List Archives

Wed May 27 12:58:06 BST 2009

Hey - less of the 'mostly wilderness'!

Pret -

we have situations where there's a leaking AAA at one hospital and a  
motorcyclist with a diffuse brain injury at another. A ventilated  
child in septic shock vs a 30 year old with a SAH. The retrieval  
service is based at the '2nd' hospital in the state, and the retrieval  
coordinator (an experienced intensivist) makes the final call. I can't  
blame them for saying that 'GCS 7' just doesn't cut it to enable them  
to make decisions.

A couple of weeks ago they were about to load my ventilated patient in  
resus, when they got a call from another hospital with a patient with  
a higher triage priority. They abandoned us and hit the road to take  
the other one instead. It's shitty, but it happens. (However they also  
stole our ICU bed in the receiving unit, which was a bit below the  
belt.)

Our radiology is excellent; the same company supplies radiology  
services to 3 out of 4 Tasmanian hospitals - as the smallest, all out  
radiologists are fly-ins. Out of hours we use a virtual reporting  
centre in another state. I have never had a complaint from the  
receiving centre as to the quality of our scans (and believe me, they  
would complain).

But I'm very lucky to live where I do: http://www.discovertasmania.com/destinations/western_wilderness/cradle_mountain-lake_st_clair_national_park

Even the view from my house is pretty impressive:

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Did I mention we're recruiting?

Fiona.

On 27/05/2009, at 7:29 AM, julie miller wrote:

> It's not screwy at all, Pret.
> Fiona has said there is only one air retrieval team in Tasmania: a  
> sparsely populated island of mostly wilderness.
> It's all about traige. We all know people who appear head-injured  
> and get intubated for agitation, combattiveness, etc for transport  
> often turn out to have no injuries. If the one retrieval team is  
> tied up transporting a minor head injury with diminished  
> consciousness because he's so drunk, so cannot pick up a 30 year old  
> woman with a brain aneurysm, it's not a good outcome.
>
> That's the system and what works best for them is Tassie.
> No more screwy than transporting minor trauma in exorbitantly  
> expensive helicopters that sometimes crash.
>
> Julie Miller
> Melbourne
>
>
>
>
> ________________________________
> From: "Bjorn, Pret" <pbjorn at emh.org>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Wednesday, May 27, 2009 12:17:53 AM
> Subject: RE: Blind burr holes
>
> Whoa.
>
> (I have hit rock bottom, and shall commence to dig.)
>
> Your trauma system indeed differs from mine.  But even admitting my
> ethnocentrism, I must say that your trauma system seems -- well,  
> screwy.
>
>
> Severe brain injuries are delayed (or refused?) by your trauma centers
> -- because of your neurosurgeons?  CAT scans are compelled, at remote
> hospitals with no (or, at best, amateur) neurosurgical resources, on
> severely-injured patients -- expressly for the benefit of your
> neurosurgeons?
>
> Eek.  And your trauma surgeons are cool with that?
>
> Be that as it may:
>
> Count the number of isolated, unstable and operatively accessible  
> SDH's
> in your system over any recent interval.  Now count total number of
> trauma patients with altered mental status otherwise compelling trauma
> center admission for the same period (any patient with clinical
> potential for subdural: all the head injuries, plus the multiple  
> traumas
> with low GCS).
>
> I'd be shocked if the ratio was greater than 1/10.  I'm actually
> thinking maybe half that.
>
> So: 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.
>
> Oh, yes, there will be VOMIT.
>
> Pret
>
>
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Fiona Wallace
> Sent: Tuesday, May 26, 2009 5:56 AM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: Blind burr holes
>
>
> Pret,
>
> This may be true for the area in which you work, and of course systems
> should be fitted to the individual region.
>
> Where I work I cannot activate the retrieval system until the
> neurosurgeons have accepted the patient, and they won't do that
> without a scan. Not unreasonably, they want to distinguish between a
> patient requiring surgery and a patient with (for example) DBI, as do
> the retrieval team because it allows them to triage the urgency (we
> have only one transfer team for the entire state of Tasmania).
>
>   A patient with a bleed is time-critical; one without may be triaged
> lower than a multitude of other diagnoses. Now maybe you're awash in
> choppers and paramedics - if so, I envy your rural hospitals because
> the decision making over here can be a bitch.
>
> We cut our cloth...
>
> Fiona.
>
>
>
>
>
>
> On 26/05/2009, at 7:32 PM, Pret Bjorn wrote:
>
>> ... and so we are inclined to move patients not to trauma centers,  
>> but
>> rather to the nearest CT scanners.  (There was a day when it
>> amounted to the
>> same thing, but hardly now.)
>>
>> Occasionally this will save a life; but much of the time it will  
>> delay
>> proper care.
>>
>> Pret
>>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org
>> ]
>> On Behalf Of Jarek
>> Sent: Tuesday, May 26, 2009 12:30 AM
>> To: Trauma-List [TRAUMA.ORG]
>> Subject: Re: Blind burr holes
>>
>> No, not only one. At the beginning of my career I had few as well-
>> truly
>> blind, no CT, just localizing signs, some of them turned out to be
>> oedema .
>>
>> Jarek
>> 2009/5/25 Miranda Voss <mvossak at yahoo.co.uk>
>>
>>>
>>> Re: Congratulations to Australian Doctor
>>>
>>> I also read this case with great admiration for the doctor, the
>>> system and
>>> the outcome. However, I would like to give another perspective on
>>> blind
>> burr
>>> holes.
>>>
>>> I have had to do it a handful of times when in the bush with no
>> possibility
>>> of referral/advice (NOT South Africa) and I think it is a HORRIBLE
>>> operation. I have only done it with documented decrease in
>>> consciousness
>> and
>>> localising signs, but I have never found a nice hematoma that could
>>> be
>>> evacuated with good results; either high pressure brain has come
>>> pouring
>> out
>>> of the burr hole, or occasionally there has been bleeding that I
>>> have not
>>> been able to stop satisfactorily. It has always left me feeling far
>>> from
>>> warm and fuzzy and to be honest, I am now very reluctant to do it.
>>>
>>> Am I the only general surgeon/occasional skull trephiner who has
>>> never had
>>> a patient waking up on the end of the drill?
>>>
>>> Miranda Voss
>>> Worcester, South Africa
>>>
>>>
>>> From: "ramalinga reddy" <drarumalla at yahoo.com>
>>> To: trauma-list at trauma.org
>>> Congrats to Rob Carson for saving the chaild
>>> Many times doctors are afraid to do such thing for fear of legal
>>> implications
>>> It is the medical faculty which should educate the general public
>>> so that
>>> litigations are minimised and doctors do such things confidently
>>> Hats off to Dr RobCarson
>>>
>>>
>>> Dr.A.R.Reddy
>>> SKS Neuro Hospitals
>>> Mobile: 9849018017
>>>
>>> --- On Fri, 22/5/09, trauma-list-request at trauma.org <
>>> trauma-list-request at trauma.org> wrote:
>>>
>>>
>>>
>>>
>>> --
>>> trauma-list : TRAUMA.ORG <http://trauma.org/>
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>>>
>>
>>
>>
>> -- 
>> _______________________
>> Jarek Gucwa
>>
>> jarekgucwa at gmail.com
>> --
>> trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe visit:
>> http://www.trauma.org/index.php?/community/
>>
>>
>>
>> ____________________________________________________________
>> All is not lost! Click now for professional data recovery.
>>
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>
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>
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