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Prevetable death? from a Qc MD

Bjorn, Pret pbjorn at emh.org
Fri Mar 27 12:26:18 GMT 2009


After all of this very interesting discussion, the question remains: IF a doctor CAN do something, does it necessarily follow that he SHOULD?  Are we willing to face the broader consequences of this mindset?

Consider: rural trauma is blunt trauma -- chiefly car crashes and falls.  (Hence the concern over EDH.)

But blunt trauma patients are clinically sticky: at every stage of assessment and treatment, he who touches the victim finds it hard to let go.

And be honest: EDH is not even OFTEN -- much less USUALLY -- a clear or isolated clinical presentation.

So: you work at a community hospital three hours by ground from the nearest trauma center.  A snowmobile crash (or a ski tumble, or a fallen hiker, or a Subaru-vs-Pulp-Truck) arrives via EMS.  Vitals are reasonable except for the low GCS.

How long does it take you to determine if local talent can drain the skull if need be?  How long does it take to get a brain CT?  How long does it take to assemble the personnel and equipment to safely manage the craniotomy?  

And what if your provisional diagnosis is wrong?  What if all this time it's an intraparenchymal bleed or a DAI, *AND/OR* the patient ALSO has a diaphragmatic rupture or a liver injury or a rapidly evolving pulmonary contusion?  (How do you know?  Did you image for all of that too?  How long did THAT take, and what calculus is required do determine whether your local damage control extends to these issues?)  

What if there are TWO victims?  More?  I hear it happens.

If it were not for so much concern over a specific (and, at least relatively, rare) injury, then your patient(s) would be a couple of hours closer to that trauma center.  But your otherwise systematic approach to major trauma is being disproportionately distracted by an individual daydream of happy-ending heroism.

I admire the enthusiasm, really; but I think you're running the risk of hurting at least as many patients as you help.

I'll shut up now.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Thursday, March 26, 2009 6:52 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: Prevetable death? from a Qc MD


Looks like we really ARE on the same page, eh?

Take care,
Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta
Sent: Wednesday, March 25, 2009 5:51 PM
To: Trauma & Critical Care mailing list
Subject: RE: Prevetable death? from a Qc MD


Ron

I also fully agree that a trauma / acute care surgeon should be able to drain an extra-dural hematoma, and personally I have been a neurosurgery resident for close to an year and know that draining an extra-dural hematoma ain't brain surgery, but I will still always consider practicalities first and heroism later.  I do not have a veil of a University protecting me and would be very careful venturing so far away from my core competence.  And thank God - I have 2 neurosurgeons working with me, whom I religiously buy coffee twice a month.


Don't get me wrong. - If I do have a patient with an extradural hematoma and no neurosurgeon, I will drain it with a craniotomy and HELL with the lawyers.



Sanjay Gupta



--- On Wed, 3/25/09, Gross, Ronald <Ronald.Gross at baystatehealth.org> wrote:

> From: Gross, Ronald <Ronald.Gross at baystatehealth.org>
> Subject: RE: Prevetable death? from a Qc MD
> To: "'Trauma & Critical Care mailing list'" <trauma-list at trauma.org>
> Date: Wednesday, March 25, 2009, 1:41 PM
> Originally sent on 3/24, but my new
> e-mail address wasn't recognized...........
>
> Sanjay, this is my feeling about this thread.  Just in
> case you hadn't figured it out as yet!  :-)
>
> -----Original Message-----
> From: Gross, Ronald
> Sent: Tuesday, March 24, 2009 3:58 PM
> To: 'Trauma &amp; Critical Care mailing list'
> Subject: RE: Prevetable death? from a Qc MD
>
> "The surgery is not complex"
> In other words, "It ain't brain surgery!"  Sorry, but
> I couldn't resist!
>
> Truth be told, it is something that any good trauma
> surgeon, or in the new parlance, "acute care surgeon", or
> from my viewpoint, "military surgeon" could and should be
> able do.  Simple, life saving and essential.
>
> Just my 2 cents,
> Ron
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Ben Addleman
> Sent: Tuesday, March 24, 2009 10:12 AM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Prevetable death? from a Qc MD
>
> Never done it, never seen it done, but large areas of
> Canada (no,
> Mont-Temblant would probably not be one of them) would be
> candidates for
> non-neurosurgeon brain surgery in emergencies. I do recall
> asking some of
> the general surgeons I worked with as a family medicine
> resident (nearest
> neurosurgeon probably almost an hour away-by fixed-wing air
> transport) who
> said they'd talked rural GPs through the procedure over the
> phone a few
> times.
> >From the Canadian Journal of Rural Medicine:
> http://www.cma.ca/index.cfm/ci_id/37275/la_id/1.htm
> (first thing listed as "equipment needed" is "a sense of
> historical
> proportion."
>
>
>
> On Tue, Mar 24, 2009 at 12:46 AM, Matt Oliver <moliverzw at gmail.com>
> wrote:
>
> > There is no reason why a general surgeon should not be
> able to deal with an
> > extradural haemorrhage. Here in Australia there is a
> workshop run by a
> > neurosurgeon from Brisbane on how to do it. There are
> many hospitals in
> > remote areas where this skill is required from time to
> time. The surgery is
> > not complex.
> >
> > Matt Oliver
> > Bendigo
> > Australia
> >
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org
> [mailto:
> > trauma-list-bounces at trauma.org]
> > On Behalf Of Charles Brault
> > Sent: Tuesday, 24 March 2009 7:19 AM
> > To: Trauma &amp; Critical Care mailing list
> > Subject: Re: Prevetable death? from a Qc MD
> >
> >
> >
> >
> >
> >
> > ----- Original Message ----
> > From: "Joe Nemeth, Mr" <joe.nemeth at mcgill.ca>
> > To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>;
> > "Trauma
> > & Critical Care mailing list" <trauma-list at trauma.org>
> > Sent: Sunday, March 22, 2009 9:28:16 PM
> > Subject: RE: Prevetable death? from a Qc MD
> >
> >
> > Agree with Pret's summary: the only surgeon who
> could've made a difference
> > would have been a Neurosurgeon...
> >
> >
> > **************************
> >
> >
> > The question is left suspended...
> >
> > Should general surgeons (emergency Physicians) be
> credentialed to do
> > emergency cranial decompressions?
> > Should there be a basic consensus as to the point
> where a "field" (outlying
> > hospital) neurochir. Intervention
> > Should there be a credentialing system put in place
> (Advanced
> > Neuro-Chirurgical Rescue certification)
> >
> > If not
> > Why not ?
> >
> >
> > Charles
> > While you are twisting their arm
> > Slap them a good one across the head and tell them to
> stop doing neonatal
> > transports
> > --
> > trauma-list : TRAUMA.ORG
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> >
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