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Tue Mar 31 14:19:01 BST 2009

http://asci.uvm.edu/equine/law/articles/024_accidents.htm

The San Antonio *Express-News* printed a letter to the editor on November
28, 2002 about a photo showing a preschool child on a horse without a
helmet.  The author of the letter, Charlene M. Morris, is president-elect of
the Association of Family Practice PAs.  Her letter makes the point that
other athletes—football, baseball, and hockey players—all wear helmets, as
do bicycle riders.  She concludes, "Prevention is a lot more important than
treatment.  Come on, cowboys of all ages, wear a helmet and live to tell
another horse tale!"

an old item with a timely message.

cmm

On Tue, Mar 31, 2009 at 8:39 AM, Thomson, Dave <dthomson at phihelico.com>wrote:

> The question is: what are the alternatives?  Stay (for a little while) and
> play can work if there is some way to get the information on the basic
> procedure to the small hospital physician in a timely fashion.  The only way
> I know of is telemedicine.  For years the technology limited this, but now
> the limitation is reimbursement policy.  How will the University /
> University surgeon get paid for mentoring the procedure over the
> telemedicine system, and what will his / her liability be?  What if the
> mentor-surgeon is in another state, or another country? Are there licensure
> issues?
>
> Scoop and run can work if there is an integrated, truly functional
> transport system that can also work across political boundaries.
>  Unfortunately we have too much collegial distrust at the present time to
> make that work.  If it's not "my helicopter" or "my ambulance" then we don't
> want them bringing patients to "my hospital."  It's time that we started to
> have systems and teams to care for patients.
>
> Finally, we need to educate the public.  We have to be vocal about the idea
> that helmets save lives.  We need to have them understand that although some
> medical care may be close by, it may not be the sort of definitive medical
> care they need.  They need to be an active part of any system, not just a
> victim.
>
> Dave Thomson
>
> David P. Thomson, MS, MD, FACEP, CMTE, CHC
> National Medical Advisor
> PHI Air Medical
>
> -----Original Message-----
> From: Sanjay Gupta [mailto:sanjaygupta99_91 at yahoo.com]
> Sent: 30 March, 2009 09:36
> To: Trauma & Critical Care mailing list
> Subject: RE: Prevetable 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 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
> > > --
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> >
> >
> >
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-- 
The one important thing I have learned over the years is the difference
between taking one's work seriously and taking one's self seriously. The
first is imperative and the second is disastrous.
Margot Fonteyn

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