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Fri May 29 11:58:33 BST 2009

Dr. Mattox,

I was (apparently unclearly) referring to HIPAA.  But since we're on the
subject: 

Our hospital provides multimedia telemedical consultations (real-time,
high-def, digital audio and video).  Imagine our surprise to discover
that a variety of rules (mostly but by no means exclusively related to
federal reimbursement) restrict these consultations to clinicians with
active privileges at the remote site.  

In other words, any of our docs who want to use the cameras have to be
credentialed at the referring hospital!  As you can imagine, with eleven
cameras on line, the administrative burdens are immense.

On a conventional telephone, we can offer all the advice and instruction
we want.  But not on camera.  How nutty is that?

Pret

-----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 12:10 PM
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

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