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Mon Aug 20 17:04:53 BST 2007

Boy, you leave the list for a few hours and WWIII breaks out. I realize this
is the Athens of America, The Mecca; but the case we discussed a couple of
days ago didn't engender this level of hyperbole. (Not knowing the hospital,
I doubt we're talking about an esteemed institution on Fruit St. as their
doors are one way valves.)

As Dr. Hammond points out, instead of Pret for once, the level of
geo-specific detail in this discussion is problematic and IMHO does not
serve a purpose. Except to establish that there is a trauma system in place
and the lead agency (dare we use Dr. David Boyd's terminology in polite
company?) is the Mass DPH. It's impossible for me to believe that a trauma
system was implemented without an Oversight Process. If not, do what Pret
says, but shame on them. Also shame on them if they did not establish a
credentialing process for who can serve as the on call trauma attending. But
just because you have a trauma system, or a car, does not mean it will
always function exactly as you intended.

And as Dr. Mattox noted this is, unfortunately, not an uncommon occurrence.
Geographically, most of our country does not have access to organized trauma
care. For a country that rightly or wrongly prides itself on the level of
health care we have that is inexcusable. Universal access to organized
trauma care should be a national priority.

Rob Smith

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Bjorn, Pret
Sent: Monday, August 20, 2007 10:49 AM
To: SURGINET: General Surgery Discussion List; Trauma &amp; Critical Care
mailing list
Subject: RE: Interhospital Quality Improvement

Dr. Glantz,

These comments, such as they are, on the invitation of Dr. Mattox from
the Trauma and Critical Care Mailing List:

In the absence of an organized and pre-defined process for PI/QI at the
system level, I'd recommend a simple but urgent debriefing among key
players, including relevant directors at each agency.  Solicit an
objective third party mediator (e.g., chief of another trauma program),
and allow yourself 2-plus hours and ample pizza and soft drinks.
Require a confidentiality agreement, and carefully record attendance.

Put your timeline on PowerPoint, and edit the presentation as you
cooperatively present it with those involved.  Summarize recommendations
at the conclusion, and save the .ppt as minutes.  Follow up as directed.

Strive for the debrief within a week; anything after two will be
pointless by comparison.  Over time, people are apt to forget or invent.

This needn't be difficult or even especially uncomfortable, especially
if you rightly assume that a) none of the players is an abject idiot, b)
none wanted to do anything besides help this poor fellow, and c) all
want to know how to not screw up in the future.  Indeed, you'll probably
find plenty to learn yourself.  You're all part of the same team, but
even all-stars have to talk in the locker room and go over the plays.  

I've never left a debriefing with hard feelings.  That happens when you
DON'T debrief.

Pret Bjorn

Trauma Coordinator

Eastern Maine Medical Center

Bangor, ME USA

-----Original Message-----
From: SURGINET: General Surgery Discussion List
[mailto:SURGINET at listserv.utoronto.ca] On Behalf Of andyglantz at aol.com
Sent: Sunday, August 19, 2007 2:36 PM
To: SURGINET at listserv.utoronto.ca
Subject: Re: Interhospital Quality Improvement

Fellow Surginetters,
    I'm sure that all of you that work at tertiary care facilities have
all received "train wreck" transfers from other hospitals.  How do you
handle the QI issues in a "politically correct" fashion?  Let me present
this mornings case to you and get some comments from some of you.
    The patient was a 35 year old man, who was apparently riding his
bicycle home from work at about 4am this morning.  He stated to the
paramedics who arrived at the scene shortly later that he was struck by
a car, and that the car drove off without stopping.  It is impossible to
determine how long he had been "down".  He arrived at the local
"regional medical center" at 4:59am.  At this hospital he was
resuscitated with about 3 liters of crystalloid (he even had an IV on
the dorsum of his left foot).  His vital signs were reported by all to
be "stable", with a hemoglobin of 11.6 and then 10.  A CT scan of his
abdomen was performed, revealing a grade IV liver injury, with segments
6 and 7 completely shattered and a moderate amount of hemoperitoneum.  A
"surgical consultation" was requested and he was seen by the local
surgeon "on-call" who was apparently a bariatric / minimally-invasive
surgeon, with less than 2 years experi! ence in private practice.
Transfer was arranged, blood for transfusion was "ordered", and the
helicopter was called.  According to the Emergency Dept staff, his vital
signs remained "stable."  The chopper staff arrived there at about 7:30
and he arrived at our facility at about 8am.  No blood was ever
transfused, nor was he sent to us with any blood on hand.  Upon arrival
to us, his BP was 60  (on high dose pressors), his hemoglobin was 8 and
his arterial pH was 7.00.  We quickly placed a large "trauma" IV line,
started transfusing 4 units of PRBC's.  His BP remained at about 60, the
IR staff was called, but it was going to take at least an hour to start
possible embolization on a Sunday morning.  We then rushed him up to the
OR.  We had his belly open by 8:45am, a Pringle tourniquet on at 9:21,
segments 6 and 7 in a basin by 9:50, 5.3 liters of cellsaver blood saved
(and transfused back), 20+ units of PRBC's, 10 units! of FFP, and 5
units of platelets transfused.  We did a median st ernotomy at about
10:00am, when he went into v-fib.  The RUQ was packed with lap pads
during this time and there was NO major hemorrhage from the liver at
this point.  Despite heroic efforts over the next 50 minutes, his pH
continued to drop from 7.00, to 6.97, to 6.88, and finally 6.77.  His
temperature at this point was 34 degrees.  He was 33 degrees at the
start of the case.  He received several rounds of bicarb, intracardiac
epi, IV calcium, etc, etc, etc.  He was pronounced at 10:47am.
   Any comments?

Andy Glantz
Boston Medical Center

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