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Sat Feb 2 08:33:48 GMT 2008

Well said John.

----- Original Message ----- 
From: "John Holmes" <docjohnholmes at hotmail.com>
To: "Trauma &amp; Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, February 01, 2008 8:37 PM
Subject: RE: Operating Room Resuscitations

>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
>
>
>
>> Date: Thu, 31 Jan 2008 22:26:12 +0000> From: atacc.doc at btinternet.com> 
>> To: trauma-list at trauma.org> Subject: Re: Operating Room Resuscitations> > 
>> Matt, Ken, Errington, Ron etc,> What music to me ears.....for years we 
>> have being tying to pry patients out of the claws of the resus room. 
>> Sadly, whilst the paramedics no longer 'stay and play' we have simply 
>> moved the problem to the resus room! Drips, level one infusors, excessive 
>> investigations and so it goes on......surely the role of the ER is rapid 
>> triage, commence life saving care and GO!! > > In the UK we have a 4 hour 
>> target for patients to leave the Emergency Dept. Incredibly, this also 
>> applies to the resus room.....4 hours!! If any patient needs for hours to 
>> commence resus or to organise further care then there is something very 
>> wrong with the system yet day after day we get patients referred to the 
>> ICU after 3hrs 50 mins who are far from sorted.....stay and play stikes 
>> again!> > What's worse is the fact that we constantly hear how they 
>> cannot make the target time and the departments are so busy. Surely by 
>> rapidly dispatching the sickest and most dependent patients then they can 
>> get on with managing all those others still waiting?> > Can we just get a 
>> good triage sister, make a decision about the route of dispatch and then 
>> get them off to theatre, ICU, angio, all within minutes? Well, Ken and 
>> his team clearly demonstrate that you can!> > In ICU if we have a 
>> critically ill patient that has active life threatening bleeding then we 
>> immediately request consultant level support from all relevant 
>> specialities, we don't haplessly struggle on for hour after hour until it 
>> is too late.> > EM has an important role to play in every hospital, but 
>> how much should they paly in major trauma or critical illness? Has the 
>> role of EM grown too far beyond immediate care?> > Regards> Mark F> UK> > 
>>  > > > ----- Original Message ----> From: Matthew Reeds 
>> <mgreeds at reeds.uk.com>> To: trauma-list at trauma.org> Sent: Thursday, 31 
>> January, 2008 12:05:49 PM> Subject: Operating Room Resuscitations> > > I 
>> agree Errington. I would in fact go further by saying that the ICU/HDU is 
>> THE ONLY place for patients who need resuscitation but DON'T need> the 
>> operating room (unless they are going to interventional radiology for 
>> embolisation etc.) > Further to Ken's comment on the role of the A&E/ED 
>> department "waving to the patient", this I fully agree with and 
>> wholeheartedly support. However I would say that the A&E does actually 
>> have ONE useful purpose - for the receptionist to book the patient into 
>> the hospital. They can also ensure that the order for massive transfusion 
>> packs is made IMMEDIATELY for them to be sent STRAIGHT to theatre/OR for 
>> the patient (for those hospitals that implement the 1:1 transfusion 
>> protocol.) I'll happily conceed that this is in fact two purposes.> 
>> Matthew> ____________________________________________________________> 
>> KMATTOX at aol.com KMATTOX at aol.com > Thu Jan 31 03:26:29 GMT > BINGO. 
>> Great point. For any trauma patient that is not going to be > able to be 
>> dismissed from the ER following minor treatment for a minor injury, > 
>> there is NO REASON TO KEEP THAT PATIENT IN THE ER ANY LONGER THAN IT 
>> TAKES TO > COMPLETE THE LOGISTICS OR PAPERWORK TO GET THEM TO THE OR, 
>> ICU, FLOOR, IR, > OR OTHER LOCATION. > > Kenneth L. Mattox, MD> Houston> 
>>  > > In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time, > 
>> errington at erringtonthompson.com writes:> > The ICU is a great place 
