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Sat Mar 17 22:03:23 GMT 2007

Roy,

Well said, and equally well thought out.  In fact if I were in that 63
year old man's shoes, with limited "useful" time, I would ask that my
reserves be maximized with the most aggressive and fastly mobilizing
therapy available - get me done and get me out.  My Dad died from lung
ca 18 months ago, and had that precise attitude, until his "useful" lfe
time had expired - and that was on his terms and his terms only.

Congratulations on your approach - medically and personally.  We could
and should all learn a lesson here.

Ron

>>> Roy Danks <roydanks at hotmail.com> 3/17/2007 11:57 AM >>>
Dear Tom,

Ah, but you would be wrong.  I was asked by the trauma service to
consult on the patient.  I am a general/trauma surgeon, and do most of
the thoracic work for our trauma service.  I did the consult, explained
everything to the pt and his wife in detail and scheduled the VATS for
the next day.

His oncologist is on board and I think he scared the patient into
thinking: 1) VATS may "spread" tumor from the lung 2) wounds won't heal
due to chemotherapy and 3) a cardiothoracic surgeon should be consulted
for a second opinion.  They opted for the second opinion and that
surgeon said he wouldn't do anything.  So, they (pt and his wife)
decided not to do so.  

On the contrary, the patient had decided, well before the injury, to
take the cancer bull by the horns.  Grim prognosis, yes, but no reason
for him to give up hope and neither would I as his surgeon.

I am very straight forward with patients about what my plans are.  I
speak at their level and explain things very clearly...using
illustrations if necessary. They are getting mixed messages from a
thoracic surgeon who, while a great guy and good surgeon, is a poor
communicator and an oncologist who has over-stepped his boundries with
what he thinks he knows about thoracic trauma (nothing).

You have complete info.  My feeling, and it's in my consult, is that
evacuation of the retained clot and air is standard of care.  Some might
argue.  He's a healthy looking guy...doesn't look washed out from the CA
or the chemo.  I think he would do well with a VATS...in fact, I think
he'd be on his way out of the hospital in a day or two.

Thanks,

RD

> Date: Sat, 17 Mar 2007 10:21:02 -0300> From: thoran at sarah.br> To:
trauma-list at trauma.org> Subject: RE: (no subject)> > Dear dr danks,>
> clearly your decision to ask this question suggests a patient whom you
believe is at the end of care; otherwise you would have already replaced
a non functioning tube with an appropriately placed one, taken a chest x
ray the day following and booked his VATS if still unsuccessful. What
motivates you to abandon the normal care in a patient who has limited
useful time and who may want to return to his home as quickly as
possible instead of being confined to hospital while his doctor
dithers?> Tom> > > ----------> > From:
trauma-list-bounces at trauma.org[SMTP:trauma-list-bounces at trauma.org]
on behalf of Roy Danks[SMTP:roydanks at hotmail.com]> > Reply To: Trauma
&amp; Critical Care mailing list> > Sent: sexta-feira, 16 de março de
2007 20:21> > To: trauma-list at trauma.org> > Subject: (no subject)> > > >
63 y.o. male falls in bathtub and has multiple, displaced left rib fx,
hemopneumothorax. Also has fairly recent dx of Stage IV colon CA (mets
to lung and liver)...mets in the affected (traumatized lung). Now 8 days
post injury and has retrained HTX (probably 300-500 ml...who knows, it's
compressing and causing atelectasis, but no hypoxemia)...and about 15%
PTX. Chest tube not in good position really.> > > > Do I: Replace the
chest tube? Do a VATS, evac the clot and place chest tube(s) then or do
nothing and see what happens?> > > > Thanks.> > > > R. Danks> >
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