List Archives

Fri Feb 1 18:24:33 GMT 2008

The priorities for the trauma patient needing resuscitation and where they
ought to be (depending upon their injury and condition) are entirely clear.
I am realistic in the practicalities of what each hospital can achieve and I
do not believe that anyone on this list is naïve enough to presume that we
live in utopia with unlimited resources and that everything we want we
actually get for our patients.

However what is clear is that we should always be continually striving for
what is best for the patient and how to improve their care yet further
(after all, every single one of us can improve upon what we do currently and
we should learn/develop new techniques and encounter new medical advances
etc. which will actually benefit our patients.) We KNOW that trauma patients
should NOT receive resuscitation in the A&E/ED but yes, frequently they do
in some parts (and this is clearly due to the hospital system in place at
that institution and/or due to the lack of resources available.)
Nevertheless some hospitals however CLEARLY demonstrate that this IS
possible. There are also instances where people chose not to go to
theatre/OR as quickly as they could or go to that ITU/HDU bed as quickly as
they could (ITU/HDU beds can frequently be rapidly created/vacated when
needed.) We should all be aiming for that, no matter who we are, what
speciality we are in or where we are working.

I fully appreciate the comments made by some A&E/ED clinicians on this list
regarding taking up the flack for the failures of other specialities and
lack of resources and, yes, this is SOMETIMES true – but NOT everywhere or
on every occasion. Just because hospitals are not performing the best for
their patient (perhaps due to the system setup and/or resources available)
does that mean that we should not strive to change things in order to
improve them? When penicillin was discovered it was a fantastic antibiotic
that reduced mortality and morbidity considerably. Does that mean that we
either didn’t or shouldn’t have discovered other drugs such as Vancomycin,
Teicoplanin, Gentamycin, Ciprofloxacin etc.? Times change and things need to
change for the BETTER (yes sometimes they don’t.) This is what we ALL should
be doing no matter what speciality we are in.

Mark’s comment regarding the young boy involved in an RTC is unsurprising;
given an occurrence that happened in my hospital’s resus room last night
(another head injury who had been admitted to the department for 2½ hours
before ANY surgeon was notified.) The referral was made when the 49 year old
patient had deteriorated to a GCS of 3 with bilateral fixed blown pupils.)
The referral was even then ONLY made because there was a disagreement over
whether to intubate and transfer the patient to ITU or not and the A&E
Consultant/ED Attending had done “his” bit in giving 4 units of gelofusine,
inserting a guerdal airway and warming the patient up with the bair hugger
and had at that point had enough and was going home for the day (i.e.
leaving someone else to sort the problem out.) Quite what the logic behind
the high volume fluid infusion, hyperthermia for the brain injury (not
cooling) and how the guerdal was going to protect the patient’s airway was I
do not know. What is clear is that this is COMPLETELY UNACCEPTABLE and
merely compounds people’s opinions of the role of A&Es/EDs in managing
trauma when this sort of “patient management” is encountered day after day.
The whole process of managing ANY trauma patient relies upon everyone
fulfilling a vital role which ensures that they ONLY act in the PATIENT’S
best interests (and NOT their personal self-interests in undertaking an
intervention because they “enjoy” performing it) and this highlights the
problems which result caused by those who do not follow this overriding
principle. Yes surgeons like to operation but it is useful to remember
that:-

“Any surgeon can operate. A better surgeon knows when to operate. The best
surgeon knows when NOT to operate.”

This can and SHOULD be applied to every speciality. I would not operate on a
patient just because I could when I knowingly believe that to do so would
NOT be in the patient’s best interests. Naturally if the patient needs an
operation I would NEVER find a reason for not operating (unless there is a
clearly an obvious reason for not doing so.)

Matthew

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