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Fri Feb 1 15:12:24 GMT 2008

Jas,
This is clearly not just managment. As John highlights, there is a lack of surge capacity in ICU and theatre, which inevitably could lead to a saturated outflow from ED, but we are talking extremes here in terms of both numbers and speed. The reality and the ideal, as ever, is likely to be compromise.In addition, it is very interesting to read the high error rate in the pre-hospital assessment>

I agree that our EM colleagues have a lot to offer in terms of intial assessement, triage and commencing reuscitation to 'buy time' for us to organise and faciltitate the next phase of care. However, the rest of the system needs the capacity and flexibility to accommodate this need for theatre/angio/ICU in less than an hour, on any 'typical' day. (Every ED knows what a 'typical' day represents from their audit data). Using it as an excuse to keep patients in the ER is poor justification. How often, if ever are we pushed by ER to get patients out of resus as part of an aggressive care strategy?

If EDs are regularly having to manage bleeding patients with fluids and further resus then we need to address the poor access to emergency theatre. This has been addressed in previous NCEPOD reports and most UK trusts already have a dedicated 'emergency theatre' and often even a 'trauma theatre' to manage this issue. Similarly, our hospital has a 'stablisation bay' where ICU level care can be provided prior to ICU or ICU transfer. This is ICU 'surge capacity' and it is provided in an area such a theatre recovery that can be 'flexed up' to 6 additional ICU beds at times of need. However, this is a very different issue to the topic initially raised on the list.

All we really want is to avoid is excessive delays and  'stay and play' in the resus room, under the dubious banner of 'resuscitation' or 'assessment'.

This very morning we have been discussing an RTC where a 12yr old child was hit by a bus and was KO'd for a number of minutes on scene. He was scooped and delivered to our ED where on admission his GCS was recorded as 8. Despite his initial triage, there was no trauma call and he was then 'observed and resuscitated' for 3 1/2hrs before finally calling the surgeons and critical care to take him to scan and to properly address his large scalp laceration, which could not be sutured as he asleep one minute and combative the next!!
He had no other apparent injuries and was cardiovasculalry stable throughout!
What were they hoping to 'observe' over all this time?!  This is another example of ED 'stay and play'
I do not believe that there is a single list member who would argue that either on scene or within minutes of arrival in the ED, looking at the kinematics and clinical state, that this child needed a tube and a scan (including FAST in the primary survey - discuss in children?!)
Why could he not have a full primary and secondary survey and then been packaged for scan in under 30 minutes (being conservative!). After all, this is what our National TBI guidelines recommend (NCEPOD, 2007).

I am pretty sure that list members all have similar views on the severly bleeding or highly unstable acute coronary patients but sadly we dont all work together in one place and many of our colleagues have different views!. Many anaesthetists hate trauma calls, many  surgeons claim to be always be 'stuck in theatre' and many EM docs hate to leave and interesting case to simply  manage the backlog in the waiting room. 
Jas, maybe I should re-consider and you are right! Maybe we should blame the managers as it cannot be the medics!!
Regards
Mark

Dr Mark Forrest
Consultant in Anaesthetics & Critical Care
Medical Director of Cheshire Fire & Rescue Service
Hon Snr Lecturer in Trauma
Medical Director of ATACC

----- Original Message ----
From: Jason Van der Velde <rescue at doctors.org.uk>
To: trauma-list at trauma.org
Sent: Friday, 1 February, 2008 1:34:00 PM
Subject: Re: Operating Room Resuscitations

John has really hit the nail on the head, well said...

Health Care "Management" and Bureaucracy is destroying 
trauma patient care. I believe that the root of our 
arguments is NOT clinical, but resources. Surge capacity 
is  "not economically viable" says the short term 
thinkers, that is until a disaster... and then the blame 
falls on us the clinicians, typical...

In third world health care systems like the NHS in the UK, 
they have no choice but to fight the good fight everyday 
with imposed targets etc. A&E trolleys/wards have become a 
side effect of years of underfunding where patient targets 
have outgrown common human decency let alone trauma 
patient care, EVERYONE should read the NCEPOD report, 
"Trauma Who Cares?" to realise that the NHS once a "crown 
jewel" is now the crown's turd...

My latter is not a dig on Emergency Medicine, FAR FAR FAR 
from it, Hey I'm an Anaesthesiologist with a special 
interest in EM...! EM is the glue in the very fabric of 
good trauma patient care, recognising time critical 
injuries and ensuring the patient gets the definitive care 
they need...

Definitive care to me is the right cloth to cover that 
individuals' needs. And some have a lot more need for 
covering than others!!! If the cloth (resource) is not 
there, the glue (EM) has to do its level best with what 
little scraps of material it has left over. SO STOP 
BLAMING THE GLUE if it does not hold the scraps together 
well!!!

The real argument is ensuring the right cloth is available 
at all times. Off to do some more tailoring...

Dr. van der Velde
EMDM-A
ATACC Disaster Response Coordinator
Trauma Research Fellow in Anaesthesia

Message: 16
Date: Fri, 1 Feb 2008 19:37:06 +1000
From: John Holmes <docjohnholmes at hotmail.com>
Subject: RE: Operating Room Resuscitations
To: "Trauma &amp; Critical Care mailing list" 
<trauma-list at trauma.org>
Message-ID: <BLU131-W22D016B862FA337F8F4561B4300 at phx.gbl>
Content-Type: text/plain; charset="iso-8859-1"

I really cannot believe the silliness of the proposition 
that the ED Resus room should be bypassed. Those of you 
making such propositions seem to be living in a world of 
unlimited resources. In the real world, access to ICUs / 
ORs etc is usually extremely limited. In most hospitals 
the theatre suites are fully booked and the ICUs fully 
occupied. Further, in other than the largest centres, 
these precious resources rarely have immediate manpower 
available. By NECESSITY the ED provides acute care, 
including resuscitation. Of course it should go without 
saying that unstable patients who are in need of 
definitive care - be that in the OR or the angiosuite - 
should get to those places ASAP. But many patients in 
resus rooms do not need hyperurgent definitive 
intervention. And this is even more so with non trauma 
cases. In fact many do not eventually even require to go 
to ICU. The ED provides not only early assessment and 
treatment but also a gatekeeping role.

In reality the ED HAS developed "far beyond immediate 
care". The UK's "4 hour rule" "was politically imposed in 
the UK and has nothing to do with medical care and 
everything to do with bureacrats' targets. It is anathema 
to those of us who see EM as part of a spectrum of care 
working seamlessly with the ICU/CCU/OR etc but NOT 
excluded or bypassed.

John

Dr John L Holmes
Director Emergency Medicine Training
AMC & OLVG
Amsterdam
The Netherlands

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