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Mon Mar 23 14:26:10 GMT 2009

Thanks, Dr. McSwain; but I think the URL is actually
http://www.cdc.gov/mmwr/PDF/rr/rr5801.pdf.

	-----Original Message-----
	From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Jr.
	Sent: Sunday, March 22, 2009 12:05 PM
	To: Trauma &amp
	Cc: rhunt at cdc.gov
	Subject: RE: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson
her life ?

	I would refer you to the recent publication of the CDC published
in Jan 2009, ( URL below) and the PHTLS 6th edition textbook for some
specifics. The 7th edition of PHTLS to be published in Aug 2010 will
have an up to date discussion but the 6th edition is not too far off
from the new modifications of the CDC.  "The Guidelines for Field Triage
of the Injured Patient" has the approval of  >20 organizations in the US
including the ACS/COT and PHTLS. It was just discussed, with approval,
at the ACS/COT meeting which ended yesterday in Chicago. The guidelines
are modification of the older ATLS  triage protocol. The modifications
are based on data (imagine that) and are discussed in great detail in
the MMWR. Worthwhile for all who see emergency patients in the field or
are involved in that decision making

	www.ccdc.gov/MMWR

	Norman

	Norman McSwain MD
	Trauma Director, Charity Hospital
	Professor of Surgery, Tulane University
	New Orleans LA
	504 988 5111
	norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

	From: trauma-list-bounces at trauma.org on behalf of Nicholas
Macartney
	Sent: Sun 3/22/2009 10:16 AM
	To: Trauma &amp; Critical Care mailing list
	Subject: Re: Lack of INTEGRATED TRAUMA SYSTEM cost Richardson
her life ?

	I remember taking part in meetings about how to arrange trauma
better, 
	bypass hospitals within 20 mins of the trauma centre, etc etc.
Died a 
	death.
	Triage seems to be "take the patient to the nearest hospital".
The 
	exception is in cardiology, where they bypass to get to a
hospital 
	that can do emergency PCI.
	I would suggest that this has happened because the cardiologists
have 
	demanded it. I have never seen any sign of neurosurgeons in this
area 
	demanding transfer to them. In fact, they are happy to say they
are 
	full - goodbye.
	Nick Macartney
	On 22 Mar 2009, at 14:21, Robert Smith wrote:

	> Nick,
	>
	> We were recently in London for international trauma conference
that 
	> Karim helped host. I know London was working toward
implementation 
	> of a full trauma system but had not achieved this yet. I'm
unclear 
	> as to who oversees triage and how it is done. But if someone
had 
	> LOC, was lucid, and then was unconscious, I assume that would
imply 
	> a low GCS currently. Why wouldn't such a person be taken to a
trauma 
	> center?
	>
	> Rob Smith
	> On Mar 22, 2009, at 9:23 AM, Nicholas Macartney wrote:
	>
	>> Dear Pret,
	>> While I know that I live in a third world country, in London,

	>> England at least a head bump with short term loss of
consciousness 
	>> would not go to a neurosurgeon. It would go to the nearest 
	>> hospital. And a head bump, followed by a lucid interval,
followed 
	>> by loss of consciousness would go to the nearest hospital
too.
	>> Bear in mind that in London, there are 6 hospitals with 
	>> neurosurgeons I can think of. One ( National Hospital for
Neurology 
	>> and Neurosurgery ) does not have an ER, so never accepts
patients 
	>> that have not gone via another hospital.
	>> With the notable exception of the Royal London ( where the
trauma 
	>> listowner works ) one has to think that some neurosurgeons do
not 
	>> want to get all the emergencies, as it would impede the
elective 
	>> work/private work.
	>>
	>> Nick Macartne
	>> On 22 Mar 2009, at 12:46, Pret Bjorn wrote:
	>>
	>>> Let's start from the ground up, an decompress this
conversation a 
	>>> bit by
	>>> admitting that (from all that the public has been allowed to
know) 
	>>> Ms.
	>>> Richardson herself played a huge part in her own trajectory.
She 
	>>> was both
	>>> exceedingly unlucky and tragically unwise.
	>>>
	>>> She was unlucky, not for cratering on a bunny slope, or even

	>>> incurring a
	>>> mortal head injury in the mix; but rather, for (apparently) 
	>>> showing little
	>>> or no loss of consciousness followed by a truly world-class
lucid 
	>>> interval.
	>>> Bright lucidity, we must admit, can occasionally be wasted
on the 
	>>> owner.
	>>>
	>>> As for that, her un-wisdom traces to at least two bad
decisions: 
	>>> first, to
	>>> not spend eight bucks renting a helmet (though why a ski
school 
	>>> wouldn't
	>>> provide this free of charge is beyond me); and second, to
decline 
	>>> medical
	>>> treatment in the immediate aftermath of her crash --
presumably 
	>>> because she
	>>> felt largely uninjured, at least moderately embarrassed, and

