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OR Resus - a great debate

Sise, Mike MD Sise.Mike at scrippshealth.org
Fri Feb 1 13:02:57 GMT 2008


Great comments on OR Resus so far. Reflects the power of this list.

 

Some complicating factors - at our >2,500 trauma patient per year center with 15% penetrating, and a very busy acute care surgery service, using the OR for anything but actual operations is not an option that is sustainable. Despite having great prehospital providers and good rapport with them, they are wrong approx. 20 - 30% in calling hemodynamic compromise and 10% in bringing in clearly dead patients. A 30 - 40% error rate in using the OR would crush our surgical service. Also, our trauma patients do not go to the ER - they go to a separate Trauma Resuscitation Bay owned, maintained and staffed by us with the support of an Emergency Medicine physician and his or her resident for airway management and an OR crew with all the equipment to initiate damage control surgical procedures. We've blurred the lines between the Trauma Bay and the OR.

 

We've embraced permissive hypotension, little or no crystalloid, stop the bleeding then 1:1 pRBCs to FFP, a 6 pack of platelets at 6 units, and active warming with the Kimberly Clark system. Our trauma nurses have termed it "Shock and Awe". Amazing how much time you seem to have when you don't pop the clot before you put the clamp on. 

 

We have the highest and most available capability to resuscitate, open chests, place lines, etc in the Trauma Bay because of the OR, Xray, respiratory, and other personnel who respond. We've asked the question about OR Resus because we are remodeling this next year to double the size of our Trauma Bay and want to create a damage control surgery/ intervention space in that area which will also have a CT scanner. In a busy acute care surgery center (especially Ortho) with lean resources, we're trying to get the right people in the right place without compromising the care of many thousands of non-trauma patients. 

 

One other observation - as surgeons we like to be in the OR. I've been looking at our damage control surgery times and at our restoration of appropriate physiologic parameters times and am concerned that we still don't ramp it up adequately in the OR compared to the resuscitation area. May reflect that we try to do too much definitive surgery once in the OR and that an advance practice trauma nurse is calling the shots in the Trauma Bay and an anesthesiologist without equal support is managing the patient in the OR. That being said, all of this may change with "Shock and Awe".

 

Mike Sise

San Diego


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