List Archives

Sun Dec 18 18:02:39 GMT 2011

I am not a lawyer, but if the ER Doc was a supervising attending per the  
requirements of the hospital, and the surgery resident was on call in the  
hospital, even in an absence of a surgical fellow or attending, then the ED 
doc  should have been able to supervise appropriately.

Invite the ACS and the Graduate Medical Education folks to  file a amicus 
briefs on the appeal....because otherwise, surgical  attendings (and by 
extension all other attendings) will be require to take in  house call....IIRC, 
this happened to the OB docs some time ago...

ck

In a message dated 12/18/11 08:20:43 Central Standard Time,  
jrhmdtraum at aol.com writes:

Court  case
Anybody having this problem.
we recently lost a case where the  surgical resident was assisting the ER 
doc during a code.
Suit that  resident was "unsupervised" by surgeon as ER doc not part of 
direct  supervision.
Judge upheld.

-----Original  Message-----
From: trauma-list-request  <trauma-list-request at trauma.org>
To: trauma-list  <trauma-list at trauma.org>
Sent: Sun, Dec 18, 2011 3:07 am
Subject:  trauma-list Digest, Vol 102, Issue 3

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Today's Topics:

1. RE:  case for comment please (Jenny Moncur)
2. Re: case for comment  please (Stephen Richey)
3. Re: case for comment please (julie  miller)
4. Re: case for comment please (Sanjay  Gupta)
5. Re: case for comment please  (medic541 at comcast.net)
6. Re: case for comment please (Gustavo  E. Flores Bauer)
7. Managers (rm khattar)
8.  Re: case for comment please (Gustavo Flores)
9. Re:  trauma-list Digest, Vol 102, Issue 2 (rm  khattar)

----------------------------------------------------------------------

Message:  1
Date: Sun, 18 Dec 2011 21:57:46 +1100
From: "Jenny Moncur"  <jmoncur at netspace.net.au>
Subject: RE: case for comment please
To:  "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:  <000001ccbd73$e2f7ef90$a8e7ceb0$@netspace.net.au>
Content-Type:  text/plain;    charset="iso-8859-1"

Thanks for reply,  Stephen
I feel the same, but will have  a hard time justifying that  when I have a
clinical review (which I WILL have - just a matter of  time).

jenny 

-----Original Message-----
From:  trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]
On  Behalf Of Stephen Richey
Sent: Sunday, 18 December 2011 9:54 PM
To:  Trauma-List [TRAUMA.ORG]
Subject: Re: case for comment  please

Honestly, I would not have even done as much as you did.   He was in an
agonal rhythm when you found him and was pulseless prior to  your arrival.
No reason to work him.

On Sun, Dec 18, 2011 at 5:49  AM, Jenny Moncur <jmoncur at netspace.net.au>
wrote:
> 35 yo male  motor bike rider around sweeping bend into a large tree at 
> approx.  100 km/hr.
>
> Bystanders arrive approx. five mins later (pt had  overtaken one of 
> them a few miles before that travelling at high  speed).
>
> No response, no spontaneous movement, 'snoring' type  breathing which 
> stopped a few minutes before paramedic  arrival.
>
> They did nothing apart from call emergency  services.
>
>
>
> O/A of paramedics pt non breathing,  no response to verbal or painful 
> stimulus, no pulse at  carotid.
>
> Monitor showed agonal cardiac rhythm of 38 but  slowing - asystole 
> after approx. 60 seconds.
>
> Pupils  fixed, dilated and non-reactive.
>
> Airway clear, no bleeding or  bruising evident around face or trunk, no 
> helmet damage (paramedics  removed helmet).
>
> Deep purplish colour on face and upper torso,  but pallor over abdo and 
> lower chest (like superior vena cava  syndrome, if you know what I mean).
>
> Probably massive pelvic  disruption just looking at the way his legs 
> were widely spread - I  suspect open book #.
>
>
>
> Treatment - IPPV with bag  valve mask - no change in rhythm.
>
> Decompressed both sides of  chest - no blood or air.
>
> CPR not  performed.
>
>
>
> We called it at that  stage.
>
> I honestly do not think we could have done anything for  this patient 
> that would have led to any meaningful outcome, as there  only two of us 
> and patient was down a steep embankment in a very  awkward position, 
> weighed approx 150 kg and closest other crews at  least 15 mins away.
>
> Closest level 1 trauma centre 40 mins by  air, but air support approx. 
> 20 mins  away.
>
>
>
> Should we or could we have done anything  else?
>
> Would welcome any  comments
>
>
>
> Jenny Moncur
>
> IC  Paramedic
>
> Victoria
>
>
>
> --
>  trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe  visit:
>  http://www.trauma.org/index.php?/community/

--
Stephen  Richey
Founder and Chief Researcher/Designer
Kolibri Aviation Safety  Research
5174-B Winterberry Circle
Indianapolis, IN  46254
317-985-4740

?"I think the best thing, and the only thing in  our infinite inadequacy in
making up for the loss of life, is to say  something we have been able to 
say
in a lot of other accidents to grieving  families. ?That is 'Those deaths
will not be in vain. We will not let them  be in vain. Every one of those
lives will be made to count in terms of  making sure that three, four, five
or ten other people do not
die."-  John J. Nance
--
trauma-list : TRAUMA.ORG
To change your settings or  unsubscribe  visit:
http://www.trauma.org/index.php?/community/

------------------------------

Message:  2
Date: Sun, 18 Dec 2011 06:01:57 -0500
From: Stephen Richey  <stephen.richey at gmail.com>
Subject: Re: case for comment  please
To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:
<CAFhEgi3N0N3k7Bdf2nk3sGNpiKWyqLsBj3R9gRB0hTvQHX_VhQ at mail.gmail.com>
Content-Type:  text/plain; charset=ISO-8859-1

I would have had a tougher time  justifying working him during our
clinical reviews back when I still worked  full time in EMS.  I think
Dr. Mattox will probably have a thing or  two to say about the futility
of resuscitation in the face of unwitnessed  blunt traumatic arrest.

On Sun, Dec 18, 2011 at 5:57 AM, Jenny Moncur  <jmoncur at netspace.net.au> 
wrote:
> Thanks for reply,  Stephen
> I feel the same, but will have ?a hard time justifying that  when I have a
> clinical review (which I WILL have - just a matter of  time).
>
> jenny
>
>
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org  
[mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Stephen  Richey
> Sent: Sunday, 18 December 2011 9:54 PM
> To: Trauma-List  [TRAUMA.ORG]
> Subject: Re: case for comment please
>
>  Honestly, I would not have even done as much as you did. ?He was in an
>  agonal rhythm when you found him and was pulseless prior to your  
arrival.
> No reason to work him.
>
> On Sun, Dec 18, 2011  at 5:49 AM, Jenny Moncur <jmoncur at netspace.net.au>
>  wrote:
>> 35 yo male motor bike rider around sweeping bend into a  large tree at
>> approx. 100 km/hr.
>>
>>  Bystanders arrive approx. five mins later (pt had overtaken one of
>>  them a few miles before that travelling at high  speed).
>>
>> No response, no spontaneous movement,  'snoring' type breathing which
>> stopped a few minutes before  paramedic arrival.
>>
>> They did nothing apart from call  emergency services.
>>
>>
>>
>> O/A of  paramedics pt non breathing, no response to verbal or painful
>>  stimulus, no pulse at carotid.
>>
>> Monitor showed agonal  cardiac rhythm of 38 but slowing - asystole
>> after approx. 60  seconds.
>>
>> Pupils fixed, dilated and  non-reactive.
>>
>> Airway clear, no bleeding or bruising  evident around face or trunk, no
>> helmet damage (paramedics removed  helmet).
>>
>> Deep purplish colour on face and upper torso,  but pallor over abdo and
>> lower chest (like superior vena cava  syndrome, if you know what I mean).
>>
>> Probably massive  pelvic disruption just looking at the way his legs
>> were widely  spread - I suspect open book  #.
>>
>>
>>
>> Treatment - IPPV with bag  valve mask - no change in rhythm.
>>
>> Decompressed both  sides of chest - no blood or air.
>>
>> CPR not  performed.
>>
>>
>>
>> We called it at  that stage.
>>
>> I honestly do not think we could have done  anything for this patient
>> that would have led to any meaningful  outcome, as there only two of us
>> and patient was down a steep  embankment in a very awkward position,
>> weighed approx 150 kg and  closest other crews at least 15 mins away.
>>
>> Closest  level 1 trauma centre 40 mins by air, but air support approx.
>> 20  mins away.
>>
>>
>>
>> Should we or could  we have done anything else?
>>
>> Would welcome any  comments
>>
>>
>>
>> Jenny  Moncur
>>
>> IC Paramedic
>>
>>  Victoria
>>
>>
>>
>> --
>>  trauma-list : TRAUMA.ORG
>> To change your settings or unsubscribe  visit:
>>  http://www.trauma.org/index.php?/community/
>
>
>
>  --
> Stephen Richey
> Founder and Chief  Researcher/Designer
> Kolibri Aviation Safety Research
> 5174-B  Winterberry Circle
> Indianapolis, IN 46254
>  317-985-4740
>
> ?"I think the best thing, and the only thing in  our infinite inadequacy 
in
> making up for the loss of life, is to say  something we have been able to 
say
> in a lot of other accidents to  grieving families. ?That is 'Those deaths
> will not be in vain. We will  not let them be in vain. Every one of those
> lives will be made to  count in terms of making sure that three, four, 
five
> or ten other  people do not
> die."- John J. Nance
> --
> 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 settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/

--  
Stephen Richey
Founder and Chief Researcher/Designer
Kolibri  Aviation Safety Research
5174-B Winterberry Circle
Indianapolis, IN  46254
317-985-4740

?"I think the best thing, and the only thing in  our infinite
inadequacy in making up for the loss of life, is to say  something we
have been able to say in a lot of other accidents to  grieving
families. ?That is 'Those deaths will not be in vain. We will not  let
them be in vain. Every one of those lives will be made to count  in
terms of making sure that three, four, five or ten other people do  not
die."- John J.  Nance

------------------------------

Message: 3
Date:  Sun, 18 Dec 2011 03:18:21 -0800 (PST)
From: julie miller  <jamiller444 at yahoo.com>
Subject: Re: case for comment please
To:  "Trauma-List \[TRAUMA.ORG\]"  <trauma-list at trauma.org>
Message-ID:
<1324207101.68662.YahooMailNeo at web161605.mail.bf1.yahoo.com>
Content-Type:  text/plain; charset=us-ascii

Dear Jenny,
You have done exactly the  right thing - no hope of survival, and by having 
the 
courage to make the  right call you have also avoided wasting precious 
health 
care  resources.
Well done.
Julie Miller
RMH  Surgeon

