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Sat Dec 6 03:55:01 GMT 2008

There is a great discussion going on this thread and I feel privileged to be part of this.  Let us please keep it civil and respectful.  I have a question of my own.  

I now work at a level 2 trauma center, no residents, new nurses in the ICU every night.  The only person in the hospital after 5 PM who knows anything about trauma is the trauma surgeon who is working alone and is managing acute care surgery and trauma - average of 2-3 surgeries and 1-2 trauma admissions after 5 Pm everyday.  If I get a patient with a stab wound in anterior precordium who is hemodynamically stable and has some effusion in the pericardium (on the FAST) I tend to do a sub-ziphoid pericardial window.  Several thoughts behind this - we can get an echo at night by a proper tech / cardiologist, but it takes time and persuasion; subxiphoid because I think that the patient in all likelihood has no tamponade or severe cardiac injury and if the patient indeed had a narrowed pulse pressure or hemodynamic instability, I would do a left thoracotomy as I have not performed too many median sternotomies.  Of course, in all patients I keep the left chest
 prepped and have all instruments ready for a left thoracotomy also and also wake up my cardiac surgeon and tell him that I might be needing him.  Being in private practice, I have to take care of the appendices and colonic perforation and if I am scrubbed up in a 2 hours case, I do not have the resources to monitor this sort of patient reliably.  I have nearly lost one such patient and I realize that many of these subxiphoid windows are unnecessary, but just like Dr. Mattox said, subxiphoid windows were popular before CT scans, echos (and surgical residents) were available, I think that in my situation, this is appropriate.  Also, our anesthesia staff has to drive in from home and several other (almost) funny situations are present that have resulted in this approach.  In addition, I do a subxiphoid window without opening the peritoneum and if I find nothing, the patient is discharged the next day and infact may be monitored on the regular floor if no
 other injuries are present.  Lastly a patient like this presents about once in six months in my hospital, so that the personnel that helped me in the previous case is no longer there and I just cannot teach everyone, everything, everytime, at 2 AM.

Sanjay Gupta
Tel: 207 576 3296

--- On Thu, 12/4/08, McSwain, Norman E Jr. <nmcswai at tulane.edu> wrote:

> From: McSwain, Norman E Jr. <nmcswai at tulane.edu>
> Subject: RE: SW to heart EMOTIONS (which have nothing to do with) the FACTS
> To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> Date: Thursday, December 4, 2008, 8:57 AM
> I will try to answer your questions
> 
> An echo answers the question - is there fluid in the
> pericardial space..
> 
> 
> The subxiphoid window is an operative procedures that needs
> to be done
> in the OR not in the ED. I do not believe it to be a
> diagnostic
> procedure . I would  do it only as a prelude to a
> thoracotomy ___WHY? 
> 
> The old rule of not opening a hematoma until proximal and
> distal control
> has been obtained is a very good rule. It prevents a
> patient from dying
> from exsanguination. The hematoma is contained as long as
> the
> pericardial sack is not opened. Once it is opened if the
> hole is
> bleeding significantly exsanguination will follow quickly.
> The blood
> must be stopped. If the subxiphoid window is done in the OR
> and the
> patient is prepped and draped immediate control can be
> obtained by a
> quick thoracotomy. In the ED the patient is not prepped and
> draped for a
> thoracotomy, anesthesia is not standing by, the instruments
> are not
> proper and the OR personnel are not ready to assist. The ED
> is just not
> the proper place for a thoracotomy if it can be avoided. It
> can be
> avoided by NOT attempting a formal surgical procedure in
> the ED
> 
> 
> . IS THIS HOW YOU WOULD ANSWER THE QUESTION OF
> ONGOING BLEEDING?
> 
> If I thought the patient had blood in the pericardium and
> that the hole
> has not self sealed (which many do)  as indicated by the
> signs and
> symptoms of a pericardial tamponade, I would take the
> patient to the OR
> and operate. If there was no indication of progression of
> the hemorrhage
> by changes in the signs and symptoms , I would think that
> the hemorrhage
> had stopped and that there was no need for a thoracotomy. A
> thoracotomy
> at this point would be unnecessary. Again the risks and
> benefits that
> need to be discussed with the patient.
