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Thu May 28 21:43:37 BST 2009

on the other hand:

One of my neurosurgical attendings when I was a resident told me of the time he was on board ship as a young general medical officer just out of his internship. A short way out of port he was presented with a young male with obvious appendicitis. He contacted the flagship to tell them that they needed to evacuate the patient and was told by the admiral "you're a doctor go ahead and take it out"

13 hours later he did get it out. The patient, being a Marine, survived.

Dick-canine orchiectomy by e-mail-Wigle
Lieut. Col. U.S. Army retired

--- On Thu, 5/28/09, LNMolino at aol.com <LNMolino at aol.com> wrote:

From: LNMolino at aol.com <LNMolino at aol.com>
Subject: Re: Crisis supervised surgery- NOT Against the LAW
To: trauma-list at trauma.org
Date: Thursday, May 28, 2009, 2:48 PM

For that matter how does this in anyway differ from tele-medicine that has  
already been done and is evolving in huge ways? 

I knew an IDMC who was on a Nuke Sub in the 1980's his MD got a hot  
Appendix and it needed to be OUT then and there middle of the pacific. The IDMC  
did the job while on a radio link with a Doctor on a Carrier as they steamed  
towards each other. The Hot Appendix Doc lived and recovered well and both 
the  IDMC and the MD were given Awards for the lifesaving procedure. 

This is not novel per se it's just unusual but perhaps it ought not to be? 

Louis N.  Molino, Sr., CET
FF/NREMT-B/FSI/EMSI
Freelance  Consultant/Trainer/Author/Journalist/Fire Protection  Consultant

LNMolino at aol.com

979-412-0890 (Cell  Phone)
979-690-7559 (IFW/FSS Office)
979-690-7562 (IFWF/SS Fax)

"A  Texan with a Jersey Attitude"

"Great minds discuss ideas; Average minds  discuss events; Small minds 
discuss people" Eleanor Roosevelt - US diplomat  & reformer (1884 - 1962)

The comments contained in this E-mail are  the opinions of the author and 
the author alone. I in no way ever intend to  speak for any person or 
organization that I am in any way whatsoever involved or  associated with unless I 
specifically state that I am doing so. Further this  E-mail is intended only 
for its stated recipient and may contain private and or  confidential 
materials retransmission is strictly prohibited unless placed in  the public 
domain by the original author.  

In a message dated 5/28/2009 11:16:47 A.M. Central Daylight Time,  
nmcswai at tulane.edu writes:

I have  been recently involved in addressing this problem. I agree with
Dr Mattox.  My general research of various literature supports  this

Norman

Norman McSwain MD
Professor, Tulane School of  Medicine
Trauma Director, Charity Hospital Trauma  Center
norman.mcswain at tulane.edu
504 988 5111

-----Original  Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of kmattox at aol.com
Sent: Thursday, May 28, 2009 11:10 AM
To:  Trauma-List [TRAUMA.ORG]
Subject: Crisis supervised surgery- NOT Against  the LAW

>From my standpoint, in the United States the emergency  operation
performed by a trained surgeon, but not in his credentialed  field, but
under the telecommunication instruction of the appropriate is  how
medicine should be practiced under such urgent crisis situations.   If
sued, I would testify in favor of the doctor.   I know of no  federal, or
state, or local law that such practice violates.   

K
Sent via BlackBerry by AT&T

-----Original  Message-----
From: "Pret Bjorn" <p.bjorn at netzero.net>

Date:  Thu, 28 May 2009 12:02:39 
To: 'Trauma-List  [TRAUMA.ORG]'<trauma-list at trauma.org>
Subject: RE: Blind burr holes -  word from the source

And with respect, it doesn't matter.  If  anything, the boy's notoriety
makes
his protected health information  more difficult to sterilize.

In the US, Julie's email would likely be  evidence of a federal crime
committed by Dr. Wallace -- unless the  patient's family had consented to
this detail of  description.

Pret

-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On  Behalf Of LNMolino at aol.com
Sent: Thursday, May 28, 2009 10:49 AM
To:  trauma-list at trauma.org
Subject: Re: Blind burr holes - word from the  source

Pret with respect the kid was on the International news.  

Louis N.  Molino, Sr.,  CET
FF/NREMT-B/FSI/EMSI
Freelance   Consultant/Trainer/Author/Journalist/Fire  Protection
Consultant

LNMolino at aol.com

979-412-0890  (Cell  Phone)
979-690-7559 (IFW/FSS Office)
979-690-7562 (IFWF/SS  Fax)

"A  Texan with a Jersey Attitude"

"Great minds discuss  ideas; Average minds  discuss events; Small minds 
discuss people"  Eleanor Roosevelt - US diplomat  & reformer (1884  -
1962)

The comments contained in this E-mail are  the opinions  of the author
and 
the author alone. I in no way ever intend to   speak for any person or 
organization that I am in any way whatsoever  involved or  associated
with
unless I 
specifically state that I  am doing so. Further this  E-mail is intended
only

for its  stated recipient and may contain private and or  confidential  
materials retransmission is strictly prohibited unless placed in   the
public

domain by the original author.