>________________________________
> From: Jenny  Moncur <jmoncur at netspace.net.au>
>To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org> 
>Sent: Sunday, December 18, 2011 9:49  PM
>Subject: case for comment please
> 
>35 yo male motor  bike rider around sweeping bend into a large tree at
>approx. 100  km/hr.
>
>Bystanders arrive approx. five mins later (pt had  overtaken one of them a
>few miles before that travelling at high  speed).
>
>No response, no spontaneous movement, 'snoring' type  breathing which 
stopped
>a few minutes before paramedic  arrival.
>
>They did nothing apart from call emergency  services.
>
>
>
>O/A of paramedics pt non breathing,  no response to verbal or painful
>stimulus, no pulse at  carotid.
>
>Monitor showed agonal cardiac rhythm of 38 but slowing  - asystole after
>approx. 60 seconds.
>
>Pupils fixed,  dilated and non-reactive.
>
>Airway clear, no bleeding or bruising  evident around face or trunk, no
>helmet damage (paramedics removed  helmet). 
>
>Deep purplish colour on face and upper torso, but  pallor over abdo and 
lower
>chest (like superior vena cava syndrome, if  you know what I mean).
>
>Probably massive pelvic disruption just  looking at the way his legs were
>widely spread - I suspect open book #.  
>
>
>
>Treatment - IPPV with bag valve mask - no  change in rhythm.
>
>Decompressed both sides of chest - no blood  or air.
>
>CPR not performed.
>
>
>
>We  called it at that stage.
>
>I honestly do not think we could have  done anything for this patient that
>would have led to any meaningful  outcome, as there only two of us and
>patient was down a steep  embankment in a very awkward position, weighed
>approx 150 kg and  closest other crews at least 15 mins away. 
>
>Closest level 1  trauma centre 40 mins by air, but air support approx. 20
>mins  away.
>
>
>
>Should we or could we have done anything  else?
>
>Would welcome any  comments
>
>
>
>Jenny Moncur
>
>IC  Paramedic
>
>Victoria
>
>
>
>--
>trauma-list  : TRAUMA.ORG
>To change your settings or unsubscribe  visit:
>http://www.trauma.org/index.php?/community/
>
>
>    

------------------------------

Message: 4
Date: Sun, 18 Dec  2011 04:10:33 -0800 (PST)
From: Sanjay Gupta  <sanjaygupta99_91 at yahoo.com>
Subject: Re: case for comment  please
To: "Trauma-List \[TRAUMA.ORG\]"  <trauma-list at trauma.org>
Message-ID:
<1324210233.36130.YahooMailNeo at web38403.mail.mud.yahoo.com>
Content-Type:  text/plain; charset=iso-8859-1

No - the patient was dead when you  arrived. ?And with a 30 min transport 
time 
and 30 min extraction time -  would have become even more dead. ?Right 
decision 
not to carry on any  further than what you did.
?
Sanjay  Gupta

________________________________
From: julie miller  <jamiller444 at yahoo.com>
To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org> 
Sent: Sunday, December 18, 2011 6:18  AM
Subject: Re: case for comment please

Dear Jenny,
You have done  exactly the right thing - no hope of survival, and by having 
the 
courage  to make the right call you have also avoided wasting precious 
health 
care  resources.
Well done.
Julie Miller
RMH  Surgeon

>________________________________
> From: Jenny  Moncur <jmoncur at netspace.net.au>
>To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org> 
>Sent: Sunday, December 18, 2011 9:49  PM
>Subject: case for comment please
> 
>35 yo male motor  bike rider around sweeping bend into a large tree at
>approx. 100  km/hr.
>
>Bystanders arrive approx. five mins later (pt had  overtaken one of them a
>few miles before that travelling at high  speed).
>
>No response, no spontaneous movement, 'snoring' type  breathing which 
stopped
>a few minutes before paramedic  arrival.
>
>They did nothing apart from call emergency  services.
>
>
>
>O/A of paramedics pt non breathing,  no response to verbal or painful
>stimulus, no pulse at  carotid.
>
>Monitor showed agonal cardiac rhythm of 38 but slowing  - asystole after
>approx. 60 seconds.
>
>Pupils fixed,  dilated and non-reactive.
>
>Airway clear, no bleeding or bruising  evident around face or trunk, no
>helmet damage (paramedics removed  helmet). 
>
>Deep purplish colour on face and upper torso, but  pallor over abdo and 
lower
>chest (like superior vena cava syndrome, if  you know what I mean).
>
>Probably massive pelvic disruption just  looking at the way his legs were
>widely spread - I suspect open book #.  
>
>
>
>Treatment - IPPV with bag valve mask - no  change in rhythm.
>
>Decompressed both sides of chest - no blood  or air.
>
>CPR not performed.
>
>
>
>We  called it at that stage.
>
>I honestly do not think we could have  done anything for this patient that
>would have led to any meaningful  outcome, as there only two of us and
>patient was down a steep  embankment in a very awkward position, weighed
>approx 150 kg and  closest other crews at least 15 mins away. 
>
>Closest level 1  trauma centre 40 mins by air, but air support approx. 20
>mins  away.
>
>
>
>Should we or could we have done anything  else?
>
>Would welcome any  comments
>
>
>
>Jenny Moncur
>
>IC  Paramedic
>
>Victoria
>
>
>
>--
>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 settings or unsubscribe  visit:
http://www.trauma.org/index.php?/community/

------------------------------

Message:  5
Date: Sun, 18 Dec 2011 12:18:30 +0000
From:  medic541 at comcast.net
Subject: Re: case for comment please
To:  "trauma-list at trauma.org"  <trauma-list at trauma.org>
Message-ID:
<1262506050-1324210710-cardhu_decombobulator_blackberry.rim.net-1596459044-@
b28.c18.bise6.blackberry>

Content-Type: text/plain

Jenny,

You did a wonderful  job!  The fact that he was down a very steep 
embankment and 
that you  chose to not wait for an angle rescue team to have yourself 
lowered 
down  to him shows that you displayed bravery and commitment to your 
patient.  

He unfortunately put himself in that situation, not you!  From  the sounds 
of it, 
even if he was close to a trauma center/surgeon it  probably wouldn't have 
changed his outcome.  

Anthony  Caruso

Paramedic

-----Original Message-----
From: julie  miller <jamiller444 at yahoo.com>
Sender:  trauma-list-bounces at trauma.org
Date: Sun, 18 Dec 2011 03:18:21 
To:  Trauma-List \[TRAUMA.ORG\]<trauma-list at trauma.org>
Reply-To:  "Trauma-List \[TRAUMA.ORG\]" <trauma-list at trauma.org>
Subject: Re:  case for comment please

Dear Jenny,
You have done exactly the right  thing - no hope of survival, and by having 
the 
courage to make the right  call you have also avoided wasting precious 
health 
care resources.
Well  done.
Julie Miller
RMH  Surgeon

>________________________________
> From: Jenny  Moncur <jmoncur at netspace.net.au>
>To: Trauma-List [TRAUMA.ORG]  <trauma-list at trauma.org> 
>Sent: Sunday, December 18, 2011 9:49  PM
>Subject: case for comment please
> 
>35 yo male motor  bike rider around sweeping bend into a large tree at
>approx. 100  km/hr.
>
>Bystanders arrive approx. five mins later (pt had  overtaken one of them a
>few miles before that travelling at high  speed).
>
>No response, no spontaneous movement, 'snoring' type  breathing which 
stopped
>a few minutes before paramedic  arrival.
>
>They did nothing apart from call emergency  services.
>
>
>
>O/A of paramedics pt non breathing,  no response to verbal or painful
>stimulus, no pulse at  carotid.
>
>Monitor showed agonal cardiac rhythm of 38 but slowing  - asystole after
>approx. 60 seconds.
>
>Pupils fixed,  dilated and non-reactive.
>
>Airway clear, no bleeding or bruising  evident around face or trunk, no
>helmet damage (paramedics removed  helmet). 
>
>Deep purplish colour on face and upper torso, but  pallor over abdo and 
lower
>chest (like superior vena cava syndrome, if  you know what I mean).
>
>Probably massive pelvic disruption just  looking at the way his legs were
>widely spread - I suspect open book #.  
>
>
>
>Treatment - IPPV with bag valve mask - no  change in rhythm.
>
>Decompressed both sides of chest - no blood  or air.
>
>CPR not performed.
>
>
>
>We  called it at that stage.
>
>I honestly do not think we could have  done anything for this patient that
>would have led to any meaningful  outcome, as there only two of us and
>patient was down a steep  embankment in a very awkward position, weighed
>approx 150 kg and  closest other crews at least 15 mins away. 
>
>Closest level 1  trauma centre 40 mins by air, but air support approx. 20
>mins  away.
>
>
>
>Should we or could we have done anything  else?
>
>Would welcome any  comments
>
>
>
>Jenny Moncur
>
>IC  Paramedic
>
>Victoria
>
>
>
>--
>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 settings or unsubscribe  visit:
http://www.trauma.org/index.php?/community/

------------------------------

Message:  6
Date: Sun, 18 Dec 2011 08:32:37 -0400
From: "Gustavo E. Flores Bauer"  <gflores911 at gmail.com>
Subject: Re: case for comment please
To:  "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:  <9487DDA6-0B26-4115-B75A-C90DCA7BBA2F at gmail.com>
Content-Type:  text/plain;    charset=us-ascii

Why would your decision come  under scrutiny? Is it due to atempting 
something 
and then calling it quits  vs not doing anything and calling it from the 
beginning?

Gustavo E.  Flores Bauer, MD, EMT-P
Director, Emergency Response Training Center  (ERTCenter)
Cel.  787-630-6301

@gflores911
@ERTCenter
@FREMScom

www.uccaribe.edu/ERTC
www.facebook.com/ERTCenter

In  God we trust. All others bring data. 

Sent via iPhone.

