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Fri Oct 12 14:01:41 BST 2007

Dr. Danks,

  Prior to going to med school I had the oportunity to be a paramedic for many years. I don't agree with Mr. Richey's candor on the matter, but i submit it is not his fault. EMS education in the US is not based upon knowledge building. Though you now get higher education credit, it is in my opinion not deserving of such. But that is another topic. You as well as I know that paramedics are taught in a "if you see x then you do y." So he has probably been taught that surgery is the goal of trauma and having had a clearence from a surgeon, believed he was acting in the best interest of the patient. The scenario could have gone many different ways, but explaining to the ED physican rather than an explative would have been my route. But it sounds like a broken Emergency/Trauma system as well. Somebody should have let the ED physician know this patient was to go straight to the OR. In my experience, it is impossible to call surgury directly, and even if you did, the reply would
 have been "go to the ED." But there is also the EMS problem of being beholden to too many masters. For example, ITLS from the EM side, or PHTLS from the surgery side? I had the oportunity this summer to take both ATLS and be a victim for ITLS. (I remain loyal to EMS roots) But some of the information between the two I noticed was contradictory. I know better than to say one or the other is wrong. But the more I learn about medicine the more I see than the role of the EM is very limited in major trauma centers. I had the great opportunity to work in a very highly respected trauma center, and somehow my unofficial duty as an in house paramedic was to mediate arguements between Trauma Surg. and EM. Mostly because I had to answer to both; when you get conflicting orders, bringing people together seems the best solution. Another problem is, there cannot be an apple to apple comparison of systems. again in my hospital experience, Surery met the patient in the ED. In all except
 very rare events of MCIs both the ED staff and Surgical staff were in the bay before the pt. and there was an exceptional relationship between the two that I have not seen anywhere else. In Mr. Richey's case, I would ask why Surgery was not in the ED waiting for the Pt. If his wounds were described as incomatible with life in the ED, it might have kept the suit open for somebody else. I have seen in numerous systems where there ED/Surgery relationship is very poor. One thinks they are better than the other. In those systems the ED bases this mostly on the standard of care of large bore IVs High volume chrystalloid and rapid infusors. But what is the point of spending 10-15 minutes putting in a chest tube on a patient who is going to have their chest opened in the OR? Why wait till 2 units of O neg leak out of a patient before you call surg? I think this idea of a quantitative goal of how long in the ED is pointless. As soon as possible, is my reply. That would depend
 largely on your system and your resources. Trauma is a surgical disease. By that very statement it is a surgeon who has the potential to do the most good for the patient. A patient with a serious MI goes to cards cath right? I would think the purpose of the EM in trauma is some stabilization measures until a disposition is reached. If the Dispo has already been determed why would the EM want to do anything other than wave good-bye?

  Mike 

Roy Danks <roydanks at hotmail.com> wrote:
  Mr Richey,

You were out of line. Go look in the mirror at your arm patches. I don't think they have "Doctor" on them. And if you said "f---you" to your deputy med director, you should be fired. It's not your call. You over-stepped your boundaries by miles. The ultimate responsibility for that patients lies in the hands of the receiving physician.

I know this is going to generate lots of responses and I look forward to the opportunity to defend my position.

I don't know where you are "practicing", but I would guess it's not Houston.

Dr. Mattox's system obviously is more efficient than many. But I stand by my previous statement that except in the most rare circumstances does it matter if you spend 10 to 20 min in the trauma bay. We do, many do and our stats bear out the fact that our high ISS patients do as well or better than national benchmarks.

We too have a dedicated elevator to the OR, but our preference is to see the patient and make some quick decisions. We do not see the volume of penetrating trauma that Dr Mattox sees. Most do not see that volume. But we do our fair share. And, prior to being here (Wichita) I was in Kansas City (KU) where we saw a moderate to large volume of high velocity penetrating trauma. We didn't whisk them to OR from the ambulance bay and our survival, again, was well in line with national numbers.

Dr Mattox wants literature...I would ask for data to prove that 10 to 20 minutes is too long in the trauma bay. Does the "Golden Hour" exist or does it not? I am under the impression it doesn't. What is the magic time? I don't know. I don't know who knows.

So, I stand by my previous post that the patient that I presented would go to our trauma bay, get a pelvic wrap and two chest tubes and would do just fine, with an average LOS and above average outcome.

And, as a paramedic, you need to learn that your knowledge base is limited by your education and experience. I was a medic in the field in a very busy system for 10 years prior to going to medical school. I didn't know what I did not know until I was way gone from the field. I am very active in EMS education and I will share your remarks (with your name and any identifiers removed) with a cadre of associates, both in and out of EMS to see what they would do with you.

K...your move...

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