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Gross, Ronald Ronald.Gross at baystatehealth.org
Sat Aug 27 21:04:08 BST 2011

Make sure you check the soles every so often!!   :-)

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Blueflightmedic
Sent: Saturday, August 27, 2011 4:01 PM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: FAST

This is so similar to our experience that reading this is like wearing an
old pair of comfortable shoes!

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Doc Holiday
Sent: 27 August 2011 00:01
To: .Trauma List
Subject: RE: FAST

We don't do much FAST at all.
I'll split it into two parts, starting with the abdominal bits...
Also, please remember that for us trauma means BLUNT trauma.
For stable patients with the need for abdominal imaging, knowing that there
is some fluid within the peritoneal cavity is not really that helpful in
deciding the management plan. What WOULD help is to have a few things ruled
out, to define any pathology which is there (even without significant
intra-peritoneal bleed) - that's CT (which is where most people send FAST
+ve stable patients anyway!). We are guided by the recently accumulating
evidence for significant pathologies sometimes being found on patients with
substantial injury mechanisms BUT NO clinical evidence upon initial
examination, i.e. "nasty surprises". A GOOD CT tends not to miss these. We
prefer it to FAST as an "early alert" because FAST only warns us about
impending doom which is already peritoneally bleeding, while CT finds
impending doom which is not yet or never will bleed into the peritoneum.
E.g. some time back (non-specific for confidentiality reasons) we had just
such a patient I recall with very mild a
 bdo discomfort, mostly on one side, after a fall from a horse at a jump.
There were a couple of low rib fractures on that side, a wedgey T11 or T12
(can't recall which), a tiny pneumo-thorax and a mild early lung contusion,
no spleen or liver injury, but a dissecting renal artery with no blood flow
either into that kidney or into the peritoneum... Nice to be able to let the
urologist know that they DO have some work AND the anaesthetist to be told
about the pneumo before ventilation.
Some stable patients DO get FAST when we have a trainee or someone else who
wants to practise the skill...;-)
For "unstable" patients, we find that the majority of these are not "that
unstable" so as to be harmed by being resuscitated "around" a CT, so we do a
CT anyway. Before anyone asks, no, we have not yet had a patient deteriorate
while in CT and make us sorry we did it.
Proper unstable patients go to the operating theatres and the less time they
spend in the ED, the better. Our statistics show that our surgeons are NOT
often sorry for finding themselves having opened up an abdomen unnecessarily
in such patients, which implies to us that a FAST would not have been of
sufficient value to have waited for... Still, on a few such cases, FAST has
got done, but these are NOT AT ALL frequent... Obviously, there is a risk
that we do them so infrequently that they become less reliable, but then we
do have radiologists doing them and our EPs here do like ultrasound and use
it A LOT, just not FAST...
Bear in mind that our mechanism spectrum is different from the more
"penetratingly violent" parts of the world. Also, one advantage of living in
a small country is that our transport times to hospitals are short
generally. We also often have a doc at scene and on the helo for the nastier
cases. I DO NOT think that every one of us should have the same way of doing
things - as with many things, ther may be more than one good way...
We do pan-CT and we're finding that we're discharging EARLY and SAFELY (as
indicated by the stats for unexpected returns or adverse outcomes) many
patients who used to spend prolonged periods in hospital getting "observed"
and serially examined. As stated before, our stats overall for trauma are
doing VERY nicely, but this cannot be attributed to this aspect alone, of
I leave to a different issue the cardiac part of FAST, which can be done by
ANYONE, including nurses or medical students and can sometimes pre-warn of
something which could go wrong QUICKLY from "stable" to very not... For
significant chest mechanisms, many of us (myself included) will whip out the
probe for 5-10 seconds (LITERALLY) to exclude e pericardial effusion, then
leave the patient to go to CT - I don't bother to move the probe South. If
there IS an effusion, then we'll get ready just in case we need to do
something before or immediately after a CT, but this has not happened
recently enough for me to recall... 		 	   		  
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