List Archives

Thu Mar 22 20:37:43 GMT 2007

Rebecca et al,

I am in complete agreement - as you read from my original post, the patient
is awaiting transfer.  In my setting, this is likely to take anywhere
between 30 and 300 minutes to arrive.  (That's another discussion, Dr K,
before you start yelling "Sentinel Event!")

To elucidate my concern:  I arrived for duty this morning to find the
patient in the condition described above.  He had been catheterised
transurethrally.  I assessed him to have blunt abdo injuries, recognised the
need for a tincture of cold steel, and encertained that the patient was
booked for transfer.  he had recieved 1000 mls of Ringer's lactate IVI.  I
decided this was insufficient, given his condition and lack of urine
output, amd taking into account the principles of permissive hypotention
restarted the infusion.  At this point a senior arrived and lambasted the
doctor on call overnight fotr placing the catheter, citing risk of infection
in a patient with possible bladder rupture.  I disagreed and was told to
remove the catheter, because "We don't want the receiving hospital to think
we don't know what we're doing."  I intimated that this course of action
would result in precisely that outcome, but was reprimanded.

I'm still convinced that the catheter was indicated, the correct procedure
was followed and the senior mistaken in his treatment, but the other doctor
involved (who had been on duty when the patient arrived) has taken this
senior's appoach to heart.

Am I off the mark here?

Ross.

On 22/03/07, RWolfer at aol.com <RWolfer at aol.com> wrote:
>
>
>
> In a message dated 3/22/2007 12:16:33 PM Eastern Daylight Time,
> Rgross at harthosp.org writes:
>
> Tim,
> I couldn't agree with you more!
> Ron
>
> >>>  "Hardcastle, Tim, Dr <tch at sun.ac.za>" <tch at sun.ac.za>
> 3/22/2007  11:29
> AM >>>
> Ross
>
> Should have gone to Trauma Centre  directly - or did he walk to you?
> Surely
> Metro-EMS or other should have been  on scene? Provincial protocol directs
> these direct to GSH or TBH????
>
> If  there is no frank blood and the pelvis appears stable there is NO
> reason
> to  not catheterise prior to transfer if time permits: you can then at
> least
> monitor output.
>
> If the catheter goes in easily and no urine comes out -  either: a bladder
> rupture or the catheter is not in right or the patient is  more shocked
> than you
> thought and needs to be transferred more urgently. Again  - this patient
> should not be at a CHC!
>
> Tim
> Dr T C  Hardcastle
> M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
> Senior Surgeon /  Senior Lecturer: Surgery (Trauma and ICU)
> ATLS  instructor and DSTC  Cape Town Course Director
> Intern program Coordinator: Surgery
> M.Med  (Emergency Medicine) Executive Committee member
> Clinical Head (Director):  Diana Princess of Wales Trauma Unit
> Division of Surgery (General) Room  4064
> Department of Surgical Sciences
> Tygerberg Hospital / University of  Stellenbosch
> PO Box 19063
> Tygerberg 7505
> Western Cape
> South  Africa
> e-mail: tch at sun.ac.za
> Cell: +27824681615
> Office: +27219389281  or 4911 pager 0302
>
>
>
> -----Original Message-----
> From:  trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]On  Behalf Of Dr Ross Hofmeyr
> Sent: Thursday, March 22, 2007 2:43 PM
> To:  TRAUMA-L
> Subject: To catheterise or not to catheterise...
> 32 male  pedestrian run over by minibus taxi.  GCS 15, Resp NAD,
> hypovolaemic
> but  perfusing well, closed tib/fib fracture.  HR 110, BP 100/60, Sp02 99%
> on
> air.  Chest & pelvis NAD but severe abdominal
> bruising.  Abdomen  distended,
> tense, becoming peritonitic. Rectal NAD.  Patient is, of  course, booked
> for
> urgent transfer to trauma center.
>
> 1)  Do you  catheterise this patient?
> 2)  Suprapubic or transurethral?
> 3)   If the patient is already catheterised and no urine is forthcoming
> (doc
> reports no difficulty in procedure), do you remove it?
> 4)  Is this  presentation suggestive of bladder rupture?
>
> I have my opinions, which  were overridden by a senior colleague.  I, of
> course, am right, (*grin*)  but need ammo.
>
> Your thoughts?
>
> R.
> _____________________
> Dr  Ross Hofmeyr
> MBChB (Stell) ATLS ACLS
> wildmedic at gmail.com
> ross at wildmedix.com
> www.wildmedix.com
> --
> trauma-list :  TRAUMA.ORG
> To change your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
> --
> trauma-list :  TRAUMA.ORG
> To change your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
>
> Confidentiality  Notice
>
> This e-mail message, including any attachments, is for the sole  use of
> the
> intended recipient(s) and may contain confidential or
> proprietary  information
> which is legally privileged.  Any unauthorized review, use,  disclosure,
> or
> distribution is prohibited.  If you are not the intended  recipient,
> please
> promptly contact the sender by reply e-mail and destroy all  copies of the
> original message.
> --
> trauma-list : TRAUMA.ORG
> To change  your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
>
>
> remeber he is still relatively young.  Yound healthy pts do not  drop
> there
> pressure until the very end. some do not even get much of
> a  tachycardia.  I
> bet he is drier than you think. I destended abd  with  possible peritneal
> signs
> tell me there is something going on in the belly and he  may need a knife.
> get
> him where needs to be ASAP and dont keep him out "running  tests anddoing
> procedures" unless you are doing definitive care; Ihave seen to  many
> people die
> because the transferring hostpial wanted to run one more test or  do one
> procedure.  Do life saving things only and get them out, ie  chest tube,
> tie off
> bleeders that are visable, give fluid blood
> RW
>
> Rebecca  Wolfer, MD, FCCP,FACS
> Assoc. Prof
> Dept. of Surgery, Marshall University,  JCESOM
> Director, Thoracic Surgery
> Director, Surgical Critical Care, Cabell  Huntington Hospital
> Director, Trauma Cabell Huntington  Hospital
>
>
>
> ************************************** AOL now offers free email to
> everyone.
> Find out more about what's free from AOL at http://www.aol.com.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>

-- 
_____________________
Ross Hofmeyr
MBChB (Stell) ATLS ACLS
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com

List Archives

For your convenience, find the Trauma List Archive Below

To catheterise or not to catheterise...