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Mon Dec 31 14:37:35 GMT 2007

We can all learn from what Dr. Michael Sise has described to exist in San  
Diego.    I applaud this 24 year ongoing cooperative community  wide EMS and 
surgical effort.   

Having said that, let there be no confusion.    I do believe  that load and 
go is the better system over stay and play.   I do  believe that surgeon 
directed evaluation and resuscitation is preferable to  anesthesiologist.    I am 
critical of a slow ambulance ride to  the trauma center.   I am critical of a 
city that has NO trauma system  or trauma centers.     I recognize however the 
political and  cultural powers that believe that their system is superior.   

k

In a message dated 12/31/2007 8:00:45 A.M. Central Standard Time,  
Sise.Mike at scrippshealth.org writes:

Regarding "standards of EMS and trauma center care": Justice Louis  Brandeis 
put it best in commenting on the behavior of public officials -   "Sunshine is 
the best disinfectant." Unless all the trauma centers in a system  or a 
region meet regularly and perform true open, honest, and non-punitive  peer review 
of all cases treated, there will be little opportunity to reduce  variability 
and improve outcomes by changing trauma surgeons' behavior. Many  systems and 
regions have a Trauma Audit Committee (TAC). In San Diego we have  a Medical 
Audit Committee (MAC) and a Prehospital Audit Committee (PAC). I've  visited 
other systems and attended their TACs only to find cultures of  defensiveness, 
opinion based conclusions, or, unfortunately, blaming poor  outcomes on the 
patient. Our MAC is going on 24 years of monthly meetings with  over a 90% 
attendance record by all 6 trauma center medical directors and the  County EMS. Each 
month, the PAC also reports on a multidisciplinary review of  all 
pre-hospital quality issues. We've learned a variety of things that are  worth 
considering. Here are my top three for trauma surgeons;  

First and foremost: A surgeon has to have peers of equal  qualifications to 
answer to and the more experience you have the more  important it is to feel 
the need to do things in a manner that will make sense  to your colleagues. Left 
alone, we become stale faster than yesterday's bread.  

Second: Abandon your assumptions at the door. If you can't defend what  you 
are doing with valid literature, you need to really worry about the  legitimacy 
of your "practice habits". At least try to have "practice  recommendations" 
that others agree on for everything you do that are based on  either proven or 
promising literature. 

Third: Create a culture of  confession. It starts with the trauma director 
being brutally honest and  critical of his or her own behavior and outcomes and 
supportively and  constructively critical of colleagues. You'll know you've 
accomplished this  when a colleague tells you as soon as possible of a mistake 
in terms like "let  me you tell you how my thinking went wrong..." and you all 
are talking in  terms of errors in judgment or technique or delays in 
diagnosis. It can't  happen unless the boss leads the way. 

This is an inherently  dangerous game we play. Unless we take the 
professional athlete's approach of  constantly measuring our performance and trying to 
understand errors to avoid  them the next time, we guarantee poor outcomes.

Mike  Sise

San Diego

________________________________

From:  KMATTOX at aol.com [mailto:KMATTOX at aol.com]
Sent: Sun 12/30/2007 6:37  PM
To: trauma-list at trauma.org
Subject: "Standards" of EMS and Trauma  Center Care

I would agree with Dr. Ursic, that ideally, EMS,  Trauma, CriticaL Care, and 
Acute Care Surgery would be  "standardized."   However, among the  trauma
centers in  Houston (There are only two level I, and 8 Level II), there is   
not
agreement as to even standards of care regarding fluid  management,  
hypothermia,
and continuity of care for simple hand and  wrist  fractures.     

One major problem is that  each "trauma surgeon" believes that her/his 
particular approach should be  the standard for their community.    Indeed, 
as our
government  and HHS is now discovering, there are often more than  one,  two,
three, or even 10 acceptable and standard approaches to one  particular  
clinical
problem.   The differences are   judgement.     

We are discovering that the "BEST  PRACTICES" developed by hospital 
non-physicians are often punitive and  regulatory for control  purposes.     

Soooooooooooooo

How do we reach agreement as to what would be  the standard.  ??

k

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