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article in the may issue of "Annals of Emergency Medicine"

claudia glamourcv at gmail.com
Sat Apr 22 06:49:36 BST 2006


I am interestingly keeping track of all this discussion.
I will dare to make some comments...

(1) As you all might know, I live in a country where in some parts
there are large areas of dense  amazonic forest., with scarce
inhabitants. There,  trauma patients are lucky if there is a nurse to
attend them.... A doctor is worth his weight in gold... a SURGEON is
something that most of them dream of, but will probably spend their
lives without seeing one :-)) The next trauma facillity is many, many
,many miles away - and material resources are as scarce as skilled
health care practitioners.

Sorry to say that, but in this kind of reality, the best has to be
done to achieve a minimum quality of care without a surgeon, and keep
the emergency surgical cases at the rare health care facillities
stable until a surgeon is reached. If we don´t manage to get it done
without a surgeon, lives will certainly be lost. So, should evidence
arise that surgeons on arrival enhance survival chances, some B plan
will immediately have to be conceived in order to save lives in places
where we don´t have surgeons available...just let me know, when any 
of you decide to start it, I will be happy to make contributions :-))

(2) 80% of all medical knowledge is devoid of cartesian evidence. Many
routine procedures which are well known to save lives could not be
proved through cartesian scientific methods - only to mention one -
the effectiveness of parachute use to prevent lesions with an injury
score > 15 and death from free fall.
nevertheless, if I ever drop from an airplane, I would really prefer
to do it with a parachute hehehe
http://bmj.bmjjournals.com/cgi/content/full/327/7429/1459
The same can be said about real trauma - if I ever get a severe
politrauma - I´d rather have an intelligent (remember - an
intelligent...) surgeon to fix me at the front door, please, but I
understand that the cost effectiveness of this procedure is yet to be
proved. No problem - 80% of what I do falls exactly in this same
classification.

;-)

claudia

(already with a bullet proof vest and helmet...)






