Login
Site Search
Trauma-List Subscription

Subscribe

Would you like to receive list emails batched into one daily digest?
No Yes
Modify Your Subscription

Modify

Home > List Archives

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

Ronald Gross Rgross at harthosp.org
Sun Apr 23 11:49:40 BST 2006


Oh yeah - I didn't think that I was outside the discussion, but merely
looking at it from a slightly different angle.  I will say that I did
agree with, and enjoy reading Claudia's post.
Hey Claudia, I got yer back!
Ron

>>> paul.middleton at usa.net 04/22 7:42 AM >>>
Thanks Ron

 

As always, a reasoned and eloquent post. You have pointed out
something
which is outside the discussion (?) so far, which is the desirability
of
having the trauma surgeon as part of the receiving team, whether or not
they
lead it. I do not think anyone can deny that this is a situation that
we all
would be enthusiastic about, and please do not take away the impression
that
I, or any others that share my views, are suggesting that ER physicians
and
trauma surgeons are interchangeable. The (review) paper was about the
evidence for any difference made in the initial period, and it
concluded
that there was little available.

 

What consistently sours the discussion on this list for many people,
and
proves an endless source of frustration (when all of us are attempting
to
improve our management of major trauma for the benefit of the
patients), is
condescension, antagonism, double standards and a narrow refusal to
consider
circumstances outside the day to day working environment of a
proportion of
list members. We are all a disparate group and work in wildly
different
circumstances, and we would all benefit from the synergies involved in
some
collaborative and creative thinking about possible solutions, rather
than
making inflammatory and dumb comments about other professional
colleagues
trying to provide the same outcomes.

 

I suggest the post by Claudia about the realities faced by the
population in
her country should humble us all and make us less prone to polemic and
more
prone to help.

 

Best wishes

 

(Oh yes.:-))

 

Paul 

 

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 Ronald Gross
Sent: Saturday, 22 April 2006 8:58 PM
To: trauma-list at trauma.org 
Subject: RE: article in the may issue of "Annals of Emergency
Medicine"

 

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.

 

 

 

 

 

 

 

----------------------------------------------------------------

 

This message was sent using IMP, the Internet Messaging Program.

 

 

 

--

 

trauma-list : TRAUMA.ORG

 

To change your settings or unsubscribe visit:

 

http://www.trauma.org/traumalist.html 

 

--

 

trauma-list : TRAUMA.ORG

 

To change your settings or unsubscribe visit:

 

http://www.trauma.org/traumalist.html 

 

 

 

 

 

 

 

 

 

--

 

trauma-list : TRAUMA.ORG

 

To change your settings or unsubscribe visit:

 

http://www.trauma.org/traumalist.html 

 

--

 

trauma-list : TRAUMA.ORG

 

To change your settings or unsubscribe visit:

 

http://www.trauma.org/traumalist.html 

 

 

 

--

trauma-list : TRAUMA.ORG

To change your settings or unsubscribe visit:

http://www.trauma.org/traumalist.html 

 

 

                                        

 

--

trauma-list : TRAUMA.ORG

To change your settings or unsubscribe visit:

http://www.trauma.org/traumalist.html 

 

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/traumalist.html


                                        



More information about the trauma-list mailing list