> 
> THIS IS MY MAIN QUESTION. I don't want to put words in
> anyone's mouth
> but
> I get the idea that you and Dr. Mattox would advocate close
> observation
> for
> patients who have fluid in the pericardial space and normal
> vital signs
> after penetrating trauma to the heart. IS THAT CORRECT
> 
> The answer is YES ( see question 2 for the explanation) I
> would not
> operate on a patient simply for the presence of fluid in
> the pericardiac
> sack.
> 
> As I said before because of untoward events with this
> approach in some
> cases, we no longer use that approach. We feel the time
> between small
> changes in vital signs and collapse can be small. DO YOU
> DISAGREE WITH
> THIS?
> 
> I do not disagree that the time can be short but
> identifying blood in
> the pericardial sack without ongoing hemorrhage would NOT
> indicate the
> need for an operation. This is clinical determination. If
> there is a
> pericardial tamponade it needs to be fixed. If no
> tamponade, then the
> patient does NOT need an operation. The exception is 
> unless the
> hemorrhage is into the thoracic cavity because there is a
> significant
> hole in the pericardium (like my patient of 3 weeks ago).
> If that
> condition is present it will be detected by increasing
> blood loss from
> the chest tube and the patient needs to go to the OR. 
> 
> The presence of a small amount of blood or fluid without
> tamponade is
> NOT an indication for a thoracotomy. On the other hand
> hemorrhage that
> does not stop anywhere in the chest ( >1500 cc of blood
> from the chest
> tube) is an indication for a thoracotomy no matter what the
> source.
> 
> I hope that this answers your questions.
> 
> 
> 
> 
> Norman
>  
> Norman McSwain MD
> Professor, Tulane School of Medicine
> Trauma Director, Charity Hospital Trauma Center
> norman.mcswain at tulane.edu
> 504 988 5111
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert
> Smith
> Sent: Thursday, December 04, 2008 7:44 AM
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: SW to heart EMOTIONS (which have nothing to do
> with) the
> FACTS
> 
> Dr. McSwain,
> 
> Thank  you for sticking with this. My questions ARE IN
> CAPS. Dr. Mattox
> must
> be too busy right now to answer my questions. Your previous
> post about
> treating complications from negative thoracotomies made my
> point for me.
> We
> basically do not have negative thoracotomies from this type
> of injury. 
> 
> 1)Because we first do a sub-xiphoid window (which does not
> enter the
> abdomen). 
> 
> 2)We feel a subxiphoid window answers the question - is
> there any
> ongoing
> bleeding into the pericardial space. An echo answers the
> question - is
> there
> fluid in the pericardial space. DO YOU DISAGREE WITH THIS?
> If so why?
> 
> 3)It is hard for me personally to imagine doing this to
> reliably answer
> the
> question, is there ongoing bleeding. As Dr. Mattox has
> often said,
> pericardiocentesis is often hit or miss and not often
> efficacious. At
> best
> could see withdrawing some fluid once. I know in ATLS we
> used to say put
> in
> a catheter with a stop cock. I've never done that or
> seen it done so I
> can't
> comment on how reliable it is. IS THIS HOW YOU WOULD ANSWER
> THE QUESTION
> OF
> ONGOING BLEEDING?
> 
> 4), 5) Agreed
> 
> 6) THIS IS MY MAIN QUESTION. I don't want to put words
> in anyone's mouth
> but
> I get the idea that you and Dr. Mattox would advocate close
> observation
> for
> patients who have fluid in the pericardial space and normal
> vital signs
> after penetrating trauma to the heart. IS THAT CORRECT?
> 
> As I said before because of untoward events with this
> approach in some
> cases, we no longer use that approach. We feel the time
> between small
> changes in vital signs and collapse can be small. DO YOU
> DISAGREE WITH
> THIS?
> 
> I have tried to be respectful in my questions and comments.
> It is a
> wonderful privilege that we get to discuss issues with
> yoursef and Dr.
