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

claudia glamourcv at gmail.com
Sun Apr 23 04:01:28 BST 2006


Jon,

I guess we all agree on this website that a surgeon and an emergency
physician working  full time shoulder to shoulder together at the ED  in the
setting of severe politrauma would be the goal for all of us.This is
something that even in the US cannot be available everywhere full time.

Knowing a bit the heterogeneity of health care design in your country,
however, I imagine it will be very difficult to design a multicenter study
to address this question - on how should be the optimal composition of the
best team -   that can fit all the particular characteristics of each trauma
center.Perhaps the Annals paper´s best achievement was to show the need for
the surgeon to be there at the indicated times - as Dr Mattox stated in his
post, many times a surgeon´s presence is needed stat at the ED,  and this is
not achieved in time - and this might spoil all the work of the physicians
at the ED, leading to multiple unecessary transfusions, cyclic
hyperesuscitation and all the problems already discussed at this list.

I believe that such a paper will reflect positively also in the reality of
Third World Countries where not always( rather say - almost never...) a
surgeon is given his deserved value in the severe acute emergency care - I
mean, here - the WHOLE TEAM ALL THE TIME- is not whole - because only in a
limited number of places  a full-time surgeon is available.Almost  the same
can be said about well-trained emergency physicians - only recently the need
of such a training has started to be recognized here, and I hope that this
trend grows more and more, since violence and trauma is the leading cause of
death in my country between 18 and 35 yo.We have many distant roads in
isolated parts of the country where a minor car crash,  with minor injuries,
becomes a very serious problem because of lack of available skilled
physicians and surgeons exposing our population to a greater risk of death.

This subject is very serious, and it certainly transcends the nature of one
or other specialty at the Trauma health care team, impacting straight to the
heart of health care pollicies and resource allocation, especially in less
developed countries.

claudia









On 4/22/06, JonWalsh at borgess.com <JonWalsh at borgess.com> wrote:
>
> 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.
>
>
>
>
>
>
>
> ----------------------------------------------------------------
>
> This message was sent using IMP, the Internet Messaging Program.
>
>
>
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