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

paul.middleton paul.middleton at usa.net
Sun Apr 23 10:57:42 BST 2006


Can I point out something that seems to have been made apparent from this
discussion, and in doing so acknowledge the remarkable breadth of consensus
that seems to have been generated from this thread. Notwithstanding any
degree of eminence, can I also acknowledge the generous and rewarding
statements made by Jon Walsh, Ken Mattox and others as part of this
discussion? Rewarding because it always gives a warm glow to feel that we
are all really part of a broader community with shared values, and although
I responded to an original grumpy post by being equally testy and defensive,
I do really feel that the trauma list has shown its real value in the last
couple of days by allowing some real communication between groups that,
although nominally working towards the same ends, frequently spend most of
their time bickering.

 

If, then, there is a real reward to the bickering of the last couple of
days, for me it will be a realisation by the eminent and truly invaluable
trauma surgeons on this list, that their way is not the only way. I would
leave this list a happy man if I thought that there were some trauma
surgeons working in Level 1 trauma centres in the US who now realised that
often it is not the emergency physician who is temporizing with excess
fluids and irrelevant investigations when the patient really needs to be in
theatre having the surgical problem fixed by surgeons, but very often
OUTSIDE THEIR INSTITUTIONS AND OUTSIDE THEIR EXPERIENCE it is the emergency
physicians with parallel learning and knowledge, and similar years of major
trauma experience who are pushing the reluctant surgeons to intervene and
STOP THE BLEEDING. If I were to count the number of times I had to almost
physically force the surgeon to take the patient to theatre when what they
wanted was to give more fluids (Ken, read cyclic hyper resuscitation - I
have been preaching your mantras for a long time!) I would almost run out of
numbers. This is not a reflection of the difference between trauma surgeons
and emergency physicians, in fact far from it; it is the difference between
non-trauma trained surgeons and trauma-trained ER physicians.

 

In the end the driving force behind any trauma resuscitation is the person
with the most experience of dealing with major trauma. If people are lucky
it is in a centre with resident, experienced available senior trauma
surgeons meeting them at the door (still not common in Australia despite the
dedication and talents of Michael Sugrue, Valerie Malka and until recently
Caesar Ursic), but in the majority of places outside the level 1 trauma
centres (to which patients will still insist on being taken, pesky awkward
people that they are) they will be almost as lucky if they meet a trauma
trained ER physician who can recognise the pathology and is not afraid to
speak very firmly to the surgical staff.

 

I look forward to writing the Optimal Teamwork Design paper with Jon, and I
think I will make sure that my next study leave application includes a visit
to the Las Vegas Trauma conference where I will make sure I take part in one
of Ken Mattox's pro / com debates!

 

Dr Paul M Middleton

Emergency Physician

Sydney

Australia

 

 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Tony Joseph
Sent: Sunday, 23 April 2006 5:36 PM
To: trauma list
Subject: Re: article in the may issue of "Annals of Emergency Medicine"

 

Dear Caesar

The availability of attending Surgeons is a little dependent on who is on

call.

I don't think that any of the surgeons you have mentioned provide a 24/7

coverage so that while the system may work when they are on call and

in-house, I don;t think it is universal in Sydney or in the rest of

Australia for that matter. The Alfred in Melbourne ( the busiest Trauma

Hospital in Australia) doesn;t have trauma surgeons in house 24/7 last time

I checked,

If a hospital can provide an attending trauma surgeon within 15 mins they

are doing pretty well down here. With the Trauma laparotomy rate at about 5%

for all major trauma cases ( and much less for a thoracotomy) it is

difficult to argue for an in-house Attending trauma surgeon. Perhaps if we

ever managed to consolidate the Trauma services in Sydney to 1 or 2 centres

providing acute Trauma and Surgical care, we may have a chance?

Hope you are well

Regards

Tony Joseph

Sydney

 

 

On 23/4/06 8:28 AM, "Caesar Ursic" <cursic at gmail.com> wrote:

 

> Dr Paul M Middleton wrote:

> 

> "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.?"

> 

> Paul, wait a sec.  Don't paint it with such broad brush strokes.  What

> you call 'the only choice' ...isn't.  The situation in Sydney is not

> quite as you describe it.  At Westmead Hospital and at Liverpool

> Hospital, and until recently at St George Hospital, an attending or

> fellow-level surgeon would be in the ER promptly for all major trauma

> activations.  Michael Sugrue and Scott D'Amours can attest to that at

> Liverpool (they sleep there when on call), and Valerie Malka at

> Westmead; and I instituted a 'fifteen minute' rule at St George during

> my two year tenure there, with specific attending call-in criteria

> (and this was part of our quality assurance process).  And I'm willing

> to bet that a similar policy exists at Auckland Hospital, although I

> cannot be 100% sure (Ian, are you lurking?)

> 

> CM Ursic, MD

> Santa Fe, New Mexico

> USA

> --

> trauma-list : TRAUMA.ORG

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