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VOMIT - Victim of Modern Imaging Technology

jjsurgmd at aol.com jjsurgmd at aol.com
Thu Aug 25 22:47:48 BST 2011


These conversations blow me away, having been a chief of trauma in two war zones and worked at several urban war zones do you folks not get it that you both are right depending on the situation that you and your patient find yourselves in,
Jj

Sent from my iPhone

On Aug 25, 2011, at 4:30 PM, "McSwain, Norman E" <nmcswai at tulane.edu> wrote:

> In your hospital the scans may take only 1-2 minutes but this is not reality. You are not counting the movement of the patient to and from radiography suite, the movement of the patient to the scanner, the set up of the scanner computer to make the images and the reconstruction of the images. Even with efficient personnel this takes upwards of 30 minutes
> 
> Norman
> Norman McSwain MD, FACS
> Professor, Tulane School of Medicine
> President, Orleans Parish Medical Society
> Trauma Director, Spirit of Charity Trauma Center, ILH/MCLNO 
> 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 Blueflightmedic
> Sent: Thursday, August 25, 2011 2:45 PM
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: VOMIT - Victim of Modern Imaging Technology
> 
> A sad story, but I can see how it happened. However, it is unfair and
> unreasonable to apportion blame here. Each was doing and trying their best,
> and a complication ensued. I have dealt with a patient who subsequently
> exsanguinated (in someone else's hands) from a torn intercostal artery which
> was not recognised at the time. 
> 
> Things happen very quickly in the patient with 'proper' trauma, and I have
> become enamoured of a swift 3 minute assessment in the ED, followed by a one
> of three decision from that; stay in ED for resuscitation including
> emergency surgery where necessary, go to theatre or go to CT.
> 
> I too am falling out of love with FAST; I get far more useful information
> from chest and pelvic plain films - and then cross-sectional imaging. Our CT
> scanners do head and neck in under a minute and the rest of the body in
> another two. 
> 
> I strongly disagree that clinical diagnostic skills are useful and should
> have primacy. Firstly, the patient has multiple problems and you will only
> pick up a proportion. Secondly, those that are obvious are those that are
> most painful or least amenable to repair and will distract you. Thirdly, you
> simply do not have time in the critical, unstable patient to do your
> assessment properly and calmly. CT Imaging will give you that information,
> and your radiology colleague can be reviewing 1000 slices while you continue
> resuscitation.
> 
> The acronym may be amusing to the slack-jawed but it is not true.
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Sanjay Gupta
> Sent: 25 August 2011 15:19
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: VOMIT - Victim of Modern Imaging Technology
> 
> Well, so it was decided to a CT of this patient's head - an extradural
> hematoma was found which was drained.  In the OR, the neurosurgeon wanted to
> maintain his MAP above 60/65 mm Hg, but the trauma surgeon said that there
> is a traumatic rupture of aorta and so they could not let the patient have a
> systolic above 90.  I do not know what happened between them finally, but
> they were not friends any longer after the OR conversation.  Anyhow, the
> patient was taken to the radiology / IR suite after that and an angiogram
> was performed - all great vessels were normal.  The patient was transferred
> to the ICU - 
> 
> and just let me complete the whole thing.  I feel like an examiner in the
> American Board of Surgery, screwing a smart alec of a candidate. 
> 
> Still no CT - no need as VOMIT may happen.
> 
> In the ICU, the patient had a drop in his blood pressure after about 2 hours
> along with a severe tachycardia.   He was taken to the OR because of the
> free fluid in his abdomen on the fast exam - a small amount of
> hemoperitoneum was found and there was a non-bleeding liver laceration.  But
> there was a large hematoma around the iliac artery and on exploring this it
> was found that the angiogram access site was bleeding copiously into the
> retroperitoneum.  The artery was repaired.  The patient lost an estimated
> 2.5 litres of blood (to do a test which was completely useless in the
> end).  He became severely hypotensive in the OR.  However, survived and was
> taken back to the ICU.  However, after the hypotensive episode, the patient
> never really regained consciousness and stayed at a GCS of 4 for the next 2
> weeks.   Family decided to withdraw care and the trauma surgeon was nice
> enough to send them flowers. 
> 
> 
> So, following this great protocol being touted on the trauma list (that is,
> no CT scans, no IV lines, no IV fluids) a young patient with an extradural
> hematoma - with no other significant injuries essentially became brain
> dead.  
> 
> 
> A CT scan is a non-invasive test - at most this guy's kidneys would have
> been knocked out.  We would have ruled out any significant aortic injury,
> would have figured out that abdomen is not a concern in this patient, and
> would have avoided a major arterial bleed. Also, would have been able to
> maintain an adequate perfusion pressure to this patient's brain at all times
> and would probably have diagnosed the epidural hematoma before his
> conciousness level deteriorated.  
> 
> Comments - are appreciated. 
> 
> I know this list is not peer- reviewed, but let us try to at least make it
> reasonable.  
> 
>  
> Sanjay Gupta
> 
> From: Kmattox <kmattox at aol.com>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Cc: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Wednesday, August 24, 2011 11:02 PM