On Dec  18, 2011, at 6:57 AM, "Jenny Moncur" <jmoncur at netspace.net.au>  
wrote:

> Thanks for reply, Stephen
> I feel the same, but will  have  a hard time justifying that when I have a
> clinical review  (which I WILL have - just a matter of time).
> 
> jenny 
>  
> 
> -----Original Message-----
> From:  trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]
>  On Behalf Of Stephen Richey
> Sent: Sunday, 18 December 2011 9:54  PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: case for comment  please
> 
> Honestly, I would not have even done as much as you  did.  He was in an
> agonal rhythm when you found him and was  pulseless prior to your arrival.
> No reason to work him.
>  
> On Sun, Dec 18, 2011 at 5:49 AM, Jenny Moncur  <jmoncur at netspace.net.au>
> wrote:
>> 35 yo male motor  bike rider around sweeping bend into a large tree at 
>> approx. 100  km/hr.
>> 
>> Bystanders arrive approx. five mins later (pt  had overtaken one of 
>> them a few miles before that travelling at  high speed).
>> 
>> No response, no spontaneous movement,  'snoring' type breathing which 
>> stopped a few minutes before  paramedic arrival.
>> 
>> They did nothing apart from call  emergency services.
>> 
>> 
>> 
>> O/A of  paramedics pt non breathing, no response to verbal or painful 
>>  stimulus, no pulse at carotid.
>> 
>> Monitor showed agonal  cardiac rhythm of 38 but slowing - asystole 
>> after approx. 60  seconds.
>> 
>> Pupils fixed, dilated and  non-reactive.
>> 
>> Airway clear, no bleeding or bruising  evident around face or trunk, no 
>> helmet damage (paramedics  removed helmet).
>> 
>> Deep purplish colour on face and  upper torso, but pallor over abdo and 
>> lower chest (like superior  vena cava syndrome, if you know what I mean).
>> 
>>  Probably massive pelvic disruption just looking at the way his legs  
>> were widely spread - I suspect open book #.
>>  
>> 
>> 
>> Treatment - IPPV with bag valve mask -  no change in rhythm.
>> 
>> Decompressed both sides of chest  - no blood or air.
>> 
>> CPR not performed.
>>  
>> 
>> 
>> We called it at that stage.
>>  
>> I honestly do not think we could have done anything for this  patient 
>> that would have led to any meaningful outcome, as there  only two of us 
>> and patient was down a steep embankment in a very  awkward position, 
>> weighed approx 150 kg and closest other crews  at least 15 mins away.
>> 
>> Closest level 1 trauma centre  40 mins by air, but air support approx. 
>> 20 mins away.
>>  
>> 
>> 
>> Should we or could we have done  anything else?
>> 
>> Would welcome any comments
>>  
>> 
>> 
>> Jenny Moncur
>> 
>>  IC Paramedic
>> 
>> Victoria
>> 
>>  
>> 
>> --
>> trauma-list : TRAUMA.ORG
>>  To change your settings or unsubscribe visit:
>>  http://www.trauma.org/index.php?/community/
> 
> 
> 
>  --
> Stephen Richey
> Founder and Chief  Researcher/Designer
> Kolibri Aviation Safety Research
> 5174-B  Winterberry Circle
> Indianapolis, IN 46254
> 317-985-4740
>  
>  "I think the best thing, and the only thing in our infinite  inadequacy 
in
> making up for the loss of life, is to say something we  have been able to 
say
> in a lot of other accidents to grieving  families.  That is 'Those deaths
> will not be in vain. We will not  let them be in vain. Every one of those
> lives will be made to count in  terms of making sure that three, four, 
five
> or ten other people do  not
> die."- John J. Nance
> --
> 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 settings or unsubscribe  visit:
>  http://www.trauma.org/index.php?/community/

------------------------------

Message:  7
Date: Sun, 18 Dec 2011 18:07:48 +0530 (IST)
From: rm khattar  <dr_rm_khattar at yahoo.co.in>
Subject: Managers
To:  trauma-list at trauma.org
Message-ID:
<1324211868.97740.YahooMailClassic at web95210.mail.in2.yahoo.com>
Content-Type:  text/plain; charset=utf-8

Talking of more managers than required .In  our hospital we have a joke 
going.We 
have one manager per  BED!
R.M.Khattar
Delhi  India.

------------------------------

Message: 8
Date:  Sun, 18 Dec 2011 08:57:48 -0400
From: Gustavo Flores  <gflores911 at gmail.com>
Subject: Re: case for comment please
To:  "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
Message-ID:
<CANRV9cnEnyWLjAjfd0LMRk5ZKhcT6WR7nfC+PL98eBa9_Bcw0w at mail.gmail.com>
Content-Type:  text/plain;  charset=UTF-8

http://emergency-medicine.jwatch.org/cgi/content/full/2011/1209/1

Consensus  Criteria Predict Futile Prehospital Trauma Resuscitation

*None of 294  patients had meaningful survival, and EMS resuscitation
triggered hospital  costs approaching $4 million.*

In 2003, the National Association of  Emergency Medical Services (EMS)
Physicians and the American College of  Surgeons Committee on Trauma
published guidelines on when to withhold or  terminate prehospital
resuscitation in traumatic cardiopulmonary arrest  (TCPA). Using data from a
level I trauma registry from 2003 through 2010,  researchers studied
prehospital TCPA patients aged [image: ?]18 years for  whom these guidelines
were violated. Criteria to withhold or terminate care  were (1) blunt trauma
with apnea, pulselessness, and no organized  electrocardiogram activity; (2)
penetrating trauma with the preceding  clinical presentation and no other
signs of life; (3) [image: ?]15 minutes  of cardiopulmonary resuscitation
without return of spontaneous circulation;  or (4) EMS-witnessed TCPA
followed by[image: ?]15 minutes of unsuccessful  resuscitation en route to
the emergency department (ED).

Among 294  patients, mechanism of injury was blunt in 90 (31%) and
penetrating in 204  (69%). Overall, 274 patients (93%) died in the ED, and
12 (4%) died during  surgery. Of the 8 patients who reached the intensive
care unit, 7 died in  the ICU, and 1 (0.3%) survived but had a Glasgow Coma
Scale score of 6 and  was discharged to a long-term care facility.

*Comment:* The charges for  hospital care for these 294 patients totaled
nearly US$4 million, and the  one surviving patient had a horrible outcome.
These data strongly support  the existing guidelines and the need to ensure
that EMS personnel  understand and adhere to them.

*? John A. Marx,  MD,
FAAEM<http://emergency-medicine.jwatch.org/misc/board_about.dtl#aMarx>
*

*Published  in* Journal Watch  Emergency
Medicine<http://emergency-medicine.jwatch.org/>
*December  9, 2011*
CITATION(S):

Mollberg NM et al. The consequences of  noncompliance with guidelines for
withholding or terminating resuscitation  in traumatic cardiac arrest
patients. *J Trauma* 2011 Oct;  71:997.

- Medline  
abstract<http://emergency-medicine.jwatch.org/cgi/external_ref?access_num=21986740&link_type=MED>
(Free)

Gustavo E. Flores Bauer, MD, EMT-P
Director,  UCC Emergency Response Training  Center
www.uccaribe.edu/ERTC
787-630-6301

Follow us  @
www.twitter.com/ERTCenter  <http://www.twitter.com/ertcenter>
www.facebook.com/ERTCenter  <http://www.facebook.com/ertcenter>

On Sun, Dec 18, 2011  at 8:18 AM, <medic541 at comcast.net> wrote:

>  Jenny,
>
> You did a wonderful job!  The fact that he was  down a very steep
> embankment and that you chose to not wait for an  angle rescue team to 
have
> yourself lowered down to him shows that you  displayed bravery and
> commitment to your patient.
>
> He  unfortunately put himself in that situation, not you!  From the  
sounds
> of it, even if he was close to a trauma center/surgeon it  probably 
wouldn't
> have changed his outcome.
>
> Anthony  Caruso
>
> Paramedic
>
> -----Original  Message-----
> From: julie miller <jamiller444 at yahoo.com>
>  Sender: trauma-list-bounces at trauma.org
> Date: Sun, 18 Dec 2011  03:18:21
> To: Trauma-List  \[TRAUMA.ORG\]<trauma-list at trauma.org>
> Reply-To: "Trauma-List  \[TRAUMA.ORG\]" <trauma-list at trauma.org>
> Subject: Re: case for  comment please
>
> Dear Jenny,
> You have done exactly the  right thing - no hope of survival, and by 
having
> the courage to make  the right call you have also avoided wasting precious
> health care  resources.
> Well done.
> Julie Miller
> RMH  Surgeon
>
>
> >________________________________
>  > From: Jenny Moncur <jmoncur at netspace.net.au>
> >To:  Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> >Sent:  Sunday, December 18, 2011 9:49 PM
> >Subject: case for comment  please
> >
> >35 yo male motor bike rider around sweeping  bend into a large tree at
> >approx. 100 km/hr.
> >
>  >Bystanders arrive approx. five mins later (pt had overtaken one of them 
 a
> >few miles before that travelling at high speed).
>  >
> >No response, no spontaneous movement, 'snoring' type  breathing which
> stopped
> >a few minutes before paramedic  arrival.
> >
> >They did nothing apart from call emergency  services.
> >
> >
> >
> >O/A of paramedics  pt non breathing, no response to verbal or painful
> >stimulus, no  pulse at carotid.
> >
> >Monitor showed agonal cardiac  rhythm of 38 but slowing - asystole after
> >approx. 60  seconds.
> >
> >Pupils fixed, dilated and  non-reactive.
> >
> >Airway clear, no bleeding or bruising  evident around face or trunk, no
> >helmet damage (paramedics removed  helmet).
> >
> >Deep purplish colour on face and upper  torso, but pallor over abdo and
> lower
> >chest (like superior  vena cava syndrome, if you know what I mean).
> >
>  >Probably massive pelvic disruption just looking at the way his legs  
were
> >widely spread - I suspect open book #.
> >
>  >
> >
> >Treatment - IPPV with bag valve mask - no change  in rhythm.
> >
> >Decompressed both sides of chest - no  blood or air.
> >
> >CPR not performed.
> >
>  >
> >
> >We called it at that stage.
> >
>  >I honestly do not think we could have done anything for this patient  
that
> >would have led to any meaningful outcome, as there only two  of us and
> >patient was down a steep embankment in a very awkward  position, weighed
> >approx 150 kg and closest other crews at least  15 mins away.
> >
> >Closest level 1 trauma centre 40 mins  by air, but air support approx. 20
> >mins away.
> >
>  >
> >
> >Should we or could we have done anything  else?
> >
> >Would welcome any comments
> >
>  >
> >
> >Jenny Moncur
> >
> >IC  Paramedic
> >
> >Victoria
> >
> >
>  >
> >--
> >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 settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
> --
> trauma-list :  TRAUMA.ORG
> To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
>

------------------------------

Message:  9
Date: Sun, 18 Dec 2011 18:37:17 +0530 (IST)
From: rm khattar  <dr_rm_khattar at yahoo.co.in>
Subject: Re: trauma-list Digest, Vol 102,  Issue 2
To: trauma-list at trauma.org
Message-ID:
<1324213637.60554.YahooMailClassic at web95203.mail.in2.yahoo.com>
Content-Type:  text/plain; charset=iso-8859-1