>> for patients who need resuscitation but DON'T need> the operating room. > 
>>  > E> ____________________________________________________________> In a 
>> message dated 1/30/2008 9:23:48 P.M. Central Standard Time, > errington 
>> at erringtonthompson.com writes:> I would add that those patient that 
>> don't need to go to the OR but still> need significant resuscitation 
>> maybe better in the ICU than the ER or> anywhere else. For the most part 
>> trauma surgeons run their own ICU's.> These are the nurses that have 
>> heard your lectures. They come to your> conferences. They know what you 
>> want. > > The ICU is a great place for patients who need resuscitation 
>> but DON'T need> the operating room. > > E> > Errington C. Thompson, MD, 
>> FACS, FCCM> Trauma/Surgical Critical Care> Author - Letter to America> 
>> Asheville, NC> > -----Original Message-----> From: trauma-list-bounces at 
>> trauma.org [mailto:trauma-list-bounces at trauma.org]> On Behalf Of 
>> Ronald Gross> Sent: Wednesday, January 30, 2008 6:52 AM> To: trauma-list 
>> at trauma.org> Subject: Re: Operating Room Resuscitations> > Yeah - what 
>> HE said! ;-)> > Matt, you and I are on the same page here - but you said 
>> it far better than> I did - Thanks!> > Take care,> Ron> > >>> Matthew 
>> Reeds <mgreeds at reeds.uk.com> 1/30/2008 5:27 AM >>>> > Mike & Ron,> 
>> When pontificating over the treatment that I give to any patient, I 
>> always> try to ask what I would want for myself and apply this to give 
>> the best> treatment to each patient. I would NOT want to be in an A&E/ED 
>> resuscitation> room but would "rather" be in either theatre/OR, ITU/HDU, 
>> the ward or> radiology (depending upon my injury) having the proper 
>> treatment that I> need. This is what I would strive for with any of my 
>> patients.> Therefore I see NO reason for the patient to remain in A&E/ED 
>> for> resuscitation. As Ron says, if the patient needs surgery, then off 
>> to> theatre/OR they go. If they need non-operative resuscitation, then 
>> off to> ITU or HDU they go for the care required. [This frees up 
>> theatre/OR> resources and time as Mike says if surgery is not required 
>> for better> utilisation.] Radiology resuscitation is ONLY required for 
>> THERAPEUTIC> intervention such as angio for pelvic haemorrhage and 
>> stabilisation (if the> extra-peritoneal pelvic packing approach is NOT 
>> used etc.)> >From my experience, there is NO need/role for A&E/ED 
>> resuscitation - if the> patient is that sick, then they need to be 
>> elsewhere (e.g. theatre/OR,> ITU/HDU etc.)> Even for major haemorrhage 
>> that requires surgery, these UNSTABLE patients> SHOULD be rapidly 
>> transported to theatre/OR for surgery for emergency> treatment. I would 
>> NOT NORMALLY advocate A&E/ED operating UNLESS absolutely> necessary which 
>> has happened to me on a couple of occasions [such as cardiac> arrest 
>> secondary to IVC transection at the bifurcation from multiple stab> 
>> wounds from a bayonet in a 19 year old male.] He had been "down" for 3 
>> mins> when he arrived in A&E by paramedics/EMT and there was no way we 
>> could> transfer him to theatre/OR on the top floor (11th floor) and at 
>> the other> end of the hospital to save him - a fault of the hospital 
>> design. Therefore> we performed a laparotomy in the A&E/ED resus room and 
>> got him back with> RAPID abdominal packing and then transferred to 
>> theatre just as rapidly.> However, this should be a RARE occasion and 
>> ONLY be absolutely necessary to> imminently save life rather than be the 
>> norm. In essence this comes down to> clinical acumen, experience and 
>> ability of the clinician to use sound> judgment and I agree with Mike, 
>> that if the patient doesn't need surgery,> then theatre/OR is not the 
>> best place to resuscitate the patient - they> should be in the ITU/HDU 
>> instead.> > Matthew> Surgery U.K.> --> trauma-list : TRAUMA.ORG> To 
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