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

JonWalsh at Borgess.com JonWalsh at Borgess.com
Sat Apr 22 18:26:52 BST 2006


Hi Paul, Charles, Claudia, Dr. M, Ron and others reading/lurking, etc...

I've had a few hours of sleep but now am back on in-house call at my 
verified trauma center which apparently is unnecessary as i'm 'just a 
wielder of cutlery'..
(did you get the sarcasm? :-) ) so...a few clarifications, corrections and 
perhaps even apologies due...

First...some email clarifications: at no time during any of my posts did i 
personally attack a poster. I've been attacked on this list before, don't 
particularly care for it, but that doesn't mean i wont engage in some 
playful banter with my colleagues (ie ALL OF YOU!), 
Second, it IS quite difficult to express intent, attitude, etc on a 
printed page, but do accept my statement that my initial salvo ('just what 
i would expect from an EM doc') was said with tongue firmly planted in 
cheek! Am i the only one who found it 'amusing' that an EM journal, 
written by an EM doc about life in the ED would have title like that! Paul 
picked up on it i think by correctly recognizing the ironic similarity to 
the american college of SURGEONS stating SURGEONS are indespensible in 
trauma centers verified by SURGEONS! :-)     Lets all lighten up and 
remember we are all intelligent colleagues here  and have some fun - - 
hasn't anyone ever attended one of Dr. Mattox's Pro/Con debates at the Las 
Vegas Trauma Conf? This is tame compared to some of the verbal jousting 
that goes on there! I would imagine if Paul and I were across a table 
instead of a computer screen, we'd both be smirking at each other's banter 
over a good pint of ale. But if anyone seriously took offense to my 
playful jab, my apologies...

Now to the topic....i was also remiss in not qualifying my statements by 
further saying that they applied to the topic of this article ONLY. That 
is, US Trauma Care. I have very little personal knowledge of international 
systems of trauma care and expect that Paul, Claudia and other colleagues 
around the world have developed systems that utilize their resources to 
the best interests of their citizens. Such is not the case in the US. As 
was pointed out, we have an enormous maldistribution of trauma resources 
across our country. And without the commitment of ALL members of a trauma 
TEAM to optimal trauma care for the patients they care for, patients die. 
Charles, I have worked in trauma centers in one of the nations largest 
city as well as one of the nations smallest on the island of Hawaii, where 
i was the ONLY surgeon, save for an OB/GYN to care for all trauma 
patients..no neurosurgeons, orthopods or other specialists. And as for 
your question of where would i rather be: big city trauma center or small 
town ED..my answer would be--it depends on the qualifications of the 
personnel at each institution...I have found both committed and uncommited 
clinicians to trauma care at both entities, so i guess i want to go where 
the staff give a darn about good trauma care. But...let's not be 
unrealistic about "stabilzation"....you can't 'stabilize' a stab to the 
heart, nor a Gr 5 splenic rupture....there are specific injuries that 
require surgical intervention RIGHT NOW....and unfortuanately, that is not 
available widely across the US. But that's NOT what this article was 
about...Trauma System design in the US is severely lacking for bringing 
optimal care to the large part of the geography that doesn't happen to 
live in the metropolitan area of a major trauma center...but that is 
fodder for another topic thread. 

This article spoke to the " 'NEED' (not clearly defined) of routine 
surgeon presence on trauma patient arrival"....and my contention was/is 
that this study did not sufficiently answer this question. Identifying the 
patient that requires emergent surgical intervention is quite difficult 
most of the time from prehospital data (in the US). When that patient is 
identified, they need surgery right now or probably more often 30 minutes 
ago. And in my opinion, the immediate presence of a surgeon for these 
'true' trauma patients, can make the difference in a patient outcome. Dr. 
Mattox stated that for these patients there is often/frequently very 
little that needs be done in the ED, and in our institution, patients 
meeting certain critical physiologic/anatomic criteria are actually 
resuscitated in the OR, which also requires the immediate presence of a 
surgeon to correctly deal with the pathology that lays before them. This 
in NO WAY, minimizes the important role of the EM physician on my team and 
we do approach these high level trauma patients as colleagues determined 
to work our butts off to help this patient survivive. But my EM docs would 
cringe at the thought of me not being there beside them when we deal with 
these patients, and i am grateful that we have EM docs who know their 
field as well as they do. But they are NOT surgeons, and I am NOT an EM 
physician. So...we work together to enhance both our strengths. 

The appropriate study, as Claudia points out, can probably not be done in 
the US. In my view, it would require each facility to be its own 
control..one week of 'immediately available surgeons", the next 
week....come when called....i sure dont want my family exposed to that...i 
want the whole team all the time!!

i'm hoping instead Paul and i might write the appropriate article for the 
Journal of Emergency Medicine, Surgery and Overall Good Care entitled: 
Optimal Teamwork Design to Enhance Patient Outcome....and my apology is to 
Paul and his family for suggesting that they couldn't get good care in a 
Trauma Center without a surgeon immediately available...that would only 
apply in the US! :-) 
So please Paul, do visit, but if you do, call me first so i can tell you 
which parts of the country will play "Trauma Russian Roulette" with you 
and your family and which parts you might find an EM doc and Trauma 
Surgeon standing shoulder to shoulder to ensure you get the best 
outcome....

jcw

Jon C. Walsh, MD, MPH, FACS
Kalamazoo, Michigan
USA





"paul.middleton" <paul.middleton at usa.net>
Sent by: trauma-list-bounces at trauma.org
04/21/2006 09:56 PM
Please respond to "Trauma &amp; Critical Care mailing list"
 
        To:     "'Trauma &amp; Critical Care mailing list'" 
<trauma-list at trauma.org>
        cc: 
        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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