It has become knee jerk reaction to  order CT in abdominal cases.As Dr 
Mattox has 
been advocating on this  forum,every clinician must be clear in his 
mind,what 
does he expect in the  CT and how will it change the management.That will 
save 
enormous  unnecessary expenditure,radiation and save lot of time for the  
clinician.Requires certain amount of mental discipline not to prescribe CT  
lightly.
R.M.Khattar  

--- On Sun, 18/12/11,  trauma-list-request at trauma.org 
<trauma-list-request at trauma.org>  
wrote:

> From: trauma-list-request at trauma.org  <trauma-list-request at trauma.org>
> Subject: trauma-list Digest,  Vol 102, Issue 2
> To: trauma-list at trauma.org
> Date: Sunday, 18  December, 2011, 4:23 PM
> 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: reply to Mommy  (daniel.gerard at comcast.net)
> ???2. WARNING:? Re: reply to Mommy  (dgsweigert at juno.com)
> ???3. Vicki Tarnow is out of the office.
>  (Vicki Tarnow)
> ???4. Re: the working week (Miranda Voss)
> ???5.  RE: the working week (Doc Holiday)
> ???6. Best of the YEAR - Prize  (KMATTOX at aol.com)
> ???7. Question about fragmentation injury
>  (Matthieu Gensburger)
> ???8. Re: Question about fragmentation
>  injury (Raul Medina Mireles MD)
> ???9. Re: Question about  fragmentation
> injury (KMATTOX at aol.com)
> ? 10. Re: Question  about fragmentation injury (Raul
> Medina Mireles MD)
> ? 11. Re:  Question about fragmentation injury (kmattox at aol.com)
> ? 12. RE:  Question about fragmentation injury
> (McSwain, Norman E)
> ? 13.  Re: Question about fragmentation injury
> (Matthieu Gensburger)
>  ? 14. Re: Question about fragmentation injury (John
> Leslie)
> ?  15. RE: Question about fragmentation injury
> (McSwain, Norman  E)
> ? 16. RE: Question about fragmentation injury
> (McSwain,  Norman E)
> ? 17. Urgent (Patrick Greiffenstein)
> ? 18. RE:  Urgent (Vic Werlhof)
> ? 19. case for comment please (Jenny  Moncur)
> ? 20. Re: case for comment please (Stephen Richey)
>  
> 
>  ----------------------------------------------------------------------
>  
> Message: 1
> Date: Wed, 14 Dec 2011 00:33:26 +0000  (UTC)
> From: daniel.gerard at comcast.net
> Subject: Re: reply to  Mommy
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Cc: jc 13  <jc.13 at btinternet.com>
> Message-ID:
> ???  
<951840027.1072786.1323822806146.JavaMail.root at sz0163a.emeryville.ca.mail.comcast.net>
>  ??? 
> Content-Type: text/plain; charset=utf-8
> 
> I  believe that whoever sent this email out on our list had
> their email  account hacked. 
> 
> I would suggest to anyone receiving this  email not to click
> the link to avoid getting a virus. 
>  
> Daniel 
> 
> 
> Daniel R. Gerard, MS, RN, NREMT-P  
> Secretary - International Association of Emergency Medical
>  Services Chief's 
> 
> http://www.linkedin.com/in/dangerard  
> 
> http://www.iaemsc.org/index.html 
> 
> -----  Original Message -----
> From: "Ronald Gross"  <Ronald.Gross at baystatehealth.org>
> 
> To: "Trauma-List  [TRAUMA.ORG]" <trauma-list at trauma.org>,
> "jc 13"  <jc.13 at btinternet.com>
> 
> Sent: Tuesday, December 13, 2011  2:15:24 PM 
> Subject: RE: reply to Mommy 
> 
> Anyone know  how this crap got onto "our" website? 
> 
> Ron 
> 
>  
> -----Original Message----- 
> From:  trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Gideon Chilton  
> Sent: Tuesday, December 13, 2011 5:05 PM 
> To:  trauma-list at trauma.org;
> jc.13 at btinternet.com
> 
> Subject:  reply to Mommy 
> 
> 
>  http://football.thetinymite.com/pictures/upgrade/q096.php?m2hzj
>  
> 
> -- 
> trauma-list : TRAUMA.ORG 
> To change your  settings or unsubscribe visit: 
>  http://www.trauma.org/index.php?/community/ 
> 
>  ----------------------------------------------------------------------
>  
> Please view our annual report at  http://baystatehealth.org/annualreport 
> 
> 
>  CONFIDENTIALITY NOTICE: This e-mail communication and any
> attachments  may contain confidential and privileged
> information for the use of the  designated recipients named
> above. If you are not the intended  recipient, you are hereby
> notified that you have received this  communication in error
> and that any review, disclosure, dissemination,  distribution
> or copying of it or its contents is prohibited. If you  have
> received this communication in error, please reply to the
>  sender immediately or by telephone at 413-794-0000 and
> destroy all  copies of this communication and any
> attachments. For further  information regarding Baystate
> Health's privacy policy, please visit  our Internet site at
> http://baystatehealth.org. 
> -- 
>  trauma-list : TRAUMA.ORG 
> To change your settings or unsubscribe  visit: 
> http://www.trauma.org/index.php?/community/ 
> 
>  
> ------------------------------
> 
> Message: 2
>  Date: Wed, 14 Dec 2011 01:22:57 GMT
> From:  "dgsweigert at juno.com"
> <dgsweigert at juno.com>
> Subject:  WARNING:? Re: reply to Mommy
> To: trauma-list at trauma.org
> Cc:  trauma-list at trauma.org,
> jc.13 at btinternet.com
> Message-ID:  <20111213.192257.14607.0 at webmail-beta02.dca.untd.com>
>  Content-Type: text/plain; charset=windows-1252
> 
> 
> DO  NOT click on the link that was provided in the original
> spam message  to this list.
> 
> Ignore and delete.
> 
> I will  handle an investigation on this end.
> 
> Wheels are  turning.
> 
> D. G. Sweigert, PhD (ABD)
> HIPAA Security  Officer
> Berkeley, California
> 
> ---------- Original  Message ----------
> From: Gideon Chilton  <gidjam60 at live.co.uk>
> To:  <trauma-list at trauma.org>,
> <jc.13 at btinternet.com>
>  Subject: reply to Mommy
> Date: Tue, 13 Dec 2011 22:05:22 +0000
>  
> 
> 
>  http://football.thetinymite.com/pictures/upgrade/q096.php?m2hzj
> ?  ???
> ????????
> ?????? ???
> ? 
> --
>  trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
> 
>  
> ____________________________________________________________
>  Penny Stock Jumping 3000%
> Sign up to the #1 voted penny stock  newsletter for free
> today!
>  http://thirdpartyoffers.juno.com/TGL3131/4ee7fabd178f3b95790st05duc
>  
> 
> ------------------------------
> 
> Message:  3
> Date: Tue, 13 Dec 2011 22:01:41 -0600
> From: Vicki Tarnow  <VTarnow at iasishealthcare.com>
> Subject: Vicki Tarnow is out of  the office.
> To: "Trauma-List \[TRAUMA.ORG\]"  <trauma-list at trauma.org>
> Message-ID:
> ???  
<OF3A89D4CC.CBC5245B-ON86257966.001620B8-86257966.001620B8 at iasishealthcare.com>
>  ??? 
> Content-Type: text/plain; charset=US-ASCII
> 
>  
> I will be out of the office starting Thu 12/09/2011 and
> will  not return
> until Tue 12/20/2011.
> 
> If you have any  issues that come up and need to get in
> touch with me I can
> be  reached by my pager or cell, otherwise I will responsed
> to my  emails
> upon returning on? 12/20/2011.
> 
> 
>  
> ------------------------------
> 
> Message: 4
>  Date: Wed, 14 Dec 2011 07:56:30 +0000 (GMT)
> From: Miranda Voss  <mvossak at yahoo.co.uk>
> Subject: Re: the working week
> To:  "trauma-list at trauma.org"
> <trauma-list at trauma.org>
>  Message-ID:
> ???  <1323849390.12747.YahooMailNeo at web29509.mail.ird.yahoo.com>
>  Content-Type: text/plain; charset=utf-8
> 
> Gosh, Matt, how much  administration does a health service
> need? Apparently NHS admin costs  went up 50% between 2004
> and 2008, with GBP360 million a year being  spent on external
> management consultants  
(http://www.telegraph.co.uk/health/healthnews/6890335/Spending-on-NHS-bureaucracy-up-50-per-cent.html).
>  
> 
> 
> And they still expect consultants to spend up to a  quarter
> of their time on management and audit activities? It  looks
> as if NHS management has become a monster that creates  its
> own need, presumably this is a result of non medical
>  managers trying to control a process they don't understand
>  (healthcare) that has an intangible, unmeasurable outcome
> (health). I  suppose there is no chance of booting the MBAs
> out, as that would  imply a certain amount of trust in the
> medical profession.
>  
> Miranda
> Worcester
> South Africa (but no room for  complacency, we may go the
> same way) 
> 
> 
>  trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
> To explain  the working week in the UK:
> 
> Doctors
>  in training  work a maximum of a 48 hour working week. They
> can spend 
>  longer than this on call, but that is the maximum time in
> the  hospital. 
> This is new. Until recently it was a maximum 56  hours
> worked with a 
> maximum 72 hours total including on call  time.
> 
> For consultants, 
> there is a maximum working  week of 48 hours. This is a
> European 
> regulation. This  includes any time the consultant has to be
> in the 
> hospital so  if they are resident on call that counts
> towards the 48 
>  hours. Also if on call from home, travel time is included.
> This is  
> statutory rather than contractual.
> 
> There is also a  contractual 
> issue. The consultant contract is divided into  "Programmed
> Activities" 
> or PAs. A PA consitutes 4 hours of  work if worked Monday to
> Friday 7 am 
> to 7 pm or 3 hours at  other times. A PA does not have to be
> a block of 
> work. So for  example if on average over a year I work 3
> hours a week 
>  either coming in or dealing with phone calls while on call,
> that's one  
> PA per week even if in some weeks I do no on call work. The
>  standard 
> consultant contract is for 10 PAs, but some  consultants
> (probably most 
> full timers) are contracted for  more than this. Of these
> PAs, 2.5 are 
> usually for "Supporting  Professional Activities". This is
> stuff that 
> does not  directly impact on patient care and includes
> management,  audit,
>  professional development etc. The remaining PAs  are
> designated "Direct 
> Clinical Care" (even for lab  specialties and radiology).
> However this is
>  not all face  to face contact as it includes clinical
> paperwork.
> 
>  So
>  the 32 hour week isn't really true as such, but it's  quite
> likely that 
> some surgeons and anaesthesiologists will  spend under 32
> hours a week 
> working with patients.
>  
> On the question of the average, in my 
> experience most  surgeons and anaesthesiologists are
> contracted for 11 or
