Prevetable death? from a Qc MD

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A-FRICKEN-MEN!!

By the end of  my neurosurgery rotation in residency I was allowed to
hold the sucker during a craniotomy, and I was allowed to drill the
holes in my last case — this was the first month of my intern year. I
never got the chance to return to the OR for neurosurgery for the rest
of my residency and fellowship. I would guess that most "modern"
residencies give their general surgery residents a similar (lack of)
experience.

It's already difficult to get general surgeons to take ANY trauma call
in small, non-trauma hospitals and you guys want them to start drilling
burr holes?!? Hell, I can't get them to whack out a smashed  spleen in
an unstable patient before transferring them (and I've stopped asking
because twice it's resulted in a patient "stabilized" with massive
crystalloid resuscitation in order to get them on the helicopter with a
"normal" blood pressure).

Look, if you want to declare open season on trial attorneys, great, I
just bought a new .308. Less radically if you want to get laws passed to
reduce or eliminate medical liability in life-threatening emergency
situations I'm good with that too — but it's not going to happen, even
Good Samaritan laws are being weakened and overturned in some
situations. In lieu of that pretending that untrained surgeons,
uninterested in trauma to begin with will start performing urgent
neurosurgical procedures here in the US is more than a bit
disingenuous.

Furthermore, there is ABSOLUTELY no way that a physician in the US will
ever be prosecuted for not  performing a procedure for which s/he 1. Has
no training 2. Has no privileges 3. Has never done before. The physician
is much more likely to be censured for performing the procedure esp. if
it has compolications or a bad outcome, certainly by a hospital looking
to protect from liability (He didn't have privileges. He was breaking
the rules and is on his own.) and maybe even from the state medical
board.

Finally, in terms of looking at themselves in the mirror it goes like
this. 1. I wasn't positive what the problem was. 2. I really couldn't
have done int right anyway. 3. They would've died no matter what. 4.
Even if they didn't die they would've been a vegetable and who want's to
live like that. 5. I wonder if I can get a tee-time tomorrow? 


>>> Sanjay Gupta <sanjaygupta99_91 at yahoo.com> 3/30/2009 9:36 AM >>>

Although I said I will shut up about this thread, it just seems to go
on.  And I will say something that is more broad based as far as the US
approach to trauma care is concerned.  

There are two ways to manage trauma

1. Stay and play

2. Scoop and run.

If you subscribe to the first philosophy, I think it makes sense to
make burr holes and drain EDHs - which I presume have been SUSPECTED on
clinical exam, even open the belly and put packs in and also put on mast
trousers.  The problem then is - when do you stop?  When does a small ER
out in the boonies say - hey that is the work of a trauma center?  

If we do not talk about a single patient, and talk about trauma systems
in general - what has a higher probability of doing more harm than good
to a population?  I mean if there are general surgeons and ER physicians
who have never made a burr hole, draining "suspected" EDHs - will that
be safe???  And will that delay fixing any other problems that the
patient has?  


For that matter, I have yet to see a trauma surgeon in a University in
US, who has even inserted an external ventricular drain or an
Intraparenchymal monitor in patients with head injuries, independently. 
How can those same people encourage general surgeons who might be 20
years out of a residency and doing gallbladders and colons for these 20
years, to drain extra-dural hematomas?  I would suggest that we should
conjure up a study and do a cross-sectional survery of all General
Surgeons in the US and ask them the signs of an Extra-dural hematoma and
what side of the head and what exact location is an exploratory
burr-hole made in case an EDH is suspected? 


Sanjay Gupta



--- On Mon, 3/30/09, 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: Monday, March 30, 2009, 5:09 AM
> >>You are going to decompress,
> realizing that the bleed is ongoing and continue to work to
> move the patient as rapidly as possible. To attempt a flap
> unless there is absolutely no way the patient can be gotten
> to definitive care is foolhardy.
> 
> Having said that we recently saw a twelve year old
> transferred 90 minutes with an obvious progressive space
> occupying EDH because the neurosurgeons" in town didn't do
> trauma".<<<
> 
> I agree completely - no destination for definitive care, no
> emergency treatment, 'cause that patient is just flat out
> gonna die.
> 
> As to the second paragraph, that should be referred on to
> the state medical society and to the licensing board,
> because that is about the worst case of unethical,
> unprofessional, and in my opinion criminal behavior you
> could ever hear of.
> 
> Ron
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org 
> [mailto:trauma-list-bounces at trauma.org] 
> On Behalf Of Richard Wigle MD FACS
> Sent: Saturday, March 28, 2009 12:16 PM
> To: Trauma & Critical Care mailing list
> Subject: Re: Prevetable death? from a Qc MD
> 
> 
> I think everyone is missing the point here
> 
> As a trauma/ general/ former military surgeon I would do
> burr holes if needed in that  circumstance. Enough said
> about that. The point is not whether there is nursing care,
> or whether your going to do it in the ICU or what EMS is
> going to think, the point is you are only going to do it in
> there is clear evidence of deteriorating function and a
> progressive space occupying lesion and you cannot get the
> patient to definitive care immediately. You are not going to
> attempt a curative procedure unless there is no way you can
> get the patient out. You are going to decompress, realizing
> that the bleed is ongoing and continue to work to move the
> patient as rapidly as possible. To attempt a flap unless
> there is absolutely no way the patient can be gotten to
> definitive care is foolhardy.
> 
> Having said that we recently saw a twelve year old
> transferred 90 minutes with an obvious progressive space
> occupying EDH because the neurosurgeons" in town didn't do
> trauma".
> 
> 
> R Wigle MD FACS
> LSUS Trauma/ Critical Care
> 
> --- On Fri, 3/27/09, Larry Torrey <LTorrey at maine.rr.com>
> wrote:
> 
> > From: Larry Torrey <LTorrey at maine.rr.com>
> > Subject: Re: Prevetable death? from a Qc MD
> > To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
> > Date: Friday, March 27, 2009, 2:22 PM
> > Bjorn, Pret wrote:
> > > ...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?...
> >
> > Pret brings up some excellent points, but this
> discussion
> > is missing one more topic.  The nursing care.
> > Given that this is a predominantly physician board, I
> guess
> > that would be natural.
> >
> > If you're going to drill a hole in someone's head in
> a
> > rural or small hospital where the physician is
> inexperienced
> > in this procedure, it follows that the nurses will be
> at
> > least as inexperienced - probably more so.  I've
> worked
> > in level I ERs for many years, and have never seen
> > this done in the department.  I wouldn't have a
> clue
> > how to manage it, and certainly the trauma team won't
> stay
> > there to feed and care for it until the ICU is ready.
> >
> > So what will you do for this pt 10 minutes after the
> > procedure?  The ER will want nothing to do with
> it,
> > because they likely have neither the equipment nor
> expertise
> > to assist or care for it.
> >
> > Do it in the OR?  Ok, good, if you can manage
> > it.  More time added to the equation to make
> that
> > arrangement, to call OR staff in from home, etc.
> > Remember, we're not in a level I here.  Maybe we
> can do
> > it quicker in the ICU?  Maybe.  Is there a
> bed
> > available?
> >
> > Great discussion about the procedure itself, but it
> will
> > not be done in a vacuum.
> >
> > LT
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/ 
> >
> 
> 
> 
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