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Fri Nov 30 05:15:19 GMT 2007

Bill

This is exactly what we have been doing in RSA for many years. Our protocols are simple and determined often by our limited resources or access to the resources. (1200 bed hospital - only two scanners, helical and a 4-slice, shared between all specialities / services)

E.g. we don't CT-head everyone - they must have some signs, otherwise they get neuro-obs only and will be scanned if they deteriorate / don't improve; mostly they wake up and go home without sequelae. CT-Abdomen is seldom done for penetrating trauma, unless we feel it may be isolated liver injury and patient is stable and we are considering non-op management. For most other penetrating trauma it is clinical judgement only as to whether to observe or operate. Blunt trauma is different; but again selective CT-abdo with CT-cystogram is used either for stable with macro-haematuria or a positive ultrasound for free fluid. No free fluid or haematuria - observe. We don't see many bleeding quietly to death because we are selective. We cut out approximately 40% of the scans that would be done if every patient that was not getting urgent surgery would otherwise get if scanning was routine. 

Again some context! - we are a high volume, government funded (20K per year trauma) mainly penetrating trauma (40% of workload) urban center in South Africa, where crime and violence feature prominently in our lower-socio-economic communities (which constitute 90% of our patient load). Also - for Ken's benefit - our medico-legal issues are minimal compared to the USA.

Regards
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 William Bromberg
Sent: Thursday, November 29, 2007 4:55 PM
To: trauma-list at trauma.org
Subject: Re: [ccm-l] BIG NEWS - CT Causes Leukemia ?

I think the best way to handle this is to have an evidence-based protocol in place that guides the decision making process. Although this does not completely protect  the physician from liability (what does?) it simplifies and automates to some extent what Dr. Mattox has recommended without requiring a full page note for every patient. Frankly that requirement would only work if 1. your volume was very low or 2. you have residents. 

Bill Bromberg

>>> <KMATTOX at aol.com> 11/28/2007 9:21 PM >>>

In a message dated 11/28/2007 8:14:04 P.M. Central Standard Time,  
castill at eng.usf.edu writes:

This  opens a can of worms then:  you don't scan them and they possibly 
sue  you for a missed injury; you scan them and they possibly sue you 
because  of cancer.  Now  what?

You MANDATE that prior to a CT being performed, the ordering physician must  
write a progress note clearly stating the EXACT reason the CT was being 
ordered,  the probabilities as to what might be found, and just what change in 
therapy  that each finding might have on changing the course of treatment if and 
when it  is discovered, AND list the many possible VOMITs which are known to 
exist with  this particular CT and what one is going to do when there is a 
disagreement  among the various specialists on interpretation of the VOMITs.  

k

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[ccm-l] BIG NEWS - CT Causes Leukemia ?