>   12 PAs, so will be doing a bit more. The rule on this is
> that as a  full
>  timer your first priority is to the NHS, so if you do  paid
> work outside
>  the NHS then you have to take on a  11th PA if asked to do
> so (otherwise
>  you forego pay  progression that year). If you don't do
> paid work 
> outside the  NHS, there is no such requirement. The
> additional PAs are 
>  paid at the same rate (so on 12 PAs you make 20% more than
> on  10)
> 
> On
>  top of this, a lot of surgeons and  anaesthesiologists
> (probably most in
>  Southern England-  which is more affluent) work a number of
> hours 
> outside the  NHS in private practice. This usually pays at a
> 
> substantially  higher hourly rate.
> 
> Another issue is that increasing numbers  of doctors are
> working part time.
> 
> Hope this answers  your question.
> 
> Matt Dunn
> 
>  ------------------------------
> 
> Message: 5
> Date: Thu,  15 Dec 2011 12:21:28 +0000
> From: Doc Holiday  <drydok at hotmail.com>
> Subject: RE: the working week
> To:  ".Trauma List" <trauma-list at trauma.org>
> Message-ID:  <SNT104-W550273A2B51B7D319BC9A8C0A30 at phx.gbl>
> Content-Type:  text/plain; charset="iso-8859-1"
> 
> 
> From:  mvossak at yahoo.co.uk
> > Gosh, Matt, how much administration does a  health
> service need? Apparently NHS admin costs went up 50%  between
> 2004 and 2008, with GBP360 million a year being spent  on
> external management consultants...
>  
> --> A  complex question.
> 1. I doubt you'll find good evidence to tell you how  much
> admin is needed. Even if you did re-define the question  by
> clarifying what the outcomes were against which the need  for
> management would be measured, I don't see how you could
>  produce good-level evidence
> 2. I am 100% certain that it's FAR LESS  than what there
> is!
> 3. The admin problem is well recognised,  but was not what
> Matt's e-mail was about - he was clarifying on  CLINICIAN
> consultant hours (not admin time). I think you are  mixing
> two types of "consultants" here. The "MBA types" might  well
> be the substance of this management inflation, but Matt  was
> providing a description (and an excellent summary, in my
>  opinion) of how a CLINICIAN consultant's time is divided.
>   
> > And they still expect consultants to spend up to a
>  quarter of their time on management and audit activities?
>   
> --> No. "They" don't. "We" have to fight to retain this
>  non-clinical time, for our sakes and our patients'. "They"
> would love  for there to be no-one else to get in their way,
> as they "manage"...  "They" dream of the day when surgeons
> would simply shut up and cut  things, radiologists would sit
> and read images where no-one could see  or hear them, EM
> consultants would hover at the hospital's door and  boot
> non-profitable cases out, physicians would do their  rounds
> and clinics and then go home and keep quiet...
>   
> First, let's quickly re-look at the numbers - most clinical
>  consultants are contracted for 11-12 PAs and only 2.5 are
>  "supportive". Using 2.5 out of 11.5, this is closer to a
> fifth  ;-)
>  
> Second, please note that management and audit are  but two
> of the list of items included in the 2.5 activities.  In
> Matt's e-mail "professional development" was also  mentioned,
> as was "etc"... Professional development includes  many
> things, but some examples are:
> - Time taken to improve  one's skills through simulation,
> practice, assessed practice, etc.  e.g. I use some such times
> to refine my intubation skills with  difficult airways,
> ultrasound skills, interpretation of complex  imaging
> (especially new modalities)
> - Time for the preparation  of lectures and their delivery
> - Time for the development of other  aspects of one's
> profession (not only the clinical ones) e.g. training  up on
> principles and concept to aid in the design of new
>  facilities for our service; improving interview techniques
> for when we  next recruit; developing new tools and databases
> for audits and  research in the department
> - Teaching on internal ATLS course and  other courses
> - Attending as candidates on internal courses and  lectures,
> e.g. Grand Rounds
> - M&M, quality control,  etc.
> - Work on departmental guidelines and their composition
> -  Research and related activities
> - etc. etc.
>  
>  Other activities, to add to these and to audit work are
> meetings with  other specialties to work up strategies for
> dealing with issues,  system-development, etc. All those
> things we want to happen that we  are NOT prepared to leavr
> to non-clinicians to "invent" and torture us  with ;-)
>  
> Consultants want these non-clinical supportive  activities,
> they think they are important and they want to be paid to  do
> them.
>  
> > It looks as if NHS management has  become a monster
> that creates its own need, presumably this is a  result of
> non medical managers trying to control a process they  don't
> understand
>  
> --> There is A LOT of waste  created by non-clinicians;
> you are right!
>  
> One  of the most important reasons, as I hope I have shown
> above, for why  surgeons, emergency physicians and ALL other
> specialists MUST have  this non-clinical time is in order for
> them to be able to take control  of these non-clinical
> aspects as well, when THEY see fit and AS they  see fit, so
> that there is less of a chance for non-clinicians to do  what
> you have correctly suggested they do!
>  
> The  huge increase in non-clinical-management-waste has come
> through  political intent from a previous government, but it
> is NOT DIRECTLY  RELATED to the non-clinical aspects of a
> clinician's job. It's a  different issue.
>  
> BTW, I am 100% convinced that this  paid non-clinical
> portion of a consultants' role is one of the major  factors
> in the REDUCTION/PREVENTION of burn-out as  well...
>  
> You could get a LOT more info by Google of  "consultant
> supporting professional activities".
> Try this link  for a nice document:  
http://www.bma.org.uk/employmentandcontracts/working_arrangements/job_planning/qualitytimespanov2010.jsp
>  ???
> ????????
> ?????? ???
> ? 
> 
>  ------------------------------
> 
> Message: 6
> Date: Fri,  16 Dec 2011 18:26:22 -0500 (EST)
> From: KMATTOX at aol.com
>  Subject: Best of the YEAR - Prize
> To: trauma-list at trauma.org
>  Cc: redstart at aol.com
> Message-ID:  <9a8f.988fd0b.3c1d2d9e at aol.com>
> Content-Type: text/plain;  charset="US-ASCII"
> 
> I wish to acknowledge that one of the  major medical centers
> in the world? 
> has given a PRIZE to its  TOP KNIFE NURSE of the?
> YEAR.? ? That prize is 
> travel,  registration, and hotel expenses to Trauma,
> Critical Care? & Acute  Care 
> Surgery 2011, the 45th anniversary year at the same  venue
> in? Caesars Palace 
> in Las Vegas, Nevada.? ???Wow, we  are
> honored? that this hospital honored 
> this program in this  way.? ???Of?
> course we would not be disappointed if every 
>  hospital, residency, trauma? fellowship, and surgical
> practice  developed a 
> similar recurrent prize to be? given to the best  of
> the best to? go? to the 
> best of? the? best.? ?
>  _www.trauma-criticalcare.com_ 
> (http://www.trauma-criticalcare.com)?  ?
> ???Do have a happy holiday season, stay warm,
> and stay  
> well.? ? See? many of you in Vegas in
> March.???
>   
> Kenneth L. Mattox, MD
> Course Director
> 
>  ------------------------------
> 
> Message: 7
> Date: Fri,  16 Dec 2011 19:14:34 +0100
> From: Matthieu Gensburger  <mat.genz at gmail.com>
> Subject: Question about fragmentation  injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:  <532B52A6-3FFB-45B7-A5C0-CABD7075FD3C at gmail.com>
> Content-Type:  text/plain; charset=us-ascii
> 
> Is it usual to find  intra-peritoneal or retro-peritoneal
> gaz bubbles on CT in patients  victim of fragmentation injury
> (grenade) in which no hollow viscus  injury was found during
> surgery?
> 
> Matthieu
>  
> ------------------------------
> 
> Message: 8
>  Date: Fri, 16 Dec 2011 19:08:54 -0700
> From: Raul Medina Mireles MD  <mylkas at prodigy.net.mx>
> Subject: Re: Question about  fragmentation injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???
>  <CAPiq5wKC2JGSqb9BSedFAr0e5roAaCkRBy9+3MmE2+2xZuDoVg at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
> 
> Not infrequent  at all...Practically all penetrant and
> perforant wounds are
>  detected to have a variable amount of gas visible on CT
> scanning. It  might
> be related to the wound ballistic effect of projectiles
>  itself, but in all
> cases, hollow viscus implication must be ruled  out.
> 
> Col Raul Medina M.
> Radiologist.
>  Chihuahua. Mexico.
> 
> 2011/12/16 Matthieu Gensburger  <mat.genz at gmail.com>
> 
> > Is it usual to find  intra-peritoneal or
> retro-peritoneal gaz bubbles on CT
> > in  patients victim of fragmentation injury (grenade)
> in which no  hollow
> > viscus injury was found during surgery?
>  >
> > Matthieu
> > --
> > trauma-list :  TRAUMA.ORG <http://trauma.org/>
> > To change your settings or  unsubscribe visit:
> >  http://www.trauma.org/index.php?/community/
> >
> 
>  
> ------------------------------
> 
> Message: 9
>  Date: Fri, 16 Dec 2011 21:30:13 -0500 (EST)
> From:  KMATTOX at aol.com
> Subject: Re: Question about fragmentation  injury
> To: trauma-list at trauma.org
> Message-ID:  <2603f.40811a44.3c1d58b4 at aol.com>
> Content-Type: text/plain;  charset="US-ASCII"
> 
> 
> First:???There is very little if  any reason
> to ever get a CT scan? in 
> penetrating trauma.? ?  
>  
> Second:???Gas in the tissues of both SW and
>  GSW is not???infrequent. 
>  
> Third:? ? Clinical evaluation  and looking at
> physiologic? symptoms is 
> always  wise
>  
> Fourth:???If you are STILL for whatever
>  reason getting CT scans? in 
> penetrating trauma,? there MUST be an  accompanying
> progress note???stating:? 
>  
> ? ?  a.???Just what do you expect
> to discover? that you did not? already?  
> know
>  
> ? ? b.???What are the
> positive?  and? negative and the VOMIT?
> implications 
> as to what you find  on CT?
>  
> ? ? c.? ? How is each of those
>  findings,? including? the Vomits GOING? TO 
> CHANGE YOUR TREATMENT  PLAN
>  
