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Wed Jan 30 14:29:31 GMT 2008

For patients in whom we know will be going to the OR anyway following  
particularilly penetrating trauma, from the information we got via telemetry in  the 
EMS, we go directly from the ambulance bay to the OR, completely bypassing  
the ER.   In such a patient, the purpose of the ER is to wave to the  patient 
as they go by.    We can be in the OR from the ambulance  dock in just about 15 
seconds more than it would have taken to go to the shock  room.   We can be 
from the ambulance dock to the OR table, with knife  in hand in 45 seconds.    

k

In a message dated 1/30/2008 5:53:20 A.M. Central Standard Time,  
Rgross at harthosp.org writes:

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.

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