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Mon Oct 26 10:47:14 GMT 2009

Not certain if it may be part of your deft irony; but this Sanjay Gupta
is not THAT Sanjay Gupta.  Which is just as well all around.

Very Sincerely,
Wolf Blitzer 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Sunday, October 25, 2009 10:43 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: selectice conservative management of stab injury abdomen-

Dr Gupta, why not run a expose' of this controversy on your next CNN
segment?
I'll be happy for you to fly me up to Atlanta or NYC or wherever your
studios are to provide the "pro" argument (or the "con" argument, if
that's
what your producers need).  I'll even stay at the Airport La Quinta Inn
Express, to minimize expenses (I'm cheap like that).

C. Ursic, MD
general surgeon

On Sun, Oct 25, 2009 at 3:36 PM, Sanjay Gupta
<sanjaygupta99_91 at yahoo.com>wrote:

> Well,now that someone has brought this point up:
>
> How many of the trauma surgeons who are Professors in a University,
> actually admit the stable patients with penetrating trauma and with no
> peritoneal signs, and do not do a CT scan, and examine them at
admission and
> every 4 hours PERSONALLY thereafter, until the patient has either been
> cleared or a laparotomy has been decided upon.  (or is the job
delegated to
> the Trauma Chief resident who in turn delegates the job to the trauma
> intern).
>
> I ask the above question because in a typical level II trauma center
in a
> community hospital in the US, there is a single trauma surgeon who
covers
> trauma, the surgical ICU and the surgical emergencies.  He or she also
> cannot delegate the above responsibility to anyone else.
>
>
> Also, in those rare instances, when laparotomy is decided to be done
in a
> delayed fashion, what is your opinion about the medico-legal risk.
>
>
> Sanjay Gupta
>
>
> (No blackberry or I-phone.Do not care for one either)
>
>
>
> ----- Original Message ----
> From: caesar ursic <cmursic at gmail.com>
> To: Trauma-List [TRAUMA.ORG <http://trauma.org/>]
<trauma-list at trauma.org>
> Sent: Sun, October 25, 2009 3:47:14 PM
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> "*There are many paths that lead to the summit of one and the same
> mountain*
> "
>
> -Buddha
>
>
>
>
>
>
> On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>
wrote:
>
> > How you management the patient with a stabbed abdomen who is
> > haemodynamically normal and has no peritonitis is one of the
simplest
> > but hardest questions in modern trauma care.   Fundamentally there
are
> > a number of ways of managing these patients.  The reason why it
> > generates such debate is because it's fundamentally a question not
of
> > the patient but of the resources and expertise available.
> >
> > If you're in a hospital with lots of doctors & nurses, enough beds
and
> > low quality imaging or imaging expertise, then admission with
regular
> > haemodynamic observation and serial clinical examination has been
> > shown to be safe and effective.  This is the case in South Africa
> > where this management plan originated and also in many parts of the
> > world.  It should be considered the safe fall-back option.
> >
> > In our situation, beds are at a premium (especially monitored beds),
> > few doctors on call and a high possibility that patients will not be
> > reviewed by a surgeon until the next morning.  We also have 2
> > high-spec scanners on site and good on-call radiology coverage.  So
we
> > use CT as a screening tool.  NOT to diagnosis bowel injury (although
> > the new scanners are pretty good) but because if the wound track
> > clearly goes nowhere near anything important then we can discharge
the
> > patient.
> >
> > The literature does not support laparoscopy for these patients.
> > HOWEVER if you are in a hospital and there is an experienced
> > laparoscopic surgeon on call perhaps they can identify bowel
> > perforation (early) reliably.  (I don't believe you should be
looking
> > at laparoscopy for just diagnosing peritoneal penetration).  But
this
> > does require beds and operating room space etc etc.
> >
> > I also don't believe local wound exploration is a good test.  Nor do
I
> > think FAST is useful in these patients.  MRI??  Never seen any
> > literature to support it but it seems, for the moment at least, like
> > expensive overkill (compared to a high-quality CT).
> >
> > So - how you manage these patient depends less on the patient and
more
> > on clinical expertise and hospital resources at your disposal.
Hence
> > the arguments - we're all looking at this from different starting
> > points.
> >
> > Karim
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'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe:
All mimsy were the borogoves,
And the mome raths outgrabe.
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selectice conservative management of stab injury abdomen-