> If you cannot write a progress? note regarding  these
> issues,???DO? NOt 
> ORDER THE? CT? and if someone ordered  the CT
> prior to? you, the surgeon seeing 
> the patient, then  they must answer? these
> questions? to you.? ? ? 
>   
> k
>  
>  
>  
>   
>  
> In a message dated 12/16/2011 8:09:10 P.M. Central  Standard
> Time,? 
> mylkas at prodigy.net.mx
> writes:
>  
> Not? infrequent at all...Practically all penetrant and
>  perforant wounds? are
> detected to have a variable amount of gas  visible on CT
> scanning. It? might
> be related to the wound  ballistic effect of projectiles
> itself, but? in all
> cases,  hollow viscus implication must be ruled out.
> 
> Col Raul? Medina  M.
> Radiologist.
> Chihuahua. Mexico.
> 
> 2011/12/16  Matthieu? Gensburger <mat.genz at gmail.com>
> 
> > Is it  usual to find? intra-peritoneal or
> retro-peritoneal gaz bubbles on  
> CT
> > in patients? victim of fragmentation injury
>  (grenade) in which no hollow
> > viscus? injury was found during  surgery?
> >
> > Matthieu
> > --
> >?  trauma-list : TRAUMA.ORG <http://trauma.org/>
> > To change  your? settings or unsubscribe visit:
> >?  http://www.trauma.org/index.php?/community/
> >
> --
>  trauma-list :? TRAUMA.ORG
> To change your settings or unsubscribe?  visit:
> http://www.trauma.org/index.php?/community/
> 
>  
> 
> ------------------------------
> 
> Message:  10
> Date: Fri, 16 Dec 2011 20:49:38 -0700
> From: Raul Medina  Mireles MD <mylkas at prodigy.net.mx>
> Subject: Re: Question about  fragmentation injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???
>  <CAPiq5wK9_0jLOKYsmwaqKDLhk_HQvC=wZ60j1+OLHnCd1Fn=iw at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
> 
> speaking of  blast...fragmentation grenade...shrapnel...mmh.
> Well, you  could
> go *physiologic-symptom* until you cut and find  out...but,
> pherhaps the
> center of this matter isn?t WHAT is  going to CHANGE your
> plans, but HOW can
> you carry them out?  more readily. Should I recall what
> is also a well
> identified  risk of being a Victim Of Medical Imaging Taken
> OF Surgeon?s
>  Hurried Inappropiate Thinking?
> ;?
> RMM
> 
>  2011/12/16 <KMATTOX at aol.com>
> 
> >
> >  First:???There is very little if any
> reason to ever get a CT scan?  in
> > penetrating trauma.
> >
> > Second:???Gas in  the tissues of both SW
> and GSW is not???infrequent.
>  >
> > Third:? ? Clinical evaluation and looking at
>  physiologic? symptoms is
> > always wise
> >
> >  Fourth:???If you are STILL for whatever
> reason getting CT scans?  in
> > penetrating trauma,? there MUST be an
> accompanying  progress note???stating:
> >
> >? ? a.???Just what do  you
> expect to discover? that you did not? already
> >  know
> >
> >? ? b.???What are the
> positive? and?  negative and the VOMIT?
> implications
> > as to what you find  on CT?
> >
> >? ? c.? ? How is each of those
>  findings,? including? the Vomits GOING? TO
> > CHANGE YOUR TREATMENT  PLAN
> >
> > If you cannot write a progress? note  regarding
> these issues,???DO? NOt
> > ORDER THE? CT? and if  someone ordered the CT
> prior to? you, the surgeon
> >  seeing
> > the patient, then they must answer? these
>  questions? to you.
> >
> > k
> >
>  >
> >
> >
> >
> > In a message dated  12/16/2011 8:09:10 P.M. Central
> Standard Time,
> >  mylkas at prodigy.net.mx
> writes:
> >
> > Not?  infrequent at all...Practically all
> penetrant and perforant  wounds
> >? are
> > detected to have a variable amount of  gas visible on
> CT scanning. It? might
> > be related to the  wound ballistic effect of
> projectiles itself, but? in all
> >  cases, hollow viscus implication must be ruled out.
> >
> >  Col Raul? Medina M.
> > Radiologist.
> > Chihuahua.  Mexico.
> >
> > 2011/12/16 Matthieu? Gensburger  <mat.genz at gmail.com>
> >
> > > Is it usual to find?  intra-peritoneal or
> retro-peritoneal gaz bubbles on
> >  CT
> > > in patients? victim of fragmentation injury
>  (grenade) in which no hollow
> > > viscus? injury was found during  surgery?
> > >
> > > Matthieu
> > >  --
> > >? trauma-list : TRAUMA.ORG <http://trauma.org/>  <http://trauma.org/>
> >? > To change your? settings  or
> unsubscribe visit:
> > >?  http://www.trauma.org/index.php?/community/
> > >
> >  --
> > trauma-list :? TRAUMA.ORG <http://trauma.org/>
>  > To change your settings or unsubscribe? visit:
> >  http://www.trauma.org/index.php?/community/
> >
> >  --
> > trauma-list : TRAUMA.ORG <http://trauma.org/>
>  > To change your settings or unsubscribe visit:
> >  http://www.trauma.org/index.php?/community/
> >
> 
>  
> ------------------------------
> 
> Message: 11
>  Date: Fri, 16 Dec 2011 21:53:28 -0600
> From: kmattox at aol.com
>  Subject: Re: Question about fragmentation injury
> To:  trauma-list at trauma.org
> Message-ID:  <v3pahixav38bsu17dbqdify4.1324094008406 at email.android.com>
>  Content-Type: text/plain; charset=utf-8
> 
> But ct does not  improve decision making in such
> cases.? ? It casues MORE confusion.?  ?
> Much overused.? ? 
> 
> Sent from Samsung tablet
>  
> Raul Medina Mireles MD <mylkas at prodigy.net.mx>
>  wrote:
> 
> >speaking of blast...fragmentation
>  grenade...shrapnel...mmh. Well, you could
> >go *physiologic-symptom*  until you cut and find
> out...but, pherhaps the
> >center of  this matter isn?t WHAT is going to CHANGE
> your plans, but HOW  can
> >you carry them out? more readily. Should I recall
> what  is also a well
> >identified risk of being a Victim Of Medical  Imaging
> Taken OF Surgeon?s
> >Hurried Inappropiate  Thinking?
> >;?
> >RMM
> >
> >2011/12/16  <KMATTOX at aol.com>
> >
> >>
> >>  First:???There is very little if
> any reason to ever get a CT scan?  in
> >> penetrating trauma.
> >>
> >>  Second:???Gas in the tissues of
> both SW and GSW is  not???infrequent.
> >>
> >> Third:? ? Clinical  evaluation and
> looking at physiologic? symptoms is
> >>  always wise
> >>
> >> Fourth:???If you are STILL  for
> whatever reason getting CT scans? in
> >> penetrating  trauma,? there MUST be an
> accompanying progress  note???stating:
> >>
> >>? ? a.???Just what do  you
> expect to discover? that you did not? already
> >>  know
> >>
> >>? ? b.???What are the
> positive?  and? negative and the VOMIT?
> implications
> >> as to what  you find on CT?
> >>
> >>? ? c.? ? How is each of  those
> findings,? including? the Vomits GOING? TO
> >>  CHANGE YOUR TREATMENT PLAN
> >>
> >> If you cannot  write a progress? note
> regarding these issues,???DO? NOt
>  >> ORDER THE? CT? and if someone ordered
> the CT prior to? you,  the surgeon
> >> seeing
> >> the patient, then they  must answer? these
> questions? to you.
> >>
>  >> k
> >>
> >>
> >>
>  >>
> >>
> >> In a message dated 12/16/2011  8:09:10 P.M. Central
> Standard Time,
> >>  mylkas at prodigy.net.mx
> writes:
> >>
> >> Not?  infrequent at all...Practically all
> penetrant and perforant  wounds
> >>? are
> >> detected to have a variable  amount of gas visible
> on CT scanning. It? might
> >> be  related to the wound ballistic effect of
> projectiles itself, but? in  all
> >> cases, hollow viscus implication must be ruled
>  out.
> >>
> >> Col Raul? Medina M.
> >>  Radiologist.
> >> Chihuahua. Mexico.
> >>
>  >> 2011/12/16 Matthieu? Gensburger <mat.genz at gmail.com>
>  >>
> >> > Is it usual to find? intra-peritoneal  or
> retro-peritoneal gaz bubbles on
> >> CT
>  >> > in patients? victim of fragmentation
> injury (grenade) in  which no hollow
> >> > viscus? injury was found during
>  surgery?
> >> >
> >> > Matthieu
> >>  > --
> >> >? trauma-list : TRAUMA.ORG  <http://trauma.org/> <http://trauma.org/>
> >>? >  To change your? settings or
> unsubscribe visit:
> >> >?  http://www.trauma.org/index.php?/community/
> >> >
>  >> --
> >> trauma-list :? TRAUMA.ORG  <http://trauma.org/>
> >> To change your settings or  unsubscribe?
> visit:
> >>  http://www.trauma.org/index.php?/community/
> >>
> >>  --
> >> trauma-list : TRAUMA.ORG  <http://trauma.org/>
> >> To change your settings or  unsubscribe visit:
> >>  http://www.trauma.org/index.php?/community/
> >>
>  >--
> >trauma-list : TRAUMA.ORG
> >To change your  settings or unsubscribe visit:
>  >http://www.trauma.org/index.php?/community/
> 
>  ------------------------------
> 
> Message: 12
> Date: Fri,  16 Dec 2011 22:34:26 -0600
> From: "McSwain, Norman E"  <nmcswai at tulane.edu>
> Subject: RE: Question about fragmentation  injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???  <B79C02DCC4FA074DB02381DF1C5D60BA0571ED5E at EX07.ad.tulane.edu>
>  Content-Type: text/plain;???
> charset="us-ascii"
> 
> Once  again I am put in the disturbing position of having to
> agree  with
> Dr Mattox. :)
> But he is very correct. Carter Nance and  Isadore Cohn
> showed the
> importance of physical examination in  1964. No one has
> produced a better
> outcome with any advance in  technology since. We MUST teach
> our young
> residents the  importance of trusting your own physical
> examination. You
> get  a CT only when the physical exam produces questions.
> The decision  is
> whether to operate or not. The decision is NOT what organ
>  is injured.
> 
> Norman
> 
> Norman McSwain MD,  FACS
> Professor of Surgery, Tulane University
> Trauma director,  Spirit of Charity Trauma Center, ILH
> 504 988 5111
> 
>  -----Original Message-----
> From:  trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of  KMATTOX at aol.com
> Sent: Friday, December 16, 2011 8:30 PM
> To:  trauma-list at trauma.org
> Subject: Re: Question about fragmentation  injury
> 
> 
> First:???There is very little if any  reason
> to ever get a CT scan? in 
> penetrating trauma.? ?  
>  
> Second:???Gas in the tissues of both SW and
>  GSW is not???infrequent. 
>  
> Third:? ? Clinical evaluation  and looking at
> physiologic? symptoms is 
> always  wise
>  
> Fourth:???If you are STILL for whatever
>  reason getting CT scans? in 
> penetrating trauma,? there MUST be an  accompanying
> progress note
> stating:? 
>  
> ?  ? a.???Just what do you expect
> to discover? that you did not?  already
> 
> know
>  
> ? ? b.???What are  the
> positive? and? negative and the VOMIT
> implications  
> as to what you find on CT?
>  
> ? ? c.? ? How is  each of those
> findings,? including? the Vomits GOING
