracostomy by
aeromedical personnel.

Davis DP, Pettit K, Rom CD, Poste JC, Sise MJ, Hoyt DB, Vilke GM.

Department of Emergency Medicine, UCSD, San Diego, CA 92103, USA.
davismd at cox.net

BACKGROUND: Aeromedical crews routinely use needle thoracostomy (NT) and
tube thoracostomy (TT) to treat major trauma victims (MTVs) with potential
tension pneumothorax; however, the efficacy of prehospital NT and TT is
unclear. OBJECTIVES: To explore the efficacy of aeromedical NT and TT in
MTVs. METHODS: A retrospective chart review was performed using prehospital
medical records and the county trauma registry over a seven-year period. All
MTVs undergoing placement of NT or TT by aeromedical personnel were included
 patients with incomplete data were excluded. Descriptive statistics were
used to report the incidence of air release, clinical improvement (improved
breath sounds or compliance if intubated, decreased dyspnea if nonintubated)
 and vital signs improvements (systolic blood pressure [SBP] increase to =90
mm Hg or increase by 5 mm Hg if < 90 mm Hg; heart rate improvement to 60-100
beats/min, increase by 10 beats/min if < 60 BPM, or decrease by 10 beats/min
if > 100 beats/min; oxygen saturation increase if < 95%) for both NT and TT
as documented in prehospital medical records. Survival and improvement in
SBP based on trauma registry data were recorded for patients stratified by
initial SBP. RESULTS: A total of 136 procedures (89 NTs and 47 TTs) in 81
patients were identified using prehospital medical records over a four-year
period. Response rates to NT (60% overall, 32% vital signs) and TT (75%
overall, 60% vital signs) were high. Vital signs improvements were observed
more often in patients with a pulse and in nonintubated patients. A total of
168 patients were identified in the trauma registry over the seven-year
study period. Normalization of SBP was observed in two-thirds of patients
with a field SBP = 90 mm Hg and one-third of patients in whom field SBP
could not be obtained. A small but significant proportion of patients
undergoing prehospital NT and TT, including some with prehospital
hypotension and high injury severity, survived to hospital discharge. The
incidence of complications was low. CONCLUSIONS: Aeromedical crews appear to
appropriately select MTVs to undergo field NT or TT. A low incidence of
complications and a small but significant group of unexpected survivors
support continued use of this procedure by aeromedical personnel.

J Emerg Med. 1995 Mar-Apr;13(2):155-63. 

Prehospital needle aspiration and tube thoracostomy in trauma victims: a
six-year experience with aeromedical crews.

Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P.

Department of Emergency Medicine, University of California, San Diego
Medical Center 92013-8676, USA.

The use of prehospital tube thoracostomy (TT) for the treatment of suspected
tension pneumothorax (TPtx) in trauma patients is controversial. A study is
presented that reviews a 6-year experience with the use of needle catheter
aspiration (NA) and chest tubes performed in the field by air medical
personnel. Prehospital flight charts and hospital records from 207 trauma
patients who underwent one or both of these procedures in the field were
retrospectively reviewed. The clinical indications used to determine
treatment are presented for both procedures. Improvement in clinical status
of patients observed by flight personnel were similar for both treatment
groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had
failed NA attempts prior to chest tube placement. Average time on scene (T.O
S.) was significantly greater for the TT group (25.7 min versus 20.3 min for
NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT
treatment compared to NA alone (7% versus 19%, respectively). Injury
severity scores, number of hospital complications, length of stay (L.O.S.),
and total hospital costs were not different between the two groups. There
were no cases of lung damage or empyema formation associated with
prehospital TT treatment. Overall mortality was similar for both groups.
>From these data, we conclude that NA is a relatively rapid intervention in
the treatment of suspected TPtx in the prehospital setting; however, TT is
an effective adjunct for definitive care without increasing morbidity or
mortality. A better understanding of the physiology of intrapleural air
masses is needed to determine the most effective decompression requirements
prior to aeromedical transport.

J Trauma. 2005 Jul;59(1):96-101.

Prehospital chest tube thoracostomy: effective treatment or additional
trauma?

Spanjersberg WR, Ringburg AN, Bergs EA, Krijen P, Schipper IB.

Department of General Surgery and Traumatology, University of Rotterdam,
Erasmus Medical Center, The Netherlands.

BACKGROUND: The use of prehospital chest tube thoracostomy (TT) remains
controversial because of presumed increased complication risks. This study
analyzed infectious complication rates for physician-performed prehospital
and emergency department (ED) TT. METHODS: Over a 40-month period, all
consecutive trauma patients with TT performed by the flight physician at the
accident scene were compared with all patients with TT performed in the
emergency department. Bacterial cultures, blood samples, and thoracic
radiographs were reviewed for TT-related infections. RESULTS: Twenty-two
patients received prehospital TTs and 101 patients received ED TTs. Infected
hemithoraces related to TTs were found in 9% of those performed in the
prehospital setting and 12% of ED-performed TTs (not significant).
CONCLUSION: The prehospital chest tube thoracostomy is a safe and lifesaving
intervention, providing added value to prehospital trauma care when
performed by a qualified physician. The infection rate for prehospital TT
does not differ from ED TT.

Mike M.

-------Original Message-------

From: KMATTOX at aol.com

Date: 04/07/06 20:02:20

To: trauma-list at trauma.org

Subject: Re: Clamp the the chest tube?

In a message dated 4/7/2006 10:00:15 P.M. Central Standard Time,

mmackinnon at cox.net writes:

Happens all the time Dr. Mattox. Long transport times where  patients are

severly injured and need a completely justifiable chest  tube.

True true and unrelated.    Show me the  data.   I know of no good data
which

has been peer reviewed by the  Trauma service in critique of flight services

  Flight services  procedures are among the most out of control of any in

medicine.

k

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Clamp the the chest tube?