> Mattox in particular. If you guys want to say that I
> personally am an
> ignorant slut who will never understand anything about
> trauma management
> because I'm not a trauma surgeon, I'm fine with
> that. Then all I ask is
> that
> you explain the errors in my thinking rather that say
> "this should never
> be
> done". (And I appreciate you taking the time to set
> out your specific
> approach and reasoning) However why posters would want to
> ridicule the
> thoughtful and well reasoned approach of one of the oldest
> and most
> esteemed
> trauma units in the country is not clear to me.
> 
> I don't know if it is scientifically feasible, but
> perhaps since there
> are
> such "emotionally" fraught differences in thought
> on this subject, we
> could
> compare approaches and outcomes.
> 
> Rob Smith
> 
> 
>  
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of McSwain, Norman E Jr.
> Sent: Wednesday, December 03, 2008 11:30 PM
> To: Trauma &amp; Trauma &amp; Critical Care mailing
> list
> Subject: RE: SW to heart EMOTIONS (which have nothing to do
> with) the
> FACTS
> 
> Sorry if I have misstated my position. Let me try again
>  
> 1) the subxiphoid approach is NOT a diagnostic approach but
> a
> therapeutic
> procedure to decompress the pericardial sack BEFORE the
> institution of
> general anesthesia. It is done under local anesthesia with
> the
> anesthiologist ready to administer the appropriate drugs
> and do an
> immediate
> intubation as soon as the pressure in the pericardial sack
> is relieved.
> The
> patient is already prepped and draped for an immediate
> thoracotomy to
> sew up
> the hole in the heart quickly. The indications for this
> procedure is
> suspected pericardial tamponade when the clinical condition
> (signs and
> symptoms) exist
>  
> 2) If I needed a diagnostic procedure in the ED I would do
> a pericardial
> sack aspiration. 
>  
> 3) I would use a long spinal needle and follow the same
> procedure as was
> discussed in the ATLS course several years ago I was
> opposed to dropping
> it
> as an included procedure then and still am. I believe that
> there are
> indications for it
>  
> 4) I also believe that the pericardial aspiration is a
> therapeutic
> procedure
> to be done in the ED while getting the patient to the OR. 
>  
> 5) I would NOT do a subxiphoid open approach in the ED for
> therapeutic
> or
> diagnostic reasons. 
>  
> 6) In the case under discussion ( as I remember the
> original
> presentation)
> stab wound in proximity of the heart, Chest tube with 500
> cc of blood,
> vital
> signs NOT indicative of a pericardial tamponade, negative
> FAST, small
> amount
> of fluid noted on the CT, and no hard signs of pericardial
> tamponade----- I
> would observe the patient closely with physical
> examination, cardiac
> assessment for pulse pressure, development of other hard
> signs, repeat
> FAST.
> Quickly to the OR if indications became apparent. Continued
> observation
> if
> no signs.
>  
> As our population drifts back to more knife use since
> Katrina, We have
> seen
> several of these type patients in the last year or so. I
> have not
> managed
> them all nor have I directed them all but I have been
> directly involved
> in
> some. The approach that I outlined is the approach that we
> use.
>  
> 7) I do not believe these are enough indications to try to
> talk a
> patient
> into a thoracotomy with the associated complications and to
> get an
> informed
> consent. I would also not do it under these conditions as
> an 'emergency'
> without an informed consent.
>  
> I hope I have cleared up my views and biases
>  
> Norman
>  
> Norman McSwain MD
> Trauma Director, Charity Hospital
> Professor of Surgery, Tulane University
> New Orleans LA
> 504 988 5111
> norman.mcswain at tulane.edu
> <mailto:norman.mcswain at tulane.edu> 
> 
> ________________________________
> 
> From: trauma-list-bounces at trauma.org on behalf of Ben
> Reynolds
> Sent: Wed 12/3/2008 9:46 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: Re: SW to heart EMOTIONS (which have nothing to do
> with) the
> FACTS
> 
> 
> 
> Yes, Norm I think we can all agree that the risks and
> benefits must be
> sufficiently weighed and explained to the patient.  And
> yes, I too have
> treated complications of thoracotomy.   My memory is
> imperfect, but I
> can't
> recall many thoracotomy complications in the young barrio
> warrior
> population
> which makes up the bulk of this penetrating injury
> population as opposed
> to
> the COPDers and smoking vasculopaths whose poor protoplasm
> lends to poor
> healing.