> TO  
> CHANGE YOUR TREATMENT PLAN
>  
> If you cannot write  a progress? note regarding these
> issues,???DO? NOt 
> ORDER THE?  CT? and if someone ordered the CT
> prior to? you, the surgeon
>  seeing 
> the patient, then they must answer? these
> questions?  to you.? ? ? 
>  
> k
>  
>   
>  
>  
>  
> In a message dated  12/16/2011 8:09:10 P.M. Central Standard
> Time,
>  mylkas at prodigy.net.mx
> writes:
> 
> Not? infrequent at  all...Practically all penetrant and
> perforant wounds
> are  detected to have a variable amount of gas visible on CT
> scanning.  It
> might be related to the wound ballistic effect of
>  projectiles itself,
> but? in all cases, hollow viscus implication must  be
> ruled out.
> 
> Col Raul? Medina M.
>  Radiologist.
> Chihuahua. Mexico.
> 
> 2011/12/16 Matthieu?  Gensburger <mat.genz at gmail.com>
> 
> > Is it usual to  find? intra-peritoneal or
> retro-peritoneal gaz bubbles 
> >  on
> CT
> > in patients? victim of fragmentation injury
>  (grenade) in which no 
> > hollow viscus? injury was found during  surgery?
> >
> > Matthieu
> > --
> >?  trauma-list : TRAUMA.ORG <http://trauma.org/> To change your? 
>  > settings or unsubscribe visit:
> >?  http://www.trauma.org/index.php?/community/
> >
> --
>  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 settings or  unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>  
> 
> ------------------------------
> 
> Message:  13
> Date: Sat, 17 Dec 2011 11:27:51 +0100
> From: Matthieu  Gensburger <mat.genz at gmail.com>
> Subject: Re: Question about  fragmentation injury
> To: "Trauma-List \[TRAUMA.ORG\]"  <trauma-list at trauma.org>
> Message-ID:  <C1C8C780-964F-4FDD-8909-AFB1A2AB0F01 at gmail.com>
> Content-Type:  text/plain; charset=us-ascii
> 
> Thank you all for your answers.  I 'am well aware of the
> Nance study in penetrating abdominal trauma,  although it is
> not clear to me if they also included patient with  injuries
> to the back, buttocks or thoraco-abdominal area. I  also
> wonder if their findings with SW and GSW can safely be
>  extrapolated to patient with multiple shrapnel injuries to
> the torso.  In the two (hemodinamicaly stable) patients I
> mentioned, clinical  findings alone mandated surgery, but
> getting (or not) the CT scan  wasn't my call. In my neck of
> the wood, penetrating trauma is rare and  high-energy
> shrapnel injury almost unheard off, so I guess  surgeons
> aren't very comfortable dealing with it. 
> 
> If  a non-operative management was chosen on clinical
> ground, what do you  think would be the role of CT scan?
> 
> Matthieu
> 
>  
> 
> 
> 
> 
>  ------------------------------
> 
> Message: 14
> Date: Sat,  17 Dec 2011 22:36:05 +1100
> From: John Leslie  <johnleslie48 at gmail.com>
> Subject: Re: Question about  fragmentation injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:  <016C7C6C-F276-4BAF-971D-ADB07A13496D at gmail.com>
> Content-Type:  text/plain;???
> charset=us-ascii
> 
> I wouldn't imagine  that many surgeons would be in any way
> comfortable with shrapnel  injuries, unless recently
> seriously involved in areas such as Iraq,  Afghanistan,
> Pakistan, ie even trauma surgeons in non war  zones.
> Certainly I would be enormously stressed, but also low
>  velocity GSWs and posterior stabs are also pretty
> worrying.? I am  learning a lot more about stabbings
> recently, particularly in Central  Australia, than where I
> spent most of my career in boring suburban  Melbourne.?
> 
> 
> What geographical area are you  from?
> 
> I am a remote area locum surgeon in Australia, where  remote
> really means remote, like sometimes hours from injury  to
> discovery, more hours for retrieval, and more again for
>  tertiary transfer if needed as is often the case.?
> ? I hope I never  see a grenade or IED injury - one of
> my residents was originally a  student and intern in Bagdhad
> and he has seen a lot in inadequately  resourced civilian
> hospitals, and he says it is just terrible, and  there is
> often just nothing that can be done.
> 
>  Personally, were I to embark on non surgical management on
> the basis  of clinical stability and lack of abdominal signs,
> I would probably  get a CT (were one available) despite what
> has been said by the  experts (mostly where they see various
> penetrating injuries on a daily  basis) I guess for my own
> reassurance and feelings of discomfort at  managing these
> injuries as anything else.? But in reality I think  one
> of the earlier responders was right; one should be  prepared
> to document a plan, and reasons for getting a CT and  what
> would be done differently dependent on findings, at least  in
> a trauma centre setting. However things are different in  the
> real world!
> 
> Regards
> 
> John Leslie  
> MB BS FRACS
> Australia
> 
> 0412528851
>  
> Sent from my iPad
> 
> On 17/12/2011, at 21:27, Matthieu  Gensburger <mat.genz at gmail.com>
> wrote:
> 
> >  Thank you all for your answers. I 'am well aware of
> the Nance study in  penetrating abdominal trauma, although it
> is not clear to me if they  also included patient with
> injuries to the back, buttocks or  thoraco-abdominal area. I
> also wonder if their findings with SW and  GSW can safely be
> extrapolated to patient with multiple shrapnel  injuries to
> the torso. In the two (hemodinamicaly stable) patients  I
> mentioned, clinical findings alone mandated surgery, but
>  getting (or not) the CT scan wasn't my call. In my neck of
> the wood,  penetrating trauma is rare and high-energy
> shrapnel injury almost  unheard off, so I guess surgeons
> aren't very comfortable dealing with  it. 
> > 
> > If a non-operative management was chosen on  clinical
> ground, what do you think would be the role of CT  scan?
> > 
> > Matthieu
> > 
> > 
>  > 
> > 
> > --
> > trauma-list :  TRAUMA.ORG
> > To change your settings or unsubscribe visit:
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> 
>  ------------------------------
> 
> Message: 15
> Date: Sat,  17 Dec 2011 12:45:02 -0600
> From: "McSwain, Norman E"  <nmcswai at tulane.edu>
> Subject: RE: Question about fragmentation  injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???  <B79C02DCC4FA074DB02381DF1C5D60BA0571ED6A at EX07.ad.tulane.edu>
>  Content-Type: text/plain;???
> charset="us-ascii"
> 
> If  clinical grounds are used to choose observational
> management.  The
> same applies. If there is no hemorrhage that requires
>  operative
> management the other organ system is the GI tract. This  Dx
> is made by
> presence or development of peritoneal signs. GI  tract
> injury in my hands
> cannot be determined by CT. Or at  least when CT signs are
> present, the
> peritoneal signs will  already manifested themselves. In
> other words the
> clinical  assessment by a good clinician is more effective
> than the CT
>  and certainly more accurate
> 
> For back injuries,? the concern  is renal. This should
> be noted by
> hematuria. At this time the  CT may be of assistance in
> determine the
> extent of the injury  and if operative or non-operative
> management is the
> correct  approach
> 
> In the patients that you discussed, if there were  clinical
> signs
> present, that is all the more reason to take  the patient
> immediately to
> the OR and not to the CT. One would  certainly not delay
> taking a patient
> to the OR with peritoneal  signs just because the CT was
> negative. The CT
> would not  change the location or the extent of the lap
> incision.
>  
> Norman
> 
> Norman McSwain MD, FACS
> Professor of  Surgery, Tulane University
> Trauma director, Spirit of Charity Trauma  Center, ILH
> 504 988 5111
> 
> 
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Matthieu  Gensburger
> Sent: Saturday, December 17, 2011 4:28 AM
> To:  Trauma-List [TRAUMA.ORG]
> Subject: Re: Question about fragmentation  injury
> 
> Thank you all for your answers. I 'am well aware of  the
> Nance study in
> penetrating abdominal trauma, although it  is not clear to
> me if they
> also included patient with injuries  to the back, buttocks
> or
> thoraco-abdominal area. I also wonder  if their findings
> with SW and GSW
> can safely be extrapolated  to patient with multiple
> shrapnel injuries to
> the torso. In  the two (hemodinamicaly stable) patients I
> mentioned,
> clinical  findings alone mandated surgery, but getting (or
> not) the CT
>  scan wasn't my call. In my neck of the wood, penetrating
> trauma is  rare
> and high-energy shrapnel injury almost unheard off, so I
>  guess surgeons
> aren't very comfortable dealing with it. 
>  
> If a non-operative management was chosen on clinical
> ground,  what do you
> think would be the role of CT scan?
> 
>  Matthieu
> 
> 
> 
> 
> --
> trauma-list :  TRAUMA.ORG
> To change your settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
> 
> 
>  ------------------------------
> 
> Message: 16
> Date: Sat,  17 Dec 2011 13:02:34 -0600
> From: "McSwain, Norman E"  <nmcswai at tulane.edu>
> Subject: RE: Question about fragmentation  injury
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???  <B79C02DCC4FA074DB02381DF1C5D60BA0571ED6B at EX07.ad.tulane.edu>
>  Content-Type: text/plain;???
> charset="us-ascii"
> 
> If I  were teaching my residents, I would divide the
> assessment  process,
> based on the potential injuries
> * hemorrhage is first  and most critical. Hemodynamic
> stability is the
> critical sign  Perhaps there are situations when a CTA is
> helpful but
> usually  not in the abdominal cavity. Chest radiograph and
> chest tube
>  drainage is the indication for CTA or angiography of
> thoracic  injuries.
> In the neck, the hard signs are important,? not CT
> *  Second is the GI tract. How is the best way to determine
>  injures:
> Physical findings? ? (CT adds nothing)
> * Third is the  retroperitoneal area. What is there? Kidney,
> ureter,
> bladder -  hematuria is the indication for further
> assessment. CT can be
>  helpful in the area. Pancreas- CT is not going to make you
>  operate.
> Spine proximity as seen on the abdominal film will  indicate
> if CT will
> be helpful or assessment
> * fourth  is soft tissue. Muscle and - fat hemorrhage is
> your indicator
>  
