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Mon Sep 14 19:56:20 BST 2009

Jeez, Rob.  Your accidental disrespect was peanuts compared to my
volitional variety.  

Give yourself a break.  Or learn to embrace the edge.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
Sent: Monday, September 14, 2009 2:05 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: TRANSMEDIASTINAL GSW

Well. I apologize for being too stupid to live and sending what was  
supposed to be a private post to the whole list. I would never be so  
disrespectful.

Thank you for addressing my question. The original post stated that  
the GSW was transmediastinal, presumably, as you say from info from  
the CXR. Given your feeling re: the utility of CT for vascular injury,  
I didn't see where a stop in CT would help the pt or you. Certainly  
not with our scanner in it's location. I understand that you can't fix  
bleeding in the resus area and I'm mindful of the utility of  
"hypotensive resuscitation". In RL sometimes it seems pts with really  
low bp will continue to trend down. It takes a few minutes to actually  
get to the OR even in the most extreme cases; call OR, blood bank,  
assemble operative and transport personnel, get to elevator and ride  
it up, etc. My surgical pack mates (not to mention anesthesia) feel  
strongly that operating on a pt with some bp is much more fun than one  
without any. So probably some type of fluids would be given to the pt  
as he is being processed to the OR, staying focussed on the fact that  
timely arrival in the OR is the point of the process.

What was the cause of your pt's intestinal ischemia? What was done  
about it and what do you think the course of her disease will be?  
Might I ask where pts like this that emergency/trauma surgery  
intervenes on go to the next day?

Rob Smith

On Sep 14, 2009, at 1:19 PM, KMATTOX at aol.com wrote:

>
>
> In a message dated 9/14/2009 12:08:37 P.M. Central Daylight Time,
> rfsmithmd at comcast.net writes:
>
> I  understand what you were saying. My question was really directed
> toward Dr. Mattox. If he thought CT scan had no value AND the pt  
> had  a
> bp of 40 because he also didn't want to do anything to improve his  bp
> (yeah I'm sure he would do nothing for someone who's bp is 40!!),  the
> why did he say he personally would have gotten a CT??? Of course  he
> didn't answer the question.
>
> What I would have done for the low BP is to go to the OR and control  
> the
> bleeding, not given "stuff" in the ambulance or ER.   My CT is  next  
> to the
> shock room and I would have looked for trajectory of the missile in  a
> mediastinal traverse.   However a close look at the chest X-ray   
> often tells you
> just what you need to do, as it was in this  case.    In this case the
> patient was hypotensive solely for what  was known to have been  
> happening in the
> Left chest, so make a left chest  incision.    BP is a very very poor
> indicator of status of  resuscitation.
>
> CT and CTA do have "some" (not no) value.   We really must  put into
> perspective, and in light of other findings, just why we are  
> getting  CTs at all.
> I had emergency surgery (and trauma) call yesterday, and  again was
> mislead.   A patient had been triaged to Medicine, because  of belly  
> pain, and the
> CT showed what the Radiology faculty stated was  air.  She had  
> abdominal
> pain from intestinal ischemia from low flow and at  laparotomy had  
> no air, and
> not really any  pathology.
>
> k
>
>
>
>
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TRANSMEDIASTINAL GSW