> 
> But ultimately it's all a matter of what you believe. 
> If you believe
> that
> approaching a problem of the heart is best achieved by an
> incision
> through
> the abdomen then have at it.  You clearly are comfortable
> with this
> approach
> and you should continue doing what you feel serves your
> ends best.  You
> are
> a master surgeon, Norm.  No one will doubt that.
> 
> A small anterior thoracotomy affords many advantages over
> the subxiphoid
> approach both for exposure and therapy should that become
> indicated in a
> fashion delivered more rapidly with a simple stroke of the
> knife instead
> of
> the uncertainty of whether a sternal saw is available,
> present,
> functioning
> correctly, assembled correctly, are the batteries charged
> or nitrogen
> power
> is in the room or plugged in or any of the other hundred
> 'maybes' that
> accompany the sketchy logistics of performing the
> occasional median
> sternotomy at 3am.   
> 
> Again, my opinion.
> 
> Ben Reynolds, PA-C
> Pittsburgh, PA
> 
> 
> 
> 
> ________________________________
> From: "McSwain, Norman E Jr."
> <nmcswai at tulane.edu>
> To: trauma-list at trauma.org
> Sent: Wednesday, December 3, 2008 4:07:50 PM
> Subject: Re: SW to heart EMOTIONS (which have nothing to do
> with) the
> FACTS
> 
> Question
> 
> How many complications of negative thoracotomy have you
> treated? They
> are
> far greater than those for negative. lapratomy and neck
> exploration.
> 
> When advising an operation one MUST consider the risks and
> benefits and
> be
> able to discuss them with the patient prior to the patient
> signing the
> INFORMED CONSENT.
> I for one would have difficulty justifying to the patient a
> thoracotomy
> based on proximity,  500 cc of blood loss from a chest
> tube, a negative
> FAST, a ??? CT and NO HARD signs of a pericardial
> tamponade.
> 
> I believe observation to be the correct management
> Typed by the thumbs of
> Norman on his BlackBerry
> 
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
> 
> ----- Original Message -----
> From: trauma-list-bounces at trauma.org
> <trauma-list-bounces at trauma.org>
> To: Trauma &amp; Critical Care mailing list
> <trauma-list at trauma.org>
> Sent: Wed Dec 03 10:46:40 2008
> Subject: Re: SW to heart EMOTIONS (which have nothing to do
> with) the
> FACTS
> 
> I'm going to have to side with Rob on this (sorry Rob).
> 
> Ken's near textbook treatise on tamponade not
> withstanding I'm not sure
> what
> relevance it has to Errington's situation.  The choices
> as I see them
> are
> either explore or not explore the pericardium. 
> 
> Fact: The patient as presented is stabbed in an anatomic
> area of the
> chest
> which by most accounts is strongly associated with a
> potential
> penetrating
> injury to the heart.
> 
> Fact: On presentation he did not have tamponade physiology
> as eloquently
> defined by Mattox.
> 
> Fact:  He had a 500ml hemothorax in the left chest and a
> negative FAST
> of
> the pericardium. 
> 
> The compelling reason to operate isn't for the presence
> of tamponade, it
> is
> to rule out a potentially life threatening injury to the
> heart in the
> absence of tamponade.  Those things which are life
> threatening include
> uncontrolled hemorrhage and the potential interval
> development of
> tamponade.
> 
> 
> There is not a single imaging study, TEE, CT or otherwise
> which can
> reliably
> help you navigate this decision tree under these
> circumstances
> successfully.
> 
> Ergo, he gets explored or not explored.  If I am to choose,
> I prefer the
> left thoracotomy and like many do not believe in the
> utility of the
> subxyphoid pericardial window if you are ONLY interested in
> the heart
> INDEPENDENT of a laparotomy.  It is a truly pointless
> procedure and I
> have
> seen  many a good surgeon struggle at performing it. 
> 
> Errington, in my view did a very defendable thing in
> observing this
> patient.
