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Fri Feb 1 19:45:11 GMT 2008

If one brings the OR to the ED be sure to bring the surgeon and surgical nurse to that surgical patient.  

K

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-----Original Message-----
From: "Matthew Reeds" <mgreeds at reeds.uk.com>

Date: Fri, 1 Feb 2008 18:58:18 
To:"'Trauma &amp; Critical Care mailing list'" <trauma-list at trauma.org>
Subject: OR Resus - a great debate

Mike,

It sounds like you have created an ideal setup in bringing the OR to the ED
for trauma patients (thereby not affecting the normal operating workload for
elective patients and being cost-effective with your OR suite yet, at the
same time, you can still provide the "Gold Standard" of care to your trauma
patients.) In essence this is really a satellite ED OR rather than being a
trauma bay of the ED as it no doubt has all the functions of both
departments and full surgical capabilities. It sounds as if it also might
act as a makeshift ITU bed as well (?) You are obviously still able to
perform DCS there, presumably there is an Interventional Radiology suite in
close proximity (?) and the ITU/HDU is nearby for rapid transfer (?) You are
therefore able to fully employ the principles of DCS, permissive
hypotension, 1:1 massive transfusion protocol and active rewarming in this
location. In this situation blurring the lines between the trauma bay of the
ED and the OR sounds perfect to me. 

Your other comment on the comfort of a safe "OR" to surgeons is also
entirely relevant, true and well made. The surgical team must realise that,
just as we rapidly transfer any patients who have had "emergency operating"
in the A&E/ED to theatre/OR, we must also ensure that we employ the same
from theatre/OR to the ITU/HDU as we know and fully appreciate, yet
sometimes might fail to do. We MUST all have the insight to remember that
theatre/OR is NOT the place for definitive care here and that definitive
procedures should NOT be undertaken at this point, because it will only
result in a deleterious effect on the patient's outcome. If we keep this at
the forefront of our minds, we can ensure shorter DCS procedures in
theatre/OR and restore normal physiological parameters much more easily,
quickly and with less morbidity/mortality on the ITU/HDU immediately
thereafter.

Shock & awe. I once thought of it as Shock and (Th)awe whilst describing the
principles to medical students. You treat the shock by correcting the
metabolic acidosis, implement 1:1 massive transfusion protocol to correct
the coagulopathy; whilst thawing the patient to rewarm them from their
hypothermia.

Matthew

Sise, Mike MD Sise.Mike at scrippshealth.org
<mailto:trauma-list%40trauma.org?Subject=OR%20Resus%20-%20a%20great%20debate
&In-Reply-To=> 
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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OR Resus - a great debate