List Archives

Sat Oct 31 01:26:04 GMT 2009

We know that the patient was female, ninety-two years old, shot in the Bronx
during the third week of October.  Narrows it down pretty nicely for anyone
who's curious.  You can Google this poor departed woman's identity, complete
with a photo, in about thirty seconds.  

Discussing her injuries in such detail, absent informed consent, is
absolutely a violation of federal privacy protections -- whether you believe
so or not.

Subscribers to the List should exercise better judgment.

Pret Bjorn, RN
Bangor, ME USA 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of galucas at att.net
Sent: Friday, October 30, 2009 7:55 PM
To: trauma-list at trauma.org
Subject: Re: Federal HIPAA Violations

I don't believe so.  No specific identifiers.  Age and wound do not tell who
that patient is.  Even if he told the weight, I don't know who that patient
could be.  And those cases are why we are here...To hear others' take on a
specific problem.  Thanks. Gayle
--
Gayle A. Lucas 

-------------- Original message from trauma-list-request at trauma.org:
-------------- 

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> When replying, please edit your Subject line so it is more specific 
> than "Re: Contents of trauma-list digest..." 
> 
> 
> Today's Topics: 
> 
> 1. Re: trauma-list Digest, Vol 76, Issue 35-Selective 
> Conservativestabs of the Abdomen (Paul Bailey) 
> 
> 
> ---------------------------------------------------------------------- 
> 
> Message: 1 
> Date: Tue, 27 Oct 2009 17:47:08 +0800 
> From: Paul Bailey 
> Subject: Re: trauma-list Digest, Vol 76, Issue 35-Selective 
> Conservativestabs of the Abdomen 
> To: "Trauma-List [TRAUMA.ORG]" 
> Message-ID: <28C17B51-ED91-49A7-BC3B-D0BA0854CD5C at gmail.com> 
> Content-Type: text/plain; charset=us-ascii; format=flowed; 
> delsp=yes 
> 
> I 
> 
> Sent from my iPhone 
> 
> On 27/10/2009, at 5:07 PM, "Pret Bjorn" wrote: 
> 
> > Dr. Teperman, unless your patient has consented to this discussion 
> > (see BTW, 
> > below), it is probably in violation of federal HIPAA restrictions. 
> > The 
> > penalties can be severe. 
> > 
> > We would all do well to take a lesson: the details of these cases 
> > belong to 
> > the patients, not us. 
> > 
> > Pret Bjorn, RN 
> > Bangor, ME USA 
> > 
> > 
> > -----Original Message----- 
> > From: trauma-list-bounces at trauma.org [mailto:trauma-list- 
> > bounces at trauma.org] 
> > On Behalf Of Teperman, Sheldon 
> > Sent: Monday, October 26, 2009 3:39 PM 
> > To: 'trauma-list at trauma.org' 
> > Subject: RE: trauma-list Digest, Vol 76, Issue 35-Selective 
> > Conservativestabs of the Abdomen 
> > 
> > 
> > 
> > Its funny-We have been trying to answer this very question up here 
> > in the 
> > Bronx. The question came about when we hired a bright young Surgeon 
> > who did 
> > his Trauma Fellowship at UC -Davis. Sal Ahmad came to us with a very 
> > aggressive bent on how to manage anterior stab wounds-that is to 
> > say- he 
> > wanted to operate on most of them -and that perhaps the air up here 
> > was too 
> > thin and we were not getting it right. So we made a bet. 
> > Sal spent the last three years looking at close to two 
> > hundred of 
> > these pts( isolated anterior stab wounds)- and we are in the process 
> > of 
> > submission. He did some fancy Artificial Neural Network Modeling- 
> > which I 
> > don't presume to understand. But bottom line- It would appear that 
> > Carter 
> > Nance and those that followed got it right. With conservative and 
> > selective 
> > management and with Liberal CT scanning ( which he says had a high 
> > positive 
> > predictive value-atleast for us). We managed not to loose a single 
> > Pt and 
> > had nary a missed injury. I agree with Dr. Brohi- that it has a lot 
> > to do 
> > with resources and how comfortable your people are with penetrating 
> > trauma. 
> > But clearly if your paying attention, you can watch lots of people 
> > without 
> > hurting them- and the CT helps with the watching 
> > 
> > ....Sheldon Teperman 
> > 
> > 
> > BTW - although we are presently writing about Stab wounds- We 
> > do 
> > specialize in another form of penetrating trauma in the Bronx... If 
> > you have 
> > been following the news coming out of NYC. A 92 year old Lady took a 
> > stray 
> > bullet through her living room window last week ( a gang thing maybe)- 
> > landing her in my OR. How that bullet found her retro hepatic cava 
> > is a 
> > mystery to me- but an even bigger mystery is how we think its fine 
> > that an 
> > 18 year old boy becomes a murderer with a gun, which if they ever 
> > find it, 
> > will have an over 90% chance of having gotten to him from a state 
> > with lax 
> > gun safety laws. Likely from a disreputable dealer or just as likely 
> > from an 
> > unregulated sale at a gun show. 
> > My older brother Lew is a Transplant surgeon- and he likes 
> > to say 
> > that when a trauma surgeon is looking at the Retrohepatic Cava- he is 
> > looking at the Pt's soul- which is Ascending to heaven. I think we 
> > all lost 
> > a bit of our collective souls that day... 
> > 
> > -----Original Message----- 
> > From: trauma-list-bounces at trauma.org [mailto:trauma-list- 
> > bounces at trauma.org] 
> > On Behalf Of trauma-list-request at trauma.org 
> > Sent: Monday, October 26, 2009 12:45 PM 
> > To: trauma-list at trauma.org 
> > Subject: trauma-list Digest, Vol 76, Issue 35 
> > 
> > Send trauma-list mailing list submissions to 