> I try to make the residents think...Judgment based on
>  knowledge
> 
> I am sure that Dr Mattox will have other thoughts  to add
> 
> Norman
> 
> Norman McSwain MD,  FACS
> Professor of Surgery, Tulane University
> Trauma director,  Spirit of Charity Trauma Center, ILH
> 504 988 5111
> 
>  
> -----Original Message-----
> From:  trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of McSwain, Norman  E
> Sent: Saturday, December 17, 2011 12:45 PM
> To: Trauma-List  [TRAUMA.ORG]
> Subject: RE: Question about fragmentation injury
>  
> If clinical grounds are used to choose observational
>  management. The
> same applies. If there is no hemorrhage that  requires
> operative
> management the other organ system is the GI  tract. This Dx
> is made by
> presence or development of  peritoneal signs. GI tract
> injury in my hands
> cannot be  determined by CT. Or at least when CT signs are
> present, the
>  peritoneal signs will already manifested themselves. In
> other words  the
> clinical assessment by a good clinician is more effective
>  than the CT
> and certainly more accurate
> 
> For back  injuries,? the concern is renal. This should
> be noted by
>  hematuria. At this time the CT may be of assistance in
> determine  the
> extent of the injury and if operative or non-operative
>  management is the
> correct approach
> 
> In the patients  that you discussed, if there were clinical
> signs
> present, that  is all the more reason to take the patient
> immediately to
> the  OR and not to the CT. One would certainly not delay
> taking a  patient
> to the OR with peritoneal signs just because the CT  was
> negative. The CT
> would not change the location or the  extent of the lap
> incision.
> 
> Norman
> 
>  Norman McSwain MD, FACS
> Professor of Surgery, Tulane  University
> Trauma director, Spirit of Charity Trauma Center,  ILH
> 504 988 5111
> 
> 
> -----Original  Message-----
> From: trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Matthieu  Gensburger
> Sent: Saturday, December 17, 2011 4:28 AM
> To:  Trauma-List [TRAUMA.ORG]
> Subject: Re: Question about fragmentation  injury
> 
> Thank you all for your answers. I 'am well aware of  the
> Nance study in
> penetrating abdominal trauma, although it  is not clear to
> me if they
> also included patient with injuries  to the back, buttocks
> or
> thoraco-abdominal area. I also wonder  if their findings
> with SW and GSW
> can safely be extrapolated  to patient with multiple
> shrapnel injuries to
> the torso. In  the two (hemodinamicaly stable) patients I
> mentioned,
> clinical  findings alone mandated surgery, but getting (or
> not) the CT
>  scan wasn't my call. In my neck of the wood, penetrating
> trauma is  rare
> and high-energy shrapnel injury almost unheard off, so I
>  guess surgeons
> aren't very comfortable dealing with it. 
>  
> If a non-operative management was chosen on clinical
> ground,  what do you
> think would be the role of CT scan?
> 
>  Matthieu
> 
> 
> 
> 
> --
> 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 settings or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
> 
> 
>  ------------------------------
> 
> Message: 17
> Date: Sat,  17 Dec 2011 13:53:40 -0600
> From: Patrick Greiffenstein  <patrickgmd at gmail.com>
> Subject: Urgent
> To:  trauma-list at trauma.org
> Message-ID:
> ???  <CALCJ2P=TMCM41KzYuuRgqpRaH9V9JgZR5SKeTENMpXWezhz8fw at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
> 
>  I was  impressed. It really works http://sit-n-bull.com/inf.php?Christmas
>  
> 
> ------------------------------
> 
> Message:  18
> Date: Sat, 17 Dec 2011 12:20:10 -0800
> From: "Vic Werlhof"  <werlhof at gmail.com>
> Subject: RE: Urgent
> To:  "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
>  Message-ID: <010c01ccbcf9$47992840$d6cb78c0$@com>
> Content-Type:  text/plain;???
> charset="us-ascii"
> 
> Spam!
>  
> -----Original Message-----
> From:  trauma-list-bounces at trauma.org
>  [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Patrick  Greiffenstein
> Sent: Saturday, December 17, 2011 11:54 AM
> To:  trauma-list at trauma.org
> Subject: Urgent
> 
>  I was  impressed. It really works http://sit-n-bull.com/inf.php?Christmas
>  --
> trauma-list : TRAUMA.ORG
> To change your settings or  unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>  
> 
> 
> ------------------------------
> 
>  Message: 19
> Date: Sun, 18 Dec 2011 21:49:36 +1100
> From: "Jenny  Moncur" <jmoncur at netspace.net.au>
> Subject: case for comment  please
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
>  <000401ccbd72$bd740340$385c09c0$@netspace.net.au>
> Content-Type:  text/plain;???
> charset="us-ascii"
> 
> 35 yo male motor  bike rider around sweeping bend into a
> large tree at
> approx.  100 km/hr.
> 
> Bystanders arrive approx. five mins later (pt had  overtaken
> one of them a
> few miles before that travelling at  high speed).
> 
> No response, no spontaneous movement, 'snoring'  type
> breathing which stopped
> a few minutes before paramedic  arrival.
> 
> They did nothing apart from call emergency  services.
> 
>  
> 
> O/A of paramedics pt non  breathing, no response to verbal
> or painful
> stimulus, no pulse  at carotid.
> 
> Monitor showed agonal cardiac rhythm of 38 but  slowing -
> asystole after
> approx. 60 seconds.
> 
>  Pupils fixed, dilated and non-reactive.
> 
> Airway clear, no  bleeding or bruising evident around face
> or trunk, no
> helmet  damage (paramedics removed helmet). 
> 
> Deep purplish colour on  face and upper torso, but pallor
> over abdo and lower
> chest  (like superior vena cava syndrome, if you know what I
> mean).
>  
> Probably massive pelvic disruption just looking at the way
>  his legs were
> widely spread - I suspect open book #. 
>  
>  
> 
> Treatment - IPPV with bag valve mask - no  change in
> rhythm.
> 
> Decompressed both sides of chest -  no blood or air.
> 
> CPR not performed.
> 
>   
> 
> We called it at that stage.
> 
> I honestly do  not think we could have done anything for
> this patient that
>  would have led to any meaningful outcome, as there only two
> of us  and
> patient was down a steep embankment in a very awkward
>  position, weighed
> approx 150 kg and closest other crews at least 15  mins
> away. 
> 
> Closest level 1 trauma centre 40 mins by  air, but air
> support approx. 20
> mins away.
>  
>  
> 
> Should we or could we have done anything  else?
> 
> Would welcome any comments
> 
>   
> 
> Jenny Moncur
> 
> IC Paramedic
> 
>  Victoria
> 
>  
> 
> 
> 
>  ------------------------------
> 
> Message: 20
> Date: Sun,  18 Dec 2011 05:53:38 -0500
> From: Stephen Richey  <stephen.richey at gmail.com>
> Subject: Re: case for comment  please
> To: "Trauma-List [TRAUMA.ORG]"  <trauma-list at trauma.org>
> Message-ID:
> ???  <CAFhEgi0Cx+v17DjtkFrByJuO1oZLwk6tkcafcOou1FWREZtayA at mail.gmail.com>
>  Content-Type: text/plain; charset=ISO-8859-1
> 
> Honestly, I  would not have even done as much as you
> did.? He was in an
>  agonal rhythm when you found him and was pulseless prior to
>  your
> arrival.? No reason to work him.
> 
> On Sun, Dec 18,  2011 at 5:49 AM, Jenny Moncur <jmoncur at netspace.net.au>
>  wrote:
> > 35 yo male motor bike rider around sweeping bend  into
> a large tree at
> > approx. 100 km/hr.
>  >
> > Bystanders arrive approx. five mins later (pt had
>  overtaken one of them a
> > few miles before that travelling at high  speed).
> >
> > No response, no spontaneous movement,  'snoring' type
> breathing which stopped
> > a few minutes  before paramedic arrival.
> >
> > They did nothing apart  from call emergency services.
> >
> >
> >
>  > O/A of paramedics pt non breathing, no response to
> verbal or  painful
> > stimulus, no pulse at carotid.
> >
> >  Monitor showed agonal cardiac rhythm of 38 but slowing
> - asystole  after
> > approx. 60 seconds.
> >
> > Pupils fixed,  dilated and non-reactive.
> >
> > Airway clear, no bleeding  or bruising evident around
> face or trunk, no
> > helmet  damage (paramedics removed helmet).
> >
> > Deep purplish  colour on face and upper torso, but
> pallor over abdo and lower
>  > chest (like superior vena cava syndrome, if you know
> what I  mean).
> >
> > Probably massive pelvic disruption just  looking at the
> way his legs were
> > widely spread - I  suspect open book #.
> >
> >
> >
> >  Treatment - IPPV with bag valve mask - no change in
> rhythm.
>  >
> > Decompressed both sides of chest - no blood or air.
>  >
> > CPR not performed.
> >
> >
>  >
> > We called it at that stage.
> >
> > I  honestly do not think we could have done anything
> for this patient  that
> > would have led to any meaningful outcome, as there
>  only two of us and
> > patient was down a steep embankment in a very  awkward
> position, weighed
> > approx 150 kg and closest other  crews at least 15 mins
> away.
> >
> > Closest level 1  trauma centre 40 mins by air, but air
> support approx. 20
> >  mins away.
> >
> >
> >
> > Should we or  could we have done anything else?
> >
> > Would welcome any  comments
> >
> >
> >
> > Jenny  Moncur
> >
> > IC Paramedic
> >
> >  Victoria
> >
> >
> >
> > --
> >  trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe  visit:
> > http://www.trauma.org/index.php?/community/
>  
> 
> 
> -- 
> Stephen Richey
> Founder and  Chief Researcher/Designer
> Kolibri Aviation Safety Research
>  5174-B Winterberry Circle
> Indianapolis, IN 46254
>  317-985-4740
> 
> ?"I think the best thing, and the only thing in  our
> infinite
> inadequacy in making up for the loss of life, is  to say
> something we
> have been able to say in a lot of other  accidents to
> grieving
> families. ?That is 'Those deaths will  not be in vain. We
> will not let
> them be in vain. Every one of  those lives will be made to
> count in
> terms of making sure that  three, four, five or ten other
> people do not
> die."- John J.  Nance
> 
> 
> ------------------------------
>  
> --
> trauma-list : TRAUMA.ORG
> To change your settings  or unsubscribe visit:
>  http://www.trauma.org/index.php?/community/
> 
> End of  trauma-list Digest, Vol 102, Issue 2
>  *******************************************
>  

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