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Needles, tubes, heroes, and boobs

bensonblues at comcast.net bensonblues at comcast.net
Sat Apr 8 18:06:10 BST 2006

Trauma victims die in spite of excellent care or as a consequence to suboptimal care, and they live as a result of excellent care or in spite of suboptimal care. Everyone in this business knows this. The presence of good and bad docs, nurses, and medics is Gaussian, and will always be. One in ten will be excellent, and one in ten will be subpar. That is the nature of things. I've been training EM docs for over a decade as a program director, coaching high level ice hockey even longer, and one thing is true: Some people are more talented than others. You can train, prod, and flog, but those without talent or those who are lazy thinkers (won't open their minds or work hard) always seem to underperform. Further, even the gifted have bad days. That's the way it is. It is our role as providers to teach each other, evaluate, remediate, and if someone just isn't getting it, we have to help them find something else to do (even if it means due process). This is how a system fixes itself. 

Needle thoracostomy? Probably a role in selected cases, but when I see them placed by the medic they tend to use too small a catheter which arrives kinked and ineffective. In the ED, I teach the residents that a tension pneumothorax is a clinical diagnosis, and the treatment is thoracostomy (making the hole); putting a tube in the hole is secondary .Clamping chest tubes? Only if you want them to die with 3 pounds of blood in their chest. I used to believe that clamping the tube to save the blood for autotransfusion was the only indication, but by the time we hung it, it had a hematocrit of 0.5%, and consisted of schizocytes, stroma and free hemoglobin. Not good for the kidneys.

Most importantly (this is for the medics and those in training): Just because you have a laryngoscope or needle in your hand doesn't mean you have to use it. Keep thinking. If the patient is holding their own during transport, you probably have time. If they get into trouble, they probably don't have much time. And sometimes, no matter what you do, they just die. As long as you can go to bed knowing you tried to do the best thing and did no harm, you can get back on the horse the next day unimpeded. If you find you've done the wrong thing (and we all have), learn from your mistake and go out of your way not to repeat it. That's all you can do. DB

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