> Subject: Re: VOMIT - Victim of Modern Imaging Technology
> 
> Finish the CT of the head.  Cut his head appropriately.  Reassess abdomen.  
> 
> k
> 
> Sent from my iPhone
> 
> On 2011-08-24, at 10:07 PM, Sanjay Gupta <sanjaygupta99_91 at yahoo.com> wrote:
> 
>> Well, this patient had come into a level 1 trauma center.  When he was
> being transferred to the radiology suite, within 3 minutes of reaching the
> trauma center (especially as no line had been deemed necessary), his
> consciousness level deteriorated to a GCS of 5 and his right pupil was
> noticed to be larger.  What to do next?
>>   
>> Sanjay Gupta
>> 
>> 
>> ________________________________
>> From: Kmattox <kmattox at aol.com>
>> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
>> Cc: "trauma-list at trauma.org" <trauma-list at trauma.org>
>> Sent: Wednesday, August 24, 2011 5:24 PM
>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>> 
>> I would put pt on afterlife reduction, cut his abdomen, starting venous
> access in the OR for 1:1:1 blood, plasma, platelets.    If no aortogram
> capability by radiology, I would make the best thoracic injury I could with
> the screening tests available to me.    
>> 
>> k
>> 
>> Sent from my iPhone
>> 
>> On 2011-08-24, at 6:01 PM, Krin135 at aol.com wrote:
>> 
>>> Dr. Mattox:
>>> 
>>> What if you were working at a smaller (level III) center without rapid  
>>> angio capability, and was not able to transfer the patient in a
> reasonable  
>>> period of time?
>>> 
>>> Would you still want more radiographs, or would you proceed to the test
> of  
>>> Bard-Parker?
>>> 
>>> ck
>>> 
>>> 
>>> In a message dated 08/24/11 14:58:36 Central Daylight Time,
> kmattox at aol.com 
>>> writes:
>>> 
>>> Thoracic  aortogram.  If there had been a screening positive chest CT for
> 
>>> a  mediastinal hematoma I would always also do a diagnostic thoracic  
>>> aortogram.    The physical exam would determine further tests on the 
> abdomen vs 
>>> straight to lap.    Increasingly I am using FAST only to  evaluate for 
>>> hemopericardium, not for any confusing belly  interpretations.    Sorry
> to not be 
>>> dogmatic enough, nut one states  a point to make a point.  
>>> 
>>> k
>>> 
>>> Sent from my iPhone
>>> 
>>> On  2011-08-24, at 4:21 PM, Sanjay Gupta <sanjaygupta99_91 at yahoo.com>  
>>> wrote:
>>> 
>>>> Dogmatism is a way of looking at facts - or rather a way of  refusing to
> 
>>> look at facts.
>>>> 
>>>> For instance: 
>>>> 
>>>> How do you manage a trauma patient who is hemodynamically stable,  with
> a 
>>> GCS of 9 and who has a widened mediastinum on a chest X-ray?  Lets  throw
> 
>>> in a positive FAST exam with fluid in the abdomen.  
>>>> 
>>>> 
>>>> Remember - no IV fluids, no IV lines, no CT  scans.
>>>> 
>>>> 
>>>> This is a "real world" example -  not  an uncommon scenario.
>>>> 
>>>> 
>>>> Sanjay  Gupta
>>>> 
>>>> 
>>>> From: Charles Brault  <c_brault at yahoo.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Wednesday, August 24, 2011 3:21  AM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> Dogmatisimes !
>>>> 
>>>> Is surprisingly ALWAYS coming  from other people 
>>>> 
>>>> Never quietly understood  that
>>>> 
>>>> Charles
>>>> 
>>>> From: Sanjay Gupta  <sanjaygupta99_91 at yahoo.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Tuesday, August 23, 2011 8:12  PM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> What I can figure out after all these discussions is - 
>>>> 
>>>> Trauma patient arrives, do not put in a line and certainly do not  give 
>>> crystalloids.  I am not sure about giving blood and if we do give  blood
> - do 
>>> we draw a specimen to cross-match or not.  Maybe a chest x-ray  will
> help.  
>>> If something is clinically obvious fix it.  If the  patient is
> hypotensive 
>>> - do some surgery based on clinical exam and chest  x-ray.  And if the 
>>> patient is hypotensive - again do not put in a line -  open the abdomen
> first, do 
>>> something and then see if a line will help.  
>>>> 
>>>> 
>>>> If not in shock - I am not clear what  to do - Whether send the patient 
>>> home or admit and observe his pulse, blood  pressure and GCS?  or there
> is 
>>> something else that needs to be  done.  
>>>> 
>>>> 
>>>> Never do a CT scan because  80% are useless - I thought the purpose of
> CT 
>>> scan is to figure out the 20% in  which it would be useful.  If we all
> knew 
>>> the 80% in whom the CT will not  be useful and also the 20% in which it 
>>> would be useful, I guess the scan will  not be done in anyone - I thought
> a CT 
>>> scan is a diagnostic test - not to  prove your clinical diagnosis. 
>>>> 
>>>> Oh yes - you pick up  VOMIT with CT scan.  Great acronym, makes you
> sound 
>>> very smart. 
>>>> 
>>>> Sanjay Gupta
>>>> 
>>>> From: caesar ursic  <cmursic at gmail.com>
>>>> To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org>
>>>> Sent: Tuesday, August 23, 2011 1:58  PM
>>>> Subject: Re: VOMIT - Victim of Modern Imaging Technology
>>>> 
>>>> *The, Dr. Mattox, you must be placing great faith in the sensitivity  of
> 
>>> the
>>>> supine AP portable chest x-ray to rule-out a thoracic aortic or  great 
>>> vessel
>>>> traumatic pseudoaneurysm.*
>>>> 
>>>> 
>>>> C.  Ursic, MD
>>>> Honolulu
>>>> 
>>>> 
>>>> 
>>>> On Mon, Aug 22,  2011 at 9:30 AM, <KMATTOX at aol.com> wrote:
>>>> 
>>>>> I know of  almost NO indications for an ACUTE CT OF THE CHEST following
>>>>> chest  trauma, especially blunt chest trauma.        Mediastinal  
>>> traverse
>>>>> following GSW,  maybe, depending on the finding of  the  initial plain 
>>> chest
>>>>> X-ray.
>>>>> 
>>>>> 
>>>>> k
>>>>> 
>>>>> 
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