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Thu Mar 22 21:22:40 GMT 2007

In a message dated 3/22/2007 4:59:09 PM Eastern Daylight Time,  
wildmedic at gmail.com writes:

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
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>
> 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
>
>
>
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--  
_____________________
Ross Hofmeyr
MBChB (Stell) ATLS  ACLS
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com
--
trauma-list  : TRAUMA.ORG
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leave the foley in. It is the best way to assess resussitation.   I recently 
saw a 14 year old MVA  with NORMAL VS except pulse 110. NO URINE  OUTPUT. Some 
tenderness to belly, free fluid in abdomen.  We took her to OR  based upon 
volume of fluid. As we cut the labs came back, Hgb  was  3........ She had 
completely destroyed her R hepatic lobe, got oversewn, packed  and embolized. She 
got over 50 units blood products, went back 3 times for pack  changes.  got no 
blood after the first 48 hours. was left with open abd for  over a week and 
eventually closed primarly.  If we had not of acted when we  did she would not 
have made it.  Young and or healthy people often do not  have significant 
changes in VS until they arrest. this girl never dropped BP  until we induced 
anesthesia.  She got severalliters of fluid and 2 units of  blood prior to surgery. 
 We gave alot because of the min UO. She survived  without sequelea, other 
then going thru withdraw post op from her "  extracurricular activities"  You 
were right to want to leave it in.  
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

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To catheterise or not to catheterise...