> The chest tube only put out 500ml and stopped which in this
> instance
> represented bleeding cessation from a wound to the heart
> (proven in the
> posthoc analysis after the thoracotomy by his partner).
> 
> My opinion reflected a belief that he (in sum) indeed had a
> mechanism
> suspicious for penetrating cardiac injury and that EVEN IF
> the chest
> tube
> output stopped it may represent a clot burden over the hole
> in the
> pericardium which now predisposes him to eventual
> tamponade; in my
> experience an event which happens at exactly 4am when the
> nurses are all
> getting coffee and the rest of the surgical house staff are
> getting
> ready
> for rounds and no one is watching the chicken coop.  So
> until someone
> builds
> a reliable crystal ball, at time zero I would choose
> explore. 
> 
> I too have treated many penetrating cardiac injuries and
> like everyone
> else
> experience molds my practice and bias hand in hand with a
> firm
> understanding
> of what the science says about the standard of care in the
> treatment of
> this
> problem.  For my part, sudden death  from acute pericardial
> tamponade is
> a
> phenomenon I have seen and am rightfully fearful of it. 
> All this being
> said, I believe it is easier to heal an incision than it is
> to revive
> the
> dead.
> 
> My opinion.
> 
> Ben Reynolds, PA-C
> Pittsburgh, PA
> 
> 
> 
> 
> ________________________________
> From: Robert Smith <rfsmithmd at comcast.net>
> To: "Trauma & Critical Care mailing list"
> <trauma-list at trauma.org>
> Sent: Wednesday, December 3, 2008 6:27:07 AM
> Subject: RE: SW to heart EMOTIONS and FACTS
> 
> Dr. Mattox,
> 
> I'm just a guy who worked in a busy trauma center. Of
> course you have
> more
> experience than me and most everyone else. I'm not
> screaming for
> anything,
> I'm just trying to understand your thinking on a
> particular issue.
> 
> So. Let's say the patient is a young male who has
> sustained a single
> stab
> wound to an area you believe may involve the heart. His
> vital signs are
> normal.
> 
> 
> Would you get an echo? If not why?
> 
> If you would, what action would you take based on the
> information you
> get?
> 
> 
> 
> 
> For us the results of an echo are basically binary. Either
> it is stone
> cold
> bone dry negative or it is positive. Is that too
> simplistic? It is
> something
> that practitioners who are not experts in echocardiography
> can decide on
> in
> the middle of the night.
> 
> Of course a very small amount of blood in the pericardial
> space is not
> going
> to harm the patient. The problem is that this is an injury
> that may
> evolve
> over time. Do we disagree that patients with stab wounds to
> the heart
> can
> present as normal and deteriorate? We have seen them do so
> abruptly. Do
> we
> disagree on that?
> 
> Within the last 8 weeks two patients presented with stab
> wounds to the
> heart
> that required emergent thoracotomies. One patient in the
> resuscitation
> area.
> The other patient who was taken care of by a close friend,
> was said to
> have
> normal vital signs. His echo was apparently markedly
> abnormal even
> showing
> compromise of the RV. He was taken to the OR. Before the
> case could be
> started, he arrested. Because the attending trauma surgeon
> was with the
> patient, she was able to do an immediate thoracotomy and
> save the
> patient.
> It is her belief that in this day the surgical residents (
> and they
> agreed )
> cannot take this type of action independently.
> 
> I admit I forgot to confirm whether the plan was to start
> with a
> subxyphoid
> window or not, so you can take me to task for that. And I
> realize I am
> anatomically challenged compared to you but I thought the
> point of doing
> a
> subxyphoid window was to avoid entering the abdomen. On the
> few I have
> seen
> that was how it was done.
> 
> What I'm asking you and Dr. McSwain and Dr. Gross is
> this. When you see
> stable patients with blood in the pericardial space but
> without
> physiologic
> derangements what do you do with them?
> 
> 
> If you choose to observe them I guess you are confident
> that you can
> intervene in time if they deteriorate. We feel that may be
> problematic.
