Prevetable death? from a Qc MD

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----- Original Message ----
From: Sanjay Gupta <sanjaygupta99_91 at yahoo.com>
To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
Sent: Monday, March 30, 20099:36:11 AM
Subject: RE: Preventable death? from a Qc MD


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 USapproach to trauma care is concerned.  

There are two ways to manage trauma

1. Stay and play
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What is becoming more and more apparent over the years is that the
Stay and play is largely a byproduct of uni(ego?)centric problem solving approach (MD-centrique)
 
It has actually impeded the "system" (Egos factor X all agreeing at the same time)
More so in France(very loose Trauma system)
And less so in Germany(Teutonic discipline) 
who does have a more systemic approach (and some Paramedics)
... but then I suspect that they also have a shorter scene times than the Latins
 
(Despite what they Latin MDs deluded themselves in thinking... they do not DO more in Trauma
And not much more in Medical calls, as compared to a decent Paramedic system
But it seems that their brain is so wired as to not even consider this even being a possible reality
 
Otherwise
How come we do not have, at this time, CLEAR numbers debunking the Fluid Resus - Stay N'Play approach ???
Dr K?
Karim ? ?
et al. ? ? ?
 
 
 


2. Scoop and run.
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The scoop and run is merely resulting from a global analysis and approach to Trauma
With a disciplinarian time/Useful Medical acts approach
10 mins on scene time 
20 mins ER times (Paying lip service to the Golden hour but not enslaved to it)
(It is always useful for a system to work that; people are wiling or obligated to toe the line... Clearly for the Medics but also ER Docs, Nurses… and specialists)
 
 


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?  
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But if they DID and in an organized manner it would be BEAUTIFUL
But history has shown that they generally don't do all these things
 


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?  
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The analysis needs to be made seriously
 (I mean we are way pass our normal medical evolution curve on this one)
Determine the clinical parameters where an improvised trepanation is proscribed 
(MANY will sigh with relief)
Determine the clinical parameters Where an improvised trepanation would be supported by "Medical Science"
And if their are indications for it, then the system should move consequenciely and provide training, certification (Indivual and Hospitals)
... create a registry, control the quality, tweak the system




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 USand 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? 
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For the longest time and even now decent hospital ERs had absolutely NO NEED of adult intra-osseous
And for very excellent reasons
These people operate in a more medically refined environment (a good thing too)
 
But that should not preclude
Adapting Medicine to various challenging environments
 
Paramedics are a good (US) example
In no way you would think to invent such a profession
... to operate in decent hospital ERs 
NO WAYHO SAY ! ! ! ;-)
 
They only start to make sense were the alternative is . . .
 
 
IS . . .
 
 
. . . certain death (EDH is a good equivalent example... for the MDs), increased morbidity, pain and suffering
 
After playing and tweaking with the model we can pretty much recognize that the approach has worked and we are pretty much there has to the how, where, who and what of the elements necessary to make this functional today and in the future … has emergency medicine evolves
 
 
Charles

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