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Thu Mar 9 15:24:37 GMT 2006

Nice case. 

E

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.erringtonthompson.com

Everyone deserves to make an informed decision
                                - Errington Thompson, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of docrickfry at aol.com
Sent: Tuesday, March 07, 2006 3:03 PM
To: trauma-list at trauma.org
Subject: Re: SV: Lapaoscopy in penetrating trauma

Kari--
Thanks for the case as it prompted a nice discussion--there is no right or
wrong here--you can't argue too much with the outcome
ERF 

-----Original Message-----
From: "Hansen, Kari Schrøder" <kari.schroder.hansen at helse-bergen.no>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Tue, 7 Mar 2006 18:59:00 +0100
Subject: SV: Lapaoscopy in penetrating trauma

We were concerned both about the diaphragm and the spleen initially and
maybe it 
was hazardous not to operate. We did not know by then that he did not have
any 
hollow viscus injury. We chose to continue observation because he was
stable, 
had no signs of peritonitis and we had the ability to follow him closely. 

I do not believe the blood in the chest was from the spleen. Remember he had
a 
tension pneumothorax. 
I believe the blood was from some kind of chest injury (lung/chest wall).

He was moved to the ward on day 3, the chest tube was removed on day 4 (a
total 
of 1,2 l blood). He is doing OK and will probably be discharged within a few

days.

This time it seems to turn out well. But what about the next time and the
next 
time after that....?
As Eric says: If you operate, you know the extent of the injury and you can
fix 
it.
If not, you are left with some questions. (......and maybe some 
complications.....)

I understand that many of you would operate. At our hospital it will depend
on 
who's on call.

Thank you for participating in the discussion.

Kari 

________________________________

    Fra: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
På vegne av Geehan, Douglas
    Sendt: 7. mars 2006 17:40
    Til: Trauma & Critical Care mailing list
    Emne: RE: SV: Lapaoscopy in penetrating trauma

    Rick,

    Don't run and cover with the old "read my posts". I am reading the
posts.  
The original poster did not indicate the patient was getting sick.  Dare I
say 
read the post, 

    "Next step:
    We continued observation in the ICU. The next day the hemoglobin was 9.3

g/dl.
    CT with peroral contrast the next day did not reveal any hollow viscus 
injury or increase of the subcapsular hematoma. (Maybe pure luck?)
    At day 4, the chest tube was removed and he is doing well. But, I know
there 
must be a diaphragm injury.
    What now?"

    The question now has become different.  Through some quirk of fate, this

individual patient has survived a non-operative approach that both you and I

would not have undertaken.  They are in the ICU.  They are not sick.  They
are 
not evidencing the bowel injury we were concerned about.  It is four days
later.  
To quote Kari,
    What now?

    Regards,

    Doug

    Douglas Geehan, M.D.
    Associate Professor
    Department of Surgery
    University of Missouri-Kansas City
    geehand at umkc.edu

________________________________

    From: trauma-list-bounces at trauma.org on behalf of docrickfry at aol.com
    Sent: Tue 3/7/2006 10:15 AM
    To: trauma-list at trauma.org
    Subject: Re: SV: Lapaoscopy in penetrating trauma

    Doug--Once again, you need to read the posts you comment on before
asking 
such quesitons.  You are mixing up all that has ben said.  So--I will say it

agian clearly this time--I would not operate on someone, including this
patient, 
just for the possibility of diaphragm perforation in the setting of
penetrating 
trauma, which is why I would not do diagnsotic testing in a patient with no 
other reason to operate to find such holes.  There is NO data to support it,
and 
in all of our past discussions, no such data ever is presented despite
numerous 
challenges to do so--all that comes out are anecdotal testimonials of the 
potential (which cannot be quantified or shown to justify the cost and risk
of 
surgery) for life threatneing complications.  Evidence does not support 
intervention, and again, those who interven must bear the burden of
justifying 
such with data. 
    And again--read my post--my comments were directed at the apparent
surprise 
that a diaphragm injury is present, with the poster apparently concerned
about 
it  and I am just saying this should have been known from the beginning
without 
doubt. If the diaphragm is of concern now, it should have been from the 
beginning, and this question asked initially, not just now.  Again, I would
have 
operated from the beginning for the spleen and possible other injuries, not
for 
the diaphragm--so no, at this point I would not be operating for the
diaphragm, 
but again, WOULD operate on this patient for the spleen and possible missed 
bowel injury being concerned as to the reason why this patient is getting so

sick--and yes, at surgery, would also fix the diaphragm while there.  AS I
said 
from the beginning...
    ERF

    -----Original Message-----
    From: Geehan, Douglas <geehand at umkc.edu>
    To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
    Sent: Tue, 7 Mar 2006 09:51:09 -0600
    Subject: RE: SV: Lapaoscopy in penetrating trauma

    Eric,

    You may be speaking from the position of fixing the diaphragm at the 
operation
    that many of us have recommended as what should have been done.  Kari, 
however,
    now has the patient in the ICU, post trauma day 4.  NO body cavity open.

Would
    you still advocate such an "easy and straghtforward" repair?

    Regards,

    Doug

    Douglas Geehan, M.D.
    Associate Professor
    Department of Surgery
    University of Missouri-Kansas City
    geehand at umkc.edu

    ________________________________

    From: trauma-list-bounces at trauma.org on behalf of docrickfry at aol.com
    Sent: Mon 3/6/2006 8:02 PM
    To: trauma-list at trauma.org
    Subject: Re: SV: Lapaoscopy in penetrating trauma

    Well, once again, fix it--it will not heal by itself, but of course you
knew
    this from the beginning--why the reluctance to make such an easy and
    straightforward repair?
    ERF

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SV: Lapaoscopy in penetrating trauma