In a  message dated 5/28/2009 8:41:58 A.M. Central Daylight Time,   
pbjorn at emh.org writes:

I assume  there are no patient privacy  regulations in effect?  

Else, we  should be careful how (or  even IF) we discuss these details in
an 
open global   forum.

Pret

-----Original Message-----
From:   trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]  On  Behalf Of julie miller
Sent: Wednesday, May 27, 2009 7:11  PM
To:  Trauma-List [TRAUMA.ORG]
Subject: Re: Blind burr holes -  word from the  source

OK, have just got off the phone with  neurosurgeon involved -  David 
Wallace. Here is his account:

-  there was NO CT scan done
-  the child had a bruise just superior and  anterior to the right ear
- the  child had a fixed, dilated right  pupil and was coning (I think he

said  something like 'opposite  clonic attack')
- the neurosurgeon  took the  call at 10am from a  general practitioner
(not 
a surgeon)
- they found a  household  drill in the hospital kitchen and dipped the
tip 
in  alcohol-iodine  solution
- the GP didn't know how to put the drill  together - someone had  to do
it 
for him
- he drilled through  both tables of skull and enlarged the  hole with
bone 
forceps with  the neurosurgeon talking him through it on  speakerphone
- he was able  to suction out 20 mls of blood.
- the  pressure head was relieved and  the pupil came right down
- a drain tube was  placed and he was  airlifted to the Royal Children's 
Hospital where he had a  "big  craniotomy" within a few hours
- there was still considerable clot  and  the artery was still bleeding
- the child was extubated that  evening and  was fine
- he was discharged home post-op day  3

Furthermore, this  neurosurgeon (with 35 years experience) told  me of
two 
other cases in his  professional memory where country  general surgeons 
performed burr holes and  then let the patients wake  up intact and go
home
without 
referral to a  neurosurgeon for  formal craniotomy. One patient (a 16
year 
old girl) died at  home  later that night and the other is still in a 
persistent vegetative   state now 20 years later.

So I suppose the lesson is that burr  holes  are a good temporizing
measure 
for someone in extremis to  take the pressure  off until they reach 
definitive care, but on their  own won't solve the   problem.

Regards,
Julie

________________________________
From:   "mvossak at yahoo.co.uk" <mvossak at yahoo.co.uk>
To:   trauma-list at trauma.org
Sent: Thursday, May 28, 2009 12:26:46  AM
Subject:  re: Blind burr holes

Thanks for the reference,  Matt. Maurice King  also covers the subject 
thoroughly in his  "Primary Surgery". Julie, I would  love to know
whether
this  
patient had a scan. Perhaps the life saving blind  burr hole is  the
stuff of

surgical legend, not surgical myth as I have   recently been suspecting!

A neurosurgeon friend of mind drilled  six  when their scanner was
broken. 
The clot was eventually found  at autopsy in the  posterior fossa.

Maybe instant gratification  will come with the next  one... 

Miranda
Worcester South  Africa.

Miranda

I  think most people who work in developed  countries don't get it. One
has  
to
do what one can do with the  facilities you have. In Rwanda and  similar
places a dropping  conscious level with localising  signs/fracture/blown  
pupil
mandate exploratory burr holes: 3 on each side.  There will  be a lot of
negative burr holes, but there is no way you can  avoid  that. A fracture
in
the temporal fossa with a lucid interval will   have a high yield of
extradurals.

If you have an X-ray machine  you  can see where a fracture is and that
then
becomes the most  likely site of  mischief. You could also do a direct
puncture carotid  angiogram and take a  couple of films which could show
you  
a
midline shift or  haematoma.

If you have a CT scanner  then you get the most accurate info  and do not
do
negative burr  holes.

Check  out
http://openlibrary.org/b/OL10554765M/Neurosurgery-in-the-Tropics

Matt   Oliver
Bendigo
Australia

-----Original  Message-----
From:  trauma-list-bounces at trauma.org  
[mailto:trauma-list-bounces at trauma.org]
On  Behalf Of Miranda  Voss
Sent: Tuesday, 26 May 2009 11:27 PM
To:   trauma-list at trauma.org
Subject: Re: Blind burr holes

No,  truly  blind, most recently in Burundi just after the war when  we
couldn't even  get a plain x ray.

Didn't realise the  Australian case was post-scan and  thought the
general
flavour of  the posts suggested that all you need in a  remote
environment is
a  Black and Decker, a doctor with a bit of backbone  and a  non
litiginous
environment and all will be well. Clearly not! My   misunderstanding.

It can be very difficult to find the clot without  a  scan and I hope I
never
have to do it  again.

Miranda  Voss
Worcester, South Africa.

The  Australian story was post-CT  demonstrating an  extra-axial
collection.....are your cases truly blind or  post CT?  -

-----Original Message-----
From:   trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]  On  Behalf Of Miranda Voss
Sent: Monday, 25 May 2009 9:00  p.m.
To:  trauma-list at trauma.org
Subject: Blind burr  holes

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
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