On 4/21/06, Gunn, Scott <gunnsr at ccm.upmc.edu> wrote:
> Well said.  It is the responsibility of the proponents of this system to
> prove its usefulness.
>
> S
>
> Scott Gunn, MD
> Medical Director, Surgical Trauma Intensive Care Unit
> Department of Critical Care Medicine
> University of Pittsburgh Medical Center
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org on behalf of paul.middleton
> Sent: Fri 4/21/2006 9:56 PM
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: article in the may issue of "Annals of Emergency Medicine"
>
>
>
> Oh... the American College of Surgeons saying that surgeons are essential...
> how surprising! :-) (The smiley face indicates gentle humour, which you
> obviously didn't realise from the last post).
>
>
>
> As you seem determined to be confrontational, let me try once again to
> explain something to you that has been attempted many times before on this
> list, although if previous threads are any evidence, the US trauma surgical
> fraternity seem to be impervious to the concept of understanding even the
> existence of any system other than their own...
>
>
>
> In many countries, in fact by far the majority, trauma centres such as you
> have there in the USA JUST DO NOT EXIST, or at best there may be only two or
> three per country!! There often are just no hospitals with dedicated trauma
> teams that even include, let alone are led by or composed of trauma
> surgeons. Regarding your fatuous comment about making some choice to take my
> family to an institution where the surgeons are on call from home, just try
> for a moment to think outside the box you are in and imagine living in a
> country (and I am talking about first-world places like the UK, Australia,
> New Zealand and many others) where THE ONLY CHOICE is a hospital with this
> arrangement. When you say they shouldn't be seeing trauma patients, then
> where should they go? I'll just have a chat to ambulance control here in
> Sydney shall I, and ask them to divert to Houston, New York, Boston.?
>
>
>
> And trying for a moment to disregard your lack of collegial respect for
> another, often similarly experienced and knowledgeable group of
> professionals, and to explain some simple facts a little more clearly for
> you, in most of the world it would NOT BE YOU standing over the patient
> "taking care of them from the minute they hit the door" it would be the
> emergency physician. And often it is THEIR years of experience in dealing
> with major trauma, not "scrapes, contusions and isolated broken bones" that
> allows them to diagnose underlying pathologies, assess those who need
> intervention and then persuade reluctant non-trauma surgeons to intervene.
> You may have to be a surgeon to treat surgical disease, but you do not have
> to be a surgeon to diagnose surgical disease, and to assume that training in
> wielding cutlery confers some extraordinary added ability to read, learn,
> practice and apply knowledge to perform the process of diagnosis is
> condescending, arrogant and obtuse.
>
>
>
> As I have no copy of the May issue of J Trauma as yet, and it is not
> available electronically, I have not had a chance to read the offending
> article, but one thing does spring to mind. The abstract provided by the
> list member stated that "There is not compelling evidence to support the
> assumption that trauma outcomes are improved by the routine presence of
> surgeons on patient arrival". It seems to me that what is therefore needed
> is to show this evidence exists.
>
>
>
> Ken Mattox said "I would be honored and delighted to respond to each of
> these comments, when the evidence to support these statements is produced.
> My impression, as weak as it might be is just the opposite". If I may
> paraphrase what Eric Frykberg is so fond of saying on this list, it is not
> up to any scientist to disprove the utility or efficacy of an intervention,
> including the presence of trauma surgeons on arrival of a patient, it is up
> to the proponents of the intervention to show its benefit. So rather than
> falling back on more Eminence Based Medicine, I look avidly forward to being
> shown the references for those well designed, controlled, hopefully
> randomised, well-powered studies that prove the point at question.
>
>
>
> Let's also see if we can indulge in this discussion without further
> disrespect to others (although again, rudeness seems to be an acceptable
> standard on here so I have little hope)!
>
>
>
> Paul
>
> :-) (Smiley face again - it means I'm still smiling at least!)
>
>
>
>
>
> Dr Paul M Middleton
>
> RGN MBBS FRCS(Eng) DipIMCRCS(Ed) FFAEM FACEM
>
>
>
> Emergency Physician
>
> Sydney
>
> Australia
>
>
>
>
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of JonWalsh at borgess.com
> Sent: Saturday, 22 April 2006 9:29 AM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: article in the may issue of "Annals of Emergency Medicine"
>
>
>
> And I make no apologies for my 'surgical perspective' as I AM the one
> standing over these patients taking care of them from the minute they hit
> the door. If there are, in your area, "many places" where surgeons aren't
> willing to make the commitment to the critically injured patient, then those
> facilities shouldn't be seeing 'trauma patients'.... Trauma (true trauma,
> not scrapes, contusions and isolated broken bones) is a SURGICAL disease.
> This nonsense of "studies" not showing the 'value' of an experienced surgeon
> using their years of judgement to optimize the full outcome of a true trauma
> patient is because of the near impossibility of doing a "study" with this
> kind of patient. If you believe trauma surgeons add no value to the initial
> care of the trauma patient,then 1) go convince the ACS COT who continue to
> see the 'immediate availability' of a surgeon as ESSENTIAL to Trauma Center
> verification, and 2) be sure to take your family to a 'trauma center that
> has surgeons taking call from home.... And if you would do that, I feel very
> badly for your family....
>
>
>
> Jcw
>
>
>
>
>
>
>
>
>
>
>
> ----- Original Message -----
>
> From: trauma-list-bounces
>
> Sent: 04/21/2006 07:01 PM
>
> To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
>
> Subject: RE: article in the may issue of "Annals of Emergency Medicine"
>
>
>
> Just the kind of response I would expect from a surgeon...unfortunately in
>
> many places they're just not there themselves for the ruptured spleen or
>
> open book fracture...and if they are they can't make up their minds!!
>
> :-)
>
>
>
>
>
> Paul
>
> Emergency Medicine
>
> Sydney
>
> Australia
>
>
>
>
>
> -----Original Message-----
>
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
>
> On Behalf Of JonWalsh at borgess.com
>
> Sent: Saturday, 22 April 2006 3:57 AM
>
> To: Trauma &amp; Critical Care mailing list
>
> Subject: Re: article in the may issue of "Annals of Emergency Medicine"
>
>
>
> Just the kind of article I would expect from an EM physician....
>
> Tell them good luck with the next pt with a ruptured spleen or open book
>
> pelvic fx....
>
> Jcw
>
>
>
>
>
>
>
>
>
> ----- Original Message -----
>
> From: trauma-list-bounces
>
> Sent: 04/21/2006 01:20 PM
>
> To: "'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
>
> Subject: article in the may issue of "Annals of Emergency Medicine"
>
>
>
>
>
> Dear list-members,
>
> Recently I've read postings about the need for trauma surgeons with
>
> education
>
> that will enable them to deal with trauma patients without the need for
>
> physicians from other specialties. In the May issue of the Annals of
>
> Emergency
>
> Medicine S.M. Green writes, if I've correctly understood,  that there is no
>
> proof that the routine presence of surgeons in the ER when trauma patients
>
> arrive is beneficial. I've brought you the abstract and wonder what the
>
> trauma
>
> masters think about it.
>
> Eli Alkalay
>
> Rural Family Physician
>
> Moshav Herut
>
> Israel
>
>
>
>
>
> Annals of emergency medicine -may 2006
>
>
>
> Is There Evidence to Support the Need for Routine Surgeon Presence on Trauma
>
> Patient Arrival?
>
> Steven M. Green MD ,
>
>
>
> The trauma center certification requirements of the American College of
>
> Surgeons
>
> include the expectation that, whenever possible, general surgeons be
>
> routinely
>
> present at the emergency department arrival of seriously injured patients.
>
> The
>
> 2 historical factors that originally prompted this requirement, frequent
>
> exploratory laparotomies and emergency physicians without trauma training,
>
> no
>
> longer exist in most modern trauma centers. Research from multiple centers
>
> and
>
> in multiple varying formats has not identified improvement in
>
> patient-oriented
>
> outcomes from early surgeon involvement. Surgeons are not routinely present
>
> during the resuscitative phase of Canadian and European trauma care, with no
>
> demonstrated or perceived decrease in the quality of care. American trauma
>
> surgeons themselves do not consistently believe that their use in this
>
> capacity
>
> is either necessary or an efficient distribution of resources. There is not
>
> compelling evidence to support the assumption that trauma outcomes are
>
> improved
>
> by the routine presence of surgeons on patient arrival. Research is
>
> necessary
>
> to clarify which trauma patients require either emergency or urgent unique
>
> expertise of a general surgeon during the initial phase of trauma
>
> management.
>
> Individual trauma centers should be permitted the flexibility necessary to
>
> perform such research and to use such findings to refine and focus their
>
> secondary triage criteria.
>
>
>
>
>
>
>
> ----------------------------------------------------------------
>
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>
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