> > trauma-list at trauma.org 
> > 
> > To subscribe or unsubscribe via the World Wide Web, visit 
> > http://list.mistral.net/mailman/listinfo/trauma-list 
> > or, via email, send a message with subject or body 'help' to 
> > trauma-list-request at trauma.org 
> > 
> > You can reach the person managing the list at 
> > trauma-list-owner at trauma.org 
> > 
> > When replying, please edit your Subject line so it is more specific 
> > than "Re: Contents of trauma-list digest..." 
> > 
> > 
> > Today's Topics: 
> > 
> > 1. RE: selectice conservative management of stab injury abdomen- 
> > (Gross, Ronald) 
> > 2. RE: selectice conservative management of stab injury abdomen- 
> > (McSwain, Norman E Jr.) 
> > 3. RE: selectice conservative management of stab injury abdomen- 
> > (Gross, Ronald) 
> > 4. RE: selectice conservative management of stab injury abdomen- 
> > (McSwain, Norman E Jr.) 
> > 5. Re: selectice conservative management of stab injury abdomen- 
> > (Krin135 at aol.com) 
> > 6. RE: selectice conservative management of stab injury abdomen- 
> > (Gross, Ronald) 
> > 7. Re: selectice conservative management of stab injury abdomen- 
> > (Krin135 at aol.com) 
> > 8. RE: selectice conservative management of stab injury abdomen- 
> > (McSwain, Norman E Jr.) 
> > 9. RE: selectice conservative management of stab injury abdomen- 
> > (Gross, Ronald) 
> > 10. RE: selectice conservative management of stab injury abdomen- 
> > (Gross, Ronald) 
> > 11. Selective Conservative Management of ant/flank abdominal stab 
> > wounds: summary (Krin135 at aol.com) 
> > 12. Re: Selective Conservative Management of ant/flank abdominal 
> > stab wounds: sum... (Krin135 at aol.com) 
> > 13. RE: Selective Conservative Management of ant/flank abdominal 
> > stab wounds:summary (McSwain, Norman E Jr.) 
> > 14. RE: Selective Conservative Management of ant/flank abdominal 
> > stabwounds: sum... (McSwain, Norman E Jr.) 
> > 
> > 
> > ---------------------------------------------------------------------- 
> > 
> > Message: 1 
> > Date: Mon, 26 Oct 2009 08:44:47 -0400 
> > From: "Gross, Ronald" 
> > Subject: RE: selectice conservative management of stab injury abdomen- 
> > To: "'Trauma-List [TRAUMA.ORG]'" 
> > Message-ID: 
> > 
> > Content-Type: text/plain; charset="us-ascii" 
> > 
> > I will get a CT if I am suspicious for peritoneal involvement, but I 
> > do 
> > personally examine these patients on admission and every 4-6 hrs 
> > thereafter 
> > for 18-24 hours, after which they are sent home. My residents 
> > follow a 
> > similar exam schedule, but on alternate times, so that in reality the 
> > patients are seen almost every 2-3 hours. 
> > Ron 
> > 
> > -----Original Message----- 
> > From: trauma-list-bounces at trauma.org [mailto:trauma-list- 
> > bounces at trauma.org] 
> > On Behalf Of Sanjay Gupta 
> > Sent: Sunday, October 25, 2009 9:37 PM 
> > To: Trauma-List [TRAUMA.ORG] 
> > Subject: Re: selectice conservative management of stab injury abdomen- 
> > 
> > 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 
> > To: Trauma-List [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 
> > 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 
> > -- 
> > trauma-list : TRAUMA.ORG 
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> > 
> > 
> > 
> > 
> > -- 
> > trauma-list : TRAUMA.ORG 
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> > 
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> > 
> > ------------------------------ 
> > 
> > Message: 2 
> > Date: Mon, 26 Oct 2009 08:29:39 -0500 
> > From: "McSwain, Norman E Jr." 
> > Subject: RE: selectice conservative management of stab injury abdomen- 
> > To: "Trauma-List [TRAUMA.ORG]" 
> > Message-ID: 
> > 
> > Content-Type: text/plain; charset="us-ascii" 
> > 
> > Ron 
> > Why do you get a CT if you are " suspicious for peritoneal 
> > involvement"? 
> > What does it all? Does it change your treatment? 
> > 
> > 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 Gross, Ronald 
> > Sent: Monday, October 26, 2009 7:45 AM 
> > To: 'Trauma-List [TRAUMA.ORG]' 
> > Subject: RE: selectice conservative management of stab injury abdomen- 
> > 
> > I will get a CT if I am suspicious for peritoneal involvement, but I 
> > do 
> > personally examine these patients on admission and every 4-6 hrs 
> > thereafter for 18-24 hours, after which they are sent home. My 
> > residents follow a similar exam schedule, but on alternate times, so 
> > that in reality the patients are seen almost every 2-3 hours. 
> > Ron 
> > 
> > -----Original Message----- 
> > From: trauma-list-bounces at trauma.org 
> > [mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta 
> > Sent: Sunday, October 25, 2009 9:37 PM 
> > To: Trauma-List [TRAUMA.ORG] 
> > Subject: Re: selectice conservative management of stab injury abdomen- 
> > 
> > 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 
> > To: Trauma-List [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 
> > 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 
> > -- 
> > trauma-list : TRAUMA.ORG 
> > To change your settings or unsubscribe visit: 
> > http://www.trauma.org/index.php?/community/ 
> > 
> > 
> > 
> > 
> > -- 
> > trauma-list : TRAUMA.ORG 
> > To change your 
> 
> 
> ------------------------------ 
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe visit: 
> http://www.trauma.org/index.php?/community/ 
> 
> End of trauma-list Digest, Vol 76, Issue 37 
> ******************************************* 
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