	>>> didn't want to
	>>> dampen her vacation over a bump on the head.  Here, a show
of 
	>>> hands: who
	>>> among us would have done otherwise?
	>>>
	>>> So.  Four hours later, as her brainstem squeezes out the
bottom of 
	>>> her
	>>> skull... WHERE are the SURGEONS?
	>>>
	>>> Forgive me when I suggest that this is at least an
unnecessarily 
	>>> obtuse, if
	>>> not altogether silly, question.  There is zero assurance
that her 
	>>> outcome
	>>> would be any better had she been injured in any resort in
Montana, 
	>>> Utah,
	>>> Colorado, or Maine.  Speaking only for Maine, I'm confident
that 
	>>> she would
	>>> have been at a trauma center in well under an hour (probably
half 
	>>> of that)
	>>> from the time of the second EMS call.  (Sorry, Ken, but I
base this
	>>> exclusively on the integration and efficiency of our
HELICOPTER 
	>>> program.)
	>>> Yet I think we're all flattering ourselves if we think that
would 
	>>> have made
	>>> much difference so late in the game.  There are indeed
miracle 
	>>> recoveries in
	>>> such stories; but there are also fates worse than death.
	>>>
	>>> I'm less willing to criticize the Quebec EMS system because
I'm 
	>>> more than
	>>> 90% ignorant of its architecture.  Generally speaking,
though, I 
	>>> hope that a
	>>> mechanical fall with objective and isolated loss of
consciousness --
	>>> anywhere in the world -- would be triaged in favor of the
closest 
	>>> hospital
	>>> with a neurosurgeon.  (Practically anybody can do a head CT
these 
	>>> days; but
	>>> that's the problem.)  I'd prefer the destination be a trauma

	>>> center; but if
	>>> that's gonna add hours to the trip, she can be
out-transferred 
	>>> after the
	>>> burr holes.  And all this admits that I have no idea whether
or to 
	>>> what
	>>> extent the Canadian healthcare system has centralized the 
	>>> neurosurgery
	>>> resources of one of the largest nations on the face of the
earth...
	>>>
	>>> These are generalizations, of course, and defy
systematization in 
	>>> the
	>>> absence of a broad enthusiasm from local, regional, and
provincial
	>>> government; prehospital and EM providers; and yes, SURGEONS.
But 
	>>> I should
	>>> think they'd all have significant and very useful input.
	>>>
	>>> Pret Bjorn, RN
	>>> Bangor, ME USA
	>>>
	>>>
	>>> -----Original Message-----
	>>> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org
	>>> ]
	>>> On Behalf Of KMATTOX at aol.com
	>>> Sent: Saturday, March 21, 2009 10:50 PM
	>>> To: trauma-list at trauma.org
	>>> Subject: Re: Lack of INTEGRATED TRAUMA SYSTEM cost
Richardson her 
	>>> life ?
	>>>
	>>> WHERE are the SURGEONS ???
	>>>
	>>>
	>>> In a message dated 3/21/2009 12:45:42 P.M. Central Daylight
Time,
	>>> c_brault at yahoo.com writes:
	>>>
	>>> Once in  a while you hear stories through the EMS grapevine
that 
	>>> EMS crews
	>>> were  sanctions for bypassing local regional hospital and
taking 
	>>> the wild
	>>> risk
	>>> of  doing diret transport to the Level 1 Trauma Center (this
can 
	>>> only happen
	>>> in
	>>> certain regions near Montreal and Quebec city)
	>>>
	>>>
	>>> When I  came back from the States 1988
	>>> Their were no Board recognised Emergency  Physicians that
were 
	>>> allowed to
	>>> exercise as such (McGill Univ has the 2nd  oldest EM program

	>>> through)
	>>> Basicaly, I found that the GPs did not trust  themselves and
there 
	>>> emergency
	>>>
	>>> medicine very much (and rightly  so)
	>>>
	>>> They
	>>> Therefore
	>>>
	>>> Did not trust their nurses  either (French Quebec nurses
have 
	>>> clearly less
	>>> autonomy than their Anglo  counterparts)
	>>>
	>>> And
	>>>
	>>> They absolutely did not trust the  "Ambulance Drivers"
	>>>
	>>>
	>>> **************Feeling the pinch at the grocery store?  Make
dinner 
	>>> for $10
	>>> or
	>>> less.
(http://food.aol.com/frugal-feasts?ncid=emlcntusfood00000001)
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	>>
	>> Dr NJD Macartney
	>> ICU Director
	>> Chase Farm Hospital
	>> The Ridgeway
	>> Enfield
	>> EN2 8JL
	>> +4420 8375 1074
	>>
	>>
	>>
	>>
	>> --
	>> trauma-list : TRAUMA.ORG
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	>> http://www.trauma.org/index.php?/community/
	>
	> --
	> trauma-list : TRAUMA.ORG
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	> http://www.trauma.org/index.php?/community/
	>

	Dr NJD Macartney
	ICU Director
	Chase Farm Hospital
	The Ridgeway
	Enfield
	EN2 8JL
	+4420 8375 1074

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Lack of INTEGRATED TRAUMA SYSTEM cost Richardson her life ?