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

Ronald Gross Rgross at harthosp.org
Sat Apr 22 11:58:18 BST 2006


It is best to have the ability to disagree without being disagreeable. 
Paul, while I may not agree with everything either of you have said, I
am glad to see that we (you) can discuss the issues without rancor -
something that is frequently seen and accepted on this site, as you have
observed.

Just one thought, however.  What we have here in the US may not exist
in other first class, first world countries because the resourses are
just not there, due to geography, population distributions, or any other
number of reasons.  My guess is that while you may not have these
resourses for whatever reason, you just might admit (to yourself, or to
all that will listen) that it would be really nice to have them.  I
don't think you will be able to find any references that cite better
outcomes with less than optimal resourses. The question is, exactly what
do you consider optimal resourses, and how does your interpretation
compare to the American version - and specifically the ACS COT version
(whether or not that organization is self-serving/selfperpetuating is a
debate I will not be drawn into here.....;-)  and I too am still
smiling.

As to the question at hand, specifically, whether the presence of the
trauma surgeon on the arrival of the severely injured patient affects
outcomes, well, I take in-house call at the age of 55 because I believe
that it does, and until someone proves me wrong, I will continue to
believe as such. 

Cheers,
Ron

>>> paul.middleton at usa.net 04/21 9:56 PM >>>
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 & 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 & 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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