Blind burr holes

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From: pbjorn at emh.org
> I have hit rock bottom, and shall commence to dig

 

--> While you've got the shovel...

I have not been following this thread and I am only today back on e-mail properly, with a few hundreds of messages to catch up on. As much as it would be logical and sensible to track back through this thread, logic and sense are two illnesses I generally am well immunised against... So I will try to work out for myself what you are replying to and ask you some follow-on questions. Hope you don't mind...

 

> Your trauma system indeed differs from mine

 

--> I believe you'll find that most do...

 

> ...I'd be shocked if the ratio was greater than 1/10...for the hypothetical benefit of one patient, we're willing to significantly delay the proper transfer of ten others? You'll be wrong FAR more often than you'll be right. 


--> You appear to have an objection to doing a CT on all these patients BEFORE sending to a NSurg centre because this may well delay significantly the intervention for the one patient who needs it for the mere saving of an "unnecessary" trip to the NSurg centre for the other 9, to have their CT there, where its results can be acted on. Your objection seems VERY logical. It is only sensible to transfer all 10, CT them all at the NSurg centre, immediately act on the 1 positive scan and apologise to the other 9, who are essentially unharmed by their trips...

 

Very logical and sensible...

 

A 1 in 10-20 ratio seems sensible... But that's only a ratio... 1 in 20 can also be 2 in 40 or 3 in 60...

 

Some time back I did a shift in an ED which sees well over 120K patients a year. It has a CT on site, but NSurg centre is 30-40mins away by road. In 6 hours on a BUSY night we did around 8 CTs for head injured patients for whom a CT was indicated (of course, I cannot recall the exact indications for each). NONE required NSurg intervention, so none were transfered (fits with the ratio you suggested). The receiving NSurg centre receives from numerous other EDs (all of which hace access to their own CT). For the whole catchment area we might be looking at the 3 in 60 end of the spectrum, rather than the 1 in 20...

 

So let's do the math:

- 60X40mins = 40 hours of 2-man-crews to get patients to the NSurg centre

- ??X40mins = ?? hours of 2-man-crews to get patients back - maybe 57 of them? So near enough another 40 hours

- So we've just employed 4 medics for a week each on this alone...

- And all these vehicles off service for that time and the time getting there

- Who knows how much in terms of staff to take care of these patients and their other injuries and issues while they are at the NSurg centre pre-scan, post-scan, awaiting transfer and NOT being operated on...

- 60X5min = 3 hours of a neurosurgeon's time on the phone accepting transfers

- Who knows how many beds to hold these people while they are NOT operated on at the NSurg centre... Just between scans... And when waiting for the ambulance for the trip back (which would be a long wait, as they are no longer urgent and all the ambulances are busy with the rest of the 60)

- Some traffic police to decongest the ambulance entrance at the NSurg centre...

- How much staff time taken up in packaging these patients for 2 transfers each (except for the unlucky 3 who'll only transfer once) and their paperwork...

- And who knows what other things are wrong with these patients, OTHER THAN their head injury - some of them would have things to sort out before being fit for transfer and then may well be put at risk during transfer related to these other injuries, while a transfer might be shown to be unnecessary if only the got scanned...

- Not sure how long a CT would take to do at the NSurg centre, with moving patient, loading onto table, settling all monitors & sundried, setting up and scanning, then getting patient back onto some bed. Say 20mins? X60 is 20 hours... How do we squeeze 20 hours of scanning into an 8-hour Saturday night?

- etc...

 

I fully admit that I have not at all defeated your logic and that your suggestion is very sensible, but, in some systems, it still might not work...

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