> If
> the persons doing the observing cannot intervene in time
> then the
> patient
> dies, which is why we do the subxyphoid window. This
> procedure is only
> diagnostic in the sense that it is used to see if there is
> any ongoing
> bleeding or if the bleeding has completely stopped. I
> don't know of any
> other test that does that so reliably. This approach does
> not seem
> overly
> complicated to me and it seems safe for the patient.
> 
> Rob Smith
> 
> 
> 
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of KMATTOX at aol.com
> Sent: Tuesday, December 02, 2008 12:31 PM
> To: trauma-list at trauma.org
> Subject: SW to heart EMOTIONS and FACTS
> 
> Penetrating wounds to the heart do still KILL people, most
> prior to ever
> 
> seeing an EMT, emergency physician, or surgeon.   
> 
> Some patients present to a facility with clear signs of a
> hemopericardium 
> and cardiac constriction:  Narrowed pulse pressure,
> decreased  systolic
> BP,
> 
> distended neck veins, etc.  These individuals need a 
> THORACOTOMY with
> or
> without a confirmatory study.  Currently the FAST  is a
> good study, when
> positive. 
>   If the FAST is negative, then  a CT or echocardiogram
> might be
> helpful.
> 
> For these  individuals it is foolish to make an abdominal
> incision
> (either
> in
> the ER or in  the OR) as there is a heart injury that needs
> fixing from
> the
> 
> chest.    If you want to do a mediansternotomy or a left 
> anterolateral
> thoracotomy, that is your preference.  In  this case, I ask
> the patient
> to
> Valsalva
> and if the pulse goes away,  they have an OR thoracotomy in
> just a few
> minutes
> later as for me that is a  positive sign enough.  There are
> also other
> signs, apprehension,  fecal incontinent,  etc.       
> 
> Some patients have a wound somewhere in the methodical box
> (fine,  that
> is
> OK, I have never used that term, but you can if you wish),
> and who
> present
> "stable".    If this patient has any sign of a 
> hemopericardium or
> tamponade, then
> they fall under the paragraph  above.    If they have a
> wide pulse
> pressure,
> 
> they virtually  never have an cardiac injury.  If the FAST
> is negative
> and
> you want  to do a CT of the chest or an echocardiogram, OK,
> but most of
> the
> time
> it is  totally negative.  I really see no reason  to do
> negative tests
> in
> patients who have totally negative physical  findings and
> negative
> history,
> etc.
>   I really see no reason to  do a sub xyphoid
> pericardiotomy in a
> patient
> with a totally negative FAST,  negative physical exam, and
> a VOMIT on
> the CT
> 
> scan with a hint of a suggestion  of a wisp of fluid in the
> pericardium,
> with the
> FAST showing full contractions  and relaxations, and NO
> narrowing of the
> pulse pressure.  The  subxyphoid pericardiotomy will always
> in such a
> patient
> yield no meaningful  results. 
> 
> The subxyphoid pericardiotomy was developed prior to the
> widespread 
> availability of the FAST and CT of the chest.    It is no
> longer  needed
> as
> a
> diagnostic modality.  AND it was never suggested as a 
> therapeutic
> modality. 
> 
> Just for the record.  I have personally seen and managed as
>  many or
> more
> cardiac injuries than most persons on this list, with the 
> exception of
> about 6
> people and you know who you are.  I have  seen none of
> those 6 persons
> screaming for subxyphoid pericardiotomy or any  other fancy
> tests.    It
> may
> be a
> matter of  experience.     
> 
> This is not rocket science.  It is relatively straight 
> forward.    LOOK
> AT
> 
> THE PATIENT.  Feel their  pulse.    Look at their neck
> veins.  Look at
> the 
> pulse pressure,  Feel the leg and pedal  pulse.      Talk
> to the
> patient,
> 
> Do a FAST  or other echocardiogram.      Do a CT if you
> really  need it.
> If
> you order an echo or CT - LOOK AT THE TEST YOURSELF, do 
> not just look
> at
> the
> report.   
> 
> Do not make a simple job hard. 
> 
> k
> 
> 
> **************Life should be easier. So should your
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> NEW
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> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
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> 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/
> 
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
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> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
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List Archives

For your convenience, find the Trauma List Archive Below

SW to heart EMOTIONS (which